Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Rosewood Rehabilitation Center during CMS and state inspections, most recent first.
Improper Medication Storage and Refrigerator Monitoring: An LPN and ADON found a resident’s meds stored in the room despite no self-administration order, incomplete med refrigerator temp logs, an expired suppository in the fridge, an unlabeled unused insulin pen in a med cart, and multiple insulin pens plus a glucometer stored together without separation. A used insulin pen was also found lying on top of lancets, and staff confirmed the storage practices were not proper.
Infection control failures involved improper PPE disposal in an EBP room, failure to place a resident with a dialysis catheter on EBP, and inadequate review of infection trends. An LPN removed PPE inappropriately, the room lacked a designated disposal bin, and the resident’s record and signage did not reflect EBP despite an indwelling device. The IP also reported increased UTIs and fungal infections, but the related investigations and staff education were not documented.
The IP did not provide documented ASP education to residents and families except when an antibiotic was prescribed, and education for all residents and representatives was not being provided. The IP also failed to ensure EBP was in place for a resident with a dialysis catheter, as the room lacked signage and the record lacked an order and care plan entry. In addition, the IP did not document adequate investigation of increased UTIs and skin infections, including shower audits and staff education.
Call Lights Not Kept Within Reach: Two residents were observed with call light devices out of reach, including one resident with limited mobility who could not reach the call light from the opposite side of the bed and another resident with MS and severe upper-extremity limitations whose call light repeatedly slid out of reach while staff left the room. The DON and IDON confirmed the call lights should have been positioned within reach, and the facility did not provide a policy on call light availability.
A resident admitted with sepsis, liver transplant status, altered mental status, and ESRD had a physician order for dialysis at an outside center three times weekly with VS before and after each session and required communication and record transfer. The baseline care plan did not include dialysis care, treatment, or interventions, and the DON confirmed the dialysis needs were omitted from the required baseline care plan.
An LPN performed PICC line dressing changes for a resident receiving IV antibiotics, but the dressing lacked documentation of when it was changed and by whom. Surveyors found the facility could not produce evidence that the LPNs performing PICC care had received training or documented competency before doing the sterile procedure, even though staff said PICC dressings were typically changed weekly and recorded on the IV MAR or in a nurse note.
PICC dressing changes were not completed and documented as ordered for a resident receiving IV antibiotics through a PICC line. The dressing lacked a date and initials, the IV MAR had blank entries for scheduled care, and the RN, DON, and wound care LPN gave conflicting accounts about who was responsible for the dressing changes.
Failure to Monitor Weight Loss and Nutritional Status: The facility did not adequately monitor a resident with significant wt loss or initiate documented nutritional interventions, and it also failed to weigh another resident on admission and weekly as required. One resident with DM, anxiety, and GERD had a documented 18.63% wt loss with inconsistent nutrition records and no alternative monitoring documented when weights were refused. Another resident with CVA-related hemiplegia and dementia had decreased PO intake, a 17.8% wt change, and no documented IDT review or MD notification of the nutritional decline.
Unlabeled Enteral Feeding Container: A resident with a gastrostomy tube and orders for Jevity 1.5 formula and free water had a tube feeding pouch hanging in the room without the required label information. An LPN confirmed the pouch was missing all labeling, and the DON stated nurses were responsible for labeling enteral feeding containers per facility policy.
Failure to administer ordered continuous oxygen and document sats. A resident with CHF and other cardiac conditions had orders for oxygen at 2 lpm via NC continuously and for titration to keep sats above 90%. Staff repeatedly observed the resident without the NC in place while the concentrator was running, and an LPN stated sats were supposed to be checked every shift but could not find documentation in the record. The DON confirmed the continuous oxygen order was not being followed and that saturation levels were not documented as expected.
Missing Dialysis Communication Form: The facility failed to retain a completed dialysis communication form for a resident receiving scheduled dialysis. The resident had ESRD and other serious diagnoses, and the ADON and DON confirmed the form was required to document pre- and post-dialysis vital signs and dialysis center notes, but the record did not contain the completed communication sheet for the resident’s first dialysis visit after admission.
A facility failed to ensure staff were trained and deemed competent before providing PICC line care to a resident receiving IV antibiotics. The resident had a PICC in the upper arm, and the dressing lacked a change date and initials. Staff gave inconsistent answers about dressing-change frequency, the wound care LPN typically performed PICC dressing changes, and the Administrator stated the facility could not find documentation showing the LPNs and RN had been trained and verified competent for PICC care.
A facility failed to follow the posted breakfast menu when some residents were served French toast instead of waffles, and residents were not notified of the change. Residents reported this happened without explanation, and the KM confirmed there were enough waffles available, no alternative meal requests were found, and staff did not notify residents when menu items changed.
Hand Sanitizer Stored With Resident Food Items: Surveyors observed an open bottle of hand sanitizer stored on a tray with a coffee pot, cups, creamer, and sugar in the resident food storage area. The [NAME] confirmed the sanitizer was kept with the coffee service items for use before serving residents coffee, and the cook stated chemicals were not to be stored with food. The facility policy stated food storage areas must be maintained in a clean, safe, and sanitary manner and toxic substances were not to be stored with food.
An LPN left a medication cart computer unlocked and displaying resident information, including medications for a resident in a room, while walking away from the cart. A staff member passed by the open screen before the LPN returned. The LPN acknowledged the computer should have been locked to protect PHI under HIPAA, and the DON stated nurses were expected to lock the cart, lock the screen, and turn over paperwork to hide resident information.
An LPN hired as a contract employee worked 29 shifts without documented abuse training. HR confirmed the required training on preventing, identifying, and reporting abuse, neglect, misappropriation of property, and exploitation had not been completed, despite the facility policy requiring it for staff.
A resident with epilepsy and AFib on Eliquis hit their head on a headboard during repositioning and reported pain and double vision. The MD was notified and told nursing to monitor for neuro changes, but the record did not show timely neuro checks or VS in the hours after the injury; the DON confirmed the first VS were documented several hours later and the neuro assessment was charted in a later daily note.
A resident with a trauma history and a documented preference for female caregivers received a bed bath from a male CNA despite an existing care plan for female-only bathing assistance. Another resident with severe mobility limitations used a chin-operated call light, but the care plan did not address placement or monitoring of the device, and the resident reported it often slid out of reach. A third resident used a trapeze for in-bed mobility and pressure relief, but the comprehensive care plan lacked goals and interventions for its use.
A resident with a history of trauma, bipolar disorder, MDD, and schizophrenia was supposed to receive bed baths only from female staff due to identified triggers and a care plan preference. Instead, a male CNA provided a bed bath, and the resident reported feeling invaded during perineal care and later had difficulty sleeping. The DON confirmed the resident should not have had a male CNA provide that care.
A resident receiving hospice services did not have ordered morphine available on site for pain or SOB, and multiple controlled substance logs were inaccurate for several residents. On one station, pregabalin, oxycodone, and diazepam counts did not match the medication cards or CDRs, and on another station hydrocodone counts were inconsistent. The DON and ADON confirmed the discrepancies and noted one dose had been administered without being signed out on the CDR.
Antibiotic Stewardship education was not provided to all residents and their families. The IP stated education was only given verbally to residents who were prescribed antibiotics and then to their representatives/families, with no documented evidence of the education. The facility policy and CDC guidance referenced resident and family education as part of the ASP, but this education was not being provided to all residents and resident representatives/families.
The facility failed to ensure current nursing hours were posted. During observation, the nursing staff posting was still dated for the previous day, and the Administrator confirmed it had not been updated and stated it should be updated at the start of the shift.
Facility Assessment missing staffing requirements based on average census. The Facility Assessment lacked documented evidence for adequate staffing levels tied to the facility’s average census, and staffing plans did not include average census or staffing levels per shift. An Administrator confirmed the staffing plans did not show how the facility would meet resident care needs, despite the facility policy stating staffing decisions were based on resident assessments and plans of care.
A resident with a history of vertebral fractures was found deceased after a CNA reported taking vital signs earlier that morning. The facility's investigation into the alleged neglect was incomplete, lacking interviews with key staff, the resident's roommate, and other residents, contrary to facility policy.
A resident with dysphagia received tube feeding based on an incomplete physician order that did not specify the formula type, and staff continued administration without this detail until the order was updated. Additionally, an LPN documented tube feeding as completed before actually administering it, then failed to return and provide the feeding after the resident requested a delay, without documenting the missed administration or a refusal.
A resident with multiple fractures and malnutrition did not have complete documentation in the clinical record regarding showers, bed baths, or refusals of care during a period when they were Covid-19 positive. Staff interviews confirmed that care and refusals should have been documented electronically, but records were missing for several days.
The facility failed to inform residents about the rules for leaving on pass both orally and in writing prior to or upon admission. A resident with type two diabetes felt confined and uninformed about the ability to leave. Staff confirmed that a physician's order was needed for leaving on pass, but this was not communicated at admission. The Director of Nursing acknowledged the omission, and the facility's admission packet lacked documentation of these rules, contrary to their policy.
The facility was found deficient in maintaining cleanliness of the ice machine and proper food storage practices. The ice machine had black buildup, and refrigerated foods, such as fruit cocktail, were uncovered and not labeled with dates. The Dietary Manager confirmed these practices did not meet the facility's expectations.
A resident with limited mobility was not informed of menu options or alternatives, leading to frustration and delays in receiving meals. The menu in the resident's room was outdated and not visible from their bed, and staff did not notify the resident of daily menu items, violating the resident's right to self-determination.
A facility failed to report an incident of resident-to-resident abuse within the required timeframe. A resident with severe vascular dementia was involved in an incident where another resident with dementia and agitation slammed their wheelchair into the first resident's legs. The incident was not reported to the State Agency until two days later, violating the facility's policy that mandates reporting within 24 hours for abuse without serious bodily harm.
The facility failed to create comprehensive care plans for two residents, one on anticoagulants with gastrointestinal bleeding symptoms and another with hypoxemia receiving oxygen therapy. The absence of care plans for these conditions was confirmed by the DON, contradicting facility policies and potentially compromising resident care.
A facility failed to monitor lab results and communicate bleeding symptoms for a resident on anticoagulant therapy. The resident, on apixaban, showed signs of gastrointestinal bleeding, but the care plan lacked documentation of the medication and symptoms. An LPN was unaware of the bleeding, and a stool sample was mishandled, leading to a lack of follow-up on test results.
A resident with hypoxemia was receiving oxygen therapy without a physician's order, contrary to the facility's policy. The resident, who had not used oxygen before admission, was unsure of its necessity. The DON confirmed the absence of a physician's order, despite the resident receiving oxygen since admission.
A medication cart was found unlocked and unattended outside the nurse's station while a resident and visitors were present. The DON confirmed the cart should have been locked when unattended, as per facility policy, which allows only authorized personnel access to medication carts.
A resident with kidney disease was served meals inconsistent with their prescribed diet order, receiving pureed and mechanically altered foods instead of a regular diet. The Dietary Supervisor misunderstood the diet requirements and failed to communicate with nursing staff for clarification. The facility lacked a policy for following diet orders, leading to this deficiency.
The facility did not follow its water management policy by failing to conduct Legionella testing every five years. The Director of Environmental Services confirmed that the maintenance department, responsible for the program, lacked testing results and had no plan for future testing. This non-compliance with the policy could lead to undetected bacteria in the water lines.
A facility failed to ensure annual elder abuse training for a Registered Nurse, as required by their policy. The nurse's personnel record showed training was last completed in August 2023, with no evidence of completion in 2024. The HR representative confirmed the lapse, despite the facility's policy mandating annual training.
A resident developed Moisture Associated Skin Damage (MASD) and a pressure injury while in the facility, despite having no active skin conditions upon admission. The facility failed to adhere to physician's orders for skin breakdown prevention, including the application of barrier cream and regular repositioning. The deficiency was confirmed by the Wound Nurse and DON, highlighting a lapse in the facility's skin and wound management practices.
A resident tripped over a sprinkler head in the courtyard, resulting in fractures, due to the facility's failure to address a known tripping hazard. Observations confirmed that sprinkler heads were raised above ground level, posing a risk. Staff interviews revealed a lack of communication and awareness about the hazard, and the facility's report did not include corrective measures.
A resident with chronic kidney disease and benign prostatic hyperplasia had a physician's order for indwelling catheter care, but the facility failed to update the care plan to include this. The DON confirmed the care plan lacked necessary updates, despite facility policy requiring comprehensive care plans.
The facility failed to ensure a high-temp dishwasher was operating correctly and expired food items were discarded. The dishwasher's final rinse cycle was below the required temperature, and expired macaroni salad and grits were found in the kitchen. The Dietary Supervisor confirmed the issues and acknowledged that the items should have been discarded according to facility policies.
The facility failed to administer pneumococcal vaccines to two residents who had requested them and did not screen or offer the influenza vaccine to 25 residents. Additionally, 12 residents who requested the influenza vaccine did not receive it. The facility's policies for immunizations were not followed, leading to a significant portion of the resident population not being vaccinated.
The facility failed to maintain the privacy of resident health information when an unattended computer screen displayed the names of three residents. An LPN admitted to forgetting to lock the screen, and the DON confirmed that staff are expected to secure screens when unattended.
The facility failed to prevent resident-to-resident abuse and neglect. One resident attempted to hit another, and in a separate incident, a resident was found soaked in urine with the call light unplugged. The facility's abuse and neglect prevention policies were not effectively implemented.
The facility failed to submit a final report for a Facility Reported Incident (FRI) involving an allegation of force-feeding by a CNA within the required five-day timeframe. The delay was due to a miscalculation of dates by the DON.
The facility failed to ensure timely transmission of MDS 3.0 assessments for five residents, with delays ranging from 14 to 15 days past the required seven-day transmission period. The MDS Coordinator confirmed the delays, acknowledging non-compliance with the RAI Manual timelines.
The facility failed to ensure care plans were person-centered and complete for residents with cognitive impairments, communication barriers, psychotropic medication needs, bedrail use, and incidents of abuse and neglect. Staff did not use designated communication tools, and care plans lacked specific details and necessary interventions.
The facility failed to follow professional standards during medication administration for two residents and did not properly assess a resident before diagnosing schizoaffective disorder and administering psychotropic medication. An LPN administered pain medication without assessing pain severity and location, and insulin without sterilizing the stopper or timing it before meals. Additionally, a resident's need for psychotropic medication was not properly assessed or documented.
The facility failed to offer a non-English speaking resident a communication device and/or provide translation services. Despite the resident's care plan documenting the need for a language line, staff members did not use it and instead relied on hand gestures, short sentences, and infrequent family visits for communication. The Director of Nursing confirmed that translation services were supposed to be used, especially during assessments.
The facility failed to ensure coordinated care with a hospice agency for a resident receiving hospice services. Despite a care plan indicating regular visits from hospice staff, there was a lack of documentation in the hospice binder and EHR regarding the care provided. Interviews revealed that hospice aides did not consistently report their visits or document the care provided, leading to a significant gap in record-keeping and communication.
Improper Medication Storage and Refrigerator Monitoring
Penalty
Summary
Medications were found stored in Resident #91’s room even though the resident did not have an order to self-administer and staff confirmed residents were not allowed to keep medications in their rooms. On 12/08/2025, a bottle of Tylenol 500 mg tablets was observed on the resident’s nightstand and Voltaren gel was found in the nightstand drawer. On 12/11/2025, Voltaren gel and a bottle of multivitamins were again found in a bin on top of the resident’s nightstand. The resident had diagnoses including fibromyalgia, chronic pain syndrome, and generalized muscle weakness, and the resident could not state when Tylenol was last taken. The Station B medication refrigerator temperature log was incomplete. The facility did not record temperatures each day and each shift as required, with multiple missing day and night shift entries in July, August, November, and December 2025, and no logs provided for September and October 2025. The ADON confirmed the refrigerator temperature was supposed to be checked and recorded twice daily, one time per shift, and stated that incomplete documentation could affect medications sensitive to temperature. Additional medication storage issues were identified in the medication rooms and carts. An expired promethazine suppository was found in the Station B medication refrigerator. An unlabeled Humalog insulin pen that had not been used was found in the B hall back medication cart, and the ADON confirmed it should not have been stored there unlabeled. In the Station A back medication cart, a used Humalog insulin pen was lying on top of lancets, eight Humalog pens and four Lantus pens for seven residents were stored together in the same compartment without barriers, and a glucometer was stored in the same compartment as the used insulin pens. The ADON confirmed the insulin pens were not properly stored and the glucometer should not have been stored with them.
Infection Control Failures With PPE Disposal, EBP Implementation, and Infection Trend Review
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices for residents on Enhanced Barrier Precautions (EBP). On 12/11/2025, an LPN was observed in a resident room designated for EBP wearing a cloth gown and disposable gloves. After administering medications, assessing bowel sounds, flushing the resident’s gastric tube, and starting enteral nutrition, the LPN removed the gown and placed it on the floor near the door, then removed the gloves in the hallway and discarded them in a trash bin on the medication cart. The gown remained on the floor later that day. The Administrator confirmed the gown should have been placed in a clear trash bag and put in the laundry hamper, and there was no designated bin or trash can in the room for PPE disposal. The IP confirmed the facility was not using dedicated bins for EBP rooms and stated staff should not throw PPE on the floor or remove gloves in the hallway. The facility also failed to implement EBP for Resident #118, who was admitted with end stage renal disease and had an implanted dialysis catheter in the right upper chest. The resident’s room lacked EBP signage, and the clinical record lacked an order and care plan entry for EBP. A progress note documented the hemodialysis port to the right chest with a clean and intact dressing, and the care plan addressed daily access site dressing care and monitoring for signs of infection. Staff interviews confirmed the resident should have been on EBP because of the dialysis catheter, but the room had no signage and the record did not reflect EBP. The IP confirmed EBP was not in place for the resident despite the indwelling device. The facility also did not adequately investigate infection trends. Infection control meeting minutes for October and November 2025 documented increased UTIs and fungal infections, and the IP stated the facility’s most frequent infections were UTIs and skin infections such as cellulitis and fungal infections. The IP described interventions such as shower audits and offering oral fluids, but stated the shower audits were not documented and the education provided to staff, who was educated, when it occurred, and any follow-up or outcomes were not documented. For the increase in UTIs, the IP reported completing four observations of incontinence care and giving verbal education to one CNA, but denied any additional investigation into contributing factors and denied that offering fluids was selected based on an investigation. The facility policy stated the IPCP included surveillance, data analysis, and investigation of infections with documentation of corrective action taken.
Infection Preventionist Failed to Provide ASP Education and Follow Infection Control Processes
Penalty
Summary
The facility failed to ensure the Infection Preventionist (IP) provided education about the Antibiotic Stewardship Program (ASP) to residents and residents’ representatives/families, and the IP did not carry out infection surveillance, investigation, prevention, and control processes according to facility policy and CDC recommendations. The IP stated that when an antibiotic was prescribed, the IP would visit the resident and later call the resident’s representative or family member to provide verbal ASP education, but the IP had no documented evidence that the education was provided. The IP also confirmed that this education was only given to residents and families of residents who were prescribed an antibiotic, and that education for all residents and representatives/families was not currently being provided. Resident #118 was admitted with end stage renal disease and had an implanted dialysis catheter in the right upper chest. During a room tour, the resident’s room lacked signage indicating Enhanced Barrier Precautions (EBP). A nurse confirmed the resident should have been on EBP because of the dialysis catheter, but the resident did not have EBP in place, the room lacked signage, and the clinical record lacked a physician order and care plan entry for EBP. The IP stated EBP was used to help prevent the spread of MDROs and should be implemented for residents with implanted medical devices, but was unsure whether it had been implemented for this resident because the record had not been reviewed. Facility infection control meeting minutes documented increased UTIs and fungal infections in October and November 2025. The IP stated the facility tracked infections with a monthly log and that the most frequent infections were UTIs and skin infections. Interventions included offering oral fluids and conducting shower audits, but the IP said the shower audits were done after an increase in skin infections and found residents often refused showers. The IP also stated CNAs were told to notify nurses when showers were refused, but there was no documentation of the audits, staff education, who was educated, when education occurred, or any follow-up or outcomes. For the increase in UTIs, the IP described four observations of incontinence care and verbal education to one CNA, but denied any additional investigation and denied documentation of the observations, education, or outcomes.
Call Lights Not Kept Within Reach
Penalty
Summary
The facility failed to ensure call light devices were kept within reach for two residents. The deficiency was identified during observations, clinical record review, interview, and document review, and involved Resident #6 and Resident #12. The report states the facility did not provide a policy related to the use and availability of call lights. Resident #6 was admitted and readmitted with diagnoses including unilateral primary osteoarthritis of the right hip, Alzheimer's disease, a stage III sacral pressure ulcer, a history of TIA, and cerebral infarction without residual deficits. On observation, the resident was sitting in a wheelchair on the right side of the bed and wanted to lie down but could not reach the call light button to request help. The call light, described as a large round disc used by residents with difficulty pressing a standard button, was found on the far-left side of the bed, out of reach. A visitor turned on the call light and went to get help, and the DON later confirmed the call light should have been on the same side of the bed and within the resident's reach because of the resident's limited mobility. Resident #12 was admitted with diagnoses including multiple sclerosis, neuromuscular dysfunction of the bladder, major depressive disorder, a stage III pressure ulcer of the back, contracture, and pain in both hands. The MDS documented unilateral upper extremity functional limitation and dependence for multiple ADLs, including eating, oral hygiene, toileting hygiene, bathing, dressing, and personal hygiene, and the resident was not able to use a scooter or wheelchair. During multiple observations, the resident's call light was found resting on the resident's chest, waist, lower abdomen, and right hip, and the resident stated it often slid out of reach and staff would forget to place it within reach before leaving the room. The resident reported being unable to call for help when the call light was not appropriately placed, and the IDON confirmed the call light should be placed on the resident's chest below the chin because the resident operated it with the chin.
Baseline Care Plan Missing Dialysis Needs
Penalty
Summary
The facility failed to develop a baseline care plan to address care and interventions for dialysis treatments for Resident #116 within 48 hours of admission. Resident #116 was admitted with diagnoses including sepsis due to methicillin susceptible staphylococcus aureus, liver transplant status, altered mental status, unspecified, and end stage renal disease. A physician’s order dated 12/06/2025 directed the resident to receive dialysis at a dialysis center every Monday, Wednesday, and Friday, with vital signs to be taken before and after each session, a communication form to be sent and received with the patient, and medical records to be scanned upon return. The resident’s baseline care plan did not include dialysis care, treatment, or interventions. The DON stated that baseline care plans were required within 48 hours of admission and should include unique health care needs and services staff would need to know to care for the resident properly, and confirmed dialysis was not included on the resident’s baseline care plan.
PICC Dressing Changes Performed Without Documented Competency
Penalty
Summary
The facility failed to ensure LPNs who performed PICC line dressing changes for Resident #96 were trained and deemed competent to perform the procedure. Resident #96 was admitted with diagnoses including sepsis and bacteremia and was receiving IV cefazolin for an infection. The resident had a PICC line in the left upper arm, and on 12/08/2025 the insertion site was covered with a transparent dressing that lacked a date and initials showing when and by whom it had been changed. The resident stated facility staff had changed the PICC line dressing but was unsure when it was last changed. The resident’s care plan and physician’s order directed PICC line care, including dressing changes every seven days and as needed if wet, loose, or soiled. The IV MAR documented PICC line care was administered by LPN1 on 11/27/2025. During the survey, an RN observed the dressing still lacked a date, and the IDON stated PICC dressings were to be changed weekly and documented on the IV MAR and/or in a nurse progress note. The IDON later stated the facility’s wound care nurse was responsible for PICC dressing changes, and LPN2 confirmed that LPN2 typically performed PICC line dressing changes for residents with PICC lines. The Administrator stated staff should receive training and have documentation of competency before performing PICC line dressing changes, but the facility could not find evidence that LPN1 or LPN2 had received such training or competency validation.
PICC Dressing Changes Not Documented or Performed as Ordered
Penalty
Summary
The facility failed to ensure PICC line dressing changes were completed according to physician orders for one resident who was admitted with diagnoses including sepsis and bacteremia and was receiving IV cefazolin for an infection. On 12/08/2025, the resident had a PICC line in the left upper arm with a transparent dressing that lacked a date and initials showing when and by whom it had been changed. The resident stated staff had changed the PICC dressing but was unsure when it was last changed. The resident’s care plan directed staff to observe the IV site daily and the physician ordered central line/PICC care with dressing and injection cap changes every seven days. The IV MAR showed scheduled dressing changes on 11/20/2025, 11/27/2025, 12/04/2025, and 12/11/2025, but the entries for 11/20/2025, 12/04/2025, and 12/11/2025 were blank. An RN confirmed the dressing lacked a date, and the IDON stated the last documented PICC dressing change was 11/27/2025. The IDON also stated the wound care nurse was responsible for PICC dressing changes, while the wound care LPN said she typically performed them for residents with PICC lines but denied completing them for this resident because she thought floor nurses were doing them.
Failure to Monitor Weight Loss and Nutritional Status
Penalty
Summary
The facility failed to monitor one resident for significant weight loss and failed to initiate timely interventions in accordance with facility policy and professional standards of practice. Resident #16 was admitted and later readmitted with diagnoses including type 2 diabetes mellitus with other diabetic kidney complication, anxiety disorder, and gastro-esophageal reflux disease. The Weights and Vitals Summary showed the resident weighed 139 pounds on 01/07/2025 and 113.1 pounds on 07/14/2025, a loss of 25.9 pounds or 18.63%. There was no documentation of weights between January 2025 and July 2025 to verify or monitor the loss. The clinical record contained Quarterly Nutrition Evaluations dated 03/08/2025, 04/07/2025, and 07/08/2025 that each documented a recent weight of 139.0 pounds, which did not match the Weights and Vitals Summary. Monthly documentation from January 2025 through July 2025 indicated the resident refused weighing, but there was no documentation that alternative monitoring measures such as intake monitoring or body measurements were completed. The RD stated the weight loss would have been noticeable and confirmed there was no documentation that the prior RD was aware of the loss before the 07/14/2025 weight. The RD also confirmed no nutritional interventions had been initiated related to the significant weight loss. The facility also failed to ensure one resident was weighed upon admission and weekly for four weeks, that the IDT evaluated the resident after decreased oral intake, and that the physician was notified of the change in nutritional status. Resident #15 had diagnoses including hemiplegia and hemiparesis following cerebrovascular disease and unspecified dementia with agitation. The resident’s record showed weights of 165 pounds on 10/23/2025 and 135.7 pounds on 11/10/2025. The resident’s care plan identified nutritional risk related to dysphagia, puree diet with slightly thickened liquids, edentulism, and dementia, and an RD note documented oral intake of 50-75% of meals. A later weight change note documented a 17.8% change with reweight pending. The RD and IDON both confirmed the resident was not weighed upon admission and weekly for four weeks, the resident’s decreased intake was not documented as having been discussed in weekly nutrition meetings, and there was no documented evidence that the physician had been notified of the change in nutritional status.
Unlabeled Enteral Feeding Container
Penalty
Summary
Enteral nutrition was not labeled according to professional standards and facility policy for Resident #12. The resident was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side and cerebral aneurysm, and required assistance with personal care. During an observation of enteral feeding administration, the tube feeding pouch hanging in the resident’s room was not labeled with the resident’s name, formula name, date and time hung, or expiration/beyond-use time. The resident had physician orders for Jevity 1.5 calorie formula via gastrostomy tube by pump at 65 cc per hour for 20 hours, with free water at 30 ml per hour for 20 hours, and a separate order for daily tube care. An LPN stated the feeding pouch should have been dated and labeled and confirmed it was missing all labeling. The Interim DON stated new tubing should have been used, bottles should have been labeled, and nurses were responsible for labeling enteral feeding containers. The facility policy required the feeding bag to be labeled with the resident’s name, room number, date and time started, kind and strength of feeding, volume, delivery rate, and initials of the staff member initiating the feeding, and required the feeding container, tubing, and syringe to be changed every 24 hours.
Failure to Administer Ordered Continuous Oxygen and Document Saturation Levels
Penalty
Summary
The facility failed to ensure oxygen was administered and oxygen saturation levels were monitored according to physician orders for a resident admitted and readmitted with chronic diastolic congestive heart failure, cognitive communication deficit, and atherosclerotic heart disease. The resident had orders for oxygen at 2 lpm via nasal cannula continuously and to titrate oxygen to keep saturations greater than 90% as needed. The care plan directed staff to administer oxygen as ordered, monitor and document side effects and effectiveness, monitor for signs and symptoms of respiratory distress, and maintain oxygen settings at 2 lpm continuously via nasal cannula. During observation, the resident was repeatedly found seated in a wheelchair next to the bed without the nasal cannula in place while the oxygen concentrator was running and tubing was lying on the bed or bundled on top of the concentrator. An LPN stated the resident was supposed to be on oxygen at all times and that saturation levels were to be checked every shift and documented, but the resident often removed the oxygen and staff were expected to replace it. The LPN could not locate saturation documentation in the clinical record, and the Weights and Vitals Summary-Oxygen Sats Summary lacked documented oxygen saturation levels for two dates. The DON confirmed the resident's continuous oxygen order was not being followed and that the facility did not have a policy on taking oxygen saturation levels, though staff were expected to monitor and document them every shift when oxygen titration was ordered.
Missing Dialysis Communication Form
Penalty
Summary
The facility failed to maintain a completed dialysis communication transfer form for one resident who required dialysis services. The resident was admitted with diagnoses including sepsis due to methicillin susceptible staphylococcus aureus, liver transplant status, altered mental status, unspecified, and end stage renal disease. A physician’s order dated 12/06/2025 directed the resident to receive dialysis every Monday, Wednesday, and Friday, with vital signs to be taken before and after each session, a communication form to be sent and received with the patient, and medical records to be scanned upon return. The resident’s clinical record did not contain documented evidence of a completed dialysis communication transfer form for the dialysis appointment on 12/08/2025. The ADON stated that this was the resident’s first dialysis appointment since admission and that the resident was sent with a dialysis communication form used to document pre-dialysis vital signs, notes from the dialysis center, and post-dialysis vital signs. The DON confirmed the facility did not have the dialysis communication sheet for that dialysis appointment, and the facility policy stated that dialysis communication forms were to be placed in the resident’s clinical record.
Lack of Competency Verification for PICC Line Care
Penalty
Summary
The facility failed to ensure staff received training and were deemed competent to provide care for PICC lines before being assigned to care for a resident receiving IV antibiotics. Resident #96 was admitted with diagnoses including sepsis and bacteremia and had a PICC line in the left upper arm for cefazolin therapy. During observation, the PICC dressing was transparent but did not have a date or initials indicating when it was changed, and the resident stated facility staff had changed the dressing but was unsure when it was last changed. The resident’s care plan and physician orders directed daily monitoring of the IV site and PICC line dressing changes every seven days, with additional changes if the dressing was wet, loose, or soiled. The November 2025 IV MAR documented central line care and flushes performed by multiple LPNs on several dates. On interview, an RN assigned to the resident stated PICC dressings were to be changed daily, while the IDON stated they were to be changed weekly and if dislodged or soiled, and that the wound care nurse was responsible for completing PICC dressing changes for residents in the facility. The facility’s wound care nurse, who was also an LPN, confirmed she typically performed PICC dressing changes for all residents with PICC lines. The Administrator stated staff should receive training and have documentation of competency before performing PICC line dressing changes, but the facility could not find evidence that the LPNs and RN involved had received training and were deemed competent to perform PICC line care. The facility’s PICC line training module, LPN job description, NAC requirements, Lippincott guidance, and CDC recommendations were reviewed in relation to the deficiency.
Menu Not Followed for Breakfast Service
Penalty
Summary
The facility failed to ensure the posted menu was followed for breakfast service. During a resident council meeting, 8 of 8 residents stated the facility often served food that was not on the menu and that residents were not notified when meal changes occurred. One resident reported that breakfast was supposed to include waffles, but some residents received French toast instead, with no explanation or notification from staff, and said this concern had been raised previously to staff. The menu for the breakfast meal listed waffles, warm syrup, breakfast meat, hot or cold cereal, and milk/juice, and the posted kitchen menu matched those items. The Kitchen Manager confirmed that waffles and sausage were supposed to be served and that there were enough waffles for all residents, but some residents were still served French toast. The Kitchen Manager could not locate any alternative meal requests for breakfast and could not explain why French toast was served. Staff also stated that if the menu changed, residents were not notified and the food was simply served as changed.
Hand Sanitizer Stored With Resident Food Items
Penalty
Summary
The facility failed to ensure an opened bottle of FLTR Pure Protectant hand sanitizer gel was removed from a resident food storage area. On 12/08/2025 at 8:23 AM, surveyors observed the open bottle of hand sanitizer on a shelf in the resident food storage area, placed on a tray with a coffee pot, cups, creamer, and sugar. At 8:25 AM, the [NAME] confirmed the open bottle of hand sanitizer was being stored with the resident dry food and explained that the sanitizer was kept on the tray with the coffee service items because staff used it before giving residents coffee when taking the tray into the hallways. The cook stated that chemicals were not to be stored with food to be served to residents. The facility policy titled Dietary Services, last revised August 2007, stated that food storage areas would be maintained in a clean, safe, and sanitary manner and that toxic substances were not to be stored in the kitchen area or store rooms for food.
Unattended Medication Cart Computer Exposed Resident PHI
Penalty
Summary
The facility failed to ensure resident-identifiable information was not visible on an unattended computer screen at a nursing station facing a public area. On 12/09/2025 at 10:01 AM, a nurse walked away from the medication cart and left a computer screen open displaying resident information, including medications for the resident in room [ROOM NUMBER]-B. At 10:03 AM, one staff member walked by the unlocked computer screen, and at 10:05 AM the nurse returned behind the nurse's station before the LPN came back to the medication cart. When asked whether the computer should have been locked before leaving the cart, the LPN stated, "I guess so," and said locking the computer when walking away was required to protect PHI under HIPAA. At 10:46 AM, the DON stated the expectation was for nurses to lock the medication cart, lock the computer screen, and ensure all paperwork was turned over to hide resident information. Review of the facility policy, HIPAA Privacy and Security Operational Guide, stated staff were required to lock medication cart computers when not in use.
Missing Abuse Training for Contract LPN
Penalty
Summary
The facility failed to ensure Employee #11, an LPN hired on 04/01/2025, completed required training on preventing, identifying, and reporting abuse, neglect, misappropriation of property, and exploitation. Employee #11’s record did not contain documented evidence that the abuse training had been completed. During interview on 12/10/2025 at 12:37 PM, the Human Resources Payroll Representative confirmed the contract LPN had worked 29 shifts and had not completed the required abuse training, despite being responsible for ensuring contract employees obtained it. The facility policy titled, Freedom from Abuse, Neglect, Exploitation, revised 10/2022, stated staff would receive training related to the prohibition and prevention, identifying and recognizing, and reporting of resident abuse, neglect, misappropriation of property, and exploitation.
Delayed Neuro Monitoring After Head Injury
Penalty
Summary
The facility failed to ensure a resident with epilepsy and atrial fibrillation who was receiving Eliquis was assessed per facility policy after a witnessed head injury. During repositioning in bed, the resident was scooted up and hit their head on the headboard, then exclaimed in pain and reported double vision. The physician was notified and instructed nursing to monitor for neurological changes. The resident’s clinical record did not include documented neurological checks or vital signs in the immediate three hours after the head injury and complaint of visual changes. The DON stated that a neurological response assessment was included in a daily note completed about six hours after the event, and the first documented vital signs were recorded about four hours after the head injury. The facility’s standard of practice required assessment for changes in level of consciousness, vital signs, impaired vision, and seizure activity after a head injury.
Missing Care Plan Interventions for Trauma-Informed Bathing, Call Light Access, and Trapeze Use
Penalty
Summary
Resident #11 had a trauma-informed care assessment documenting a history of intimate partner violence, distrust of men, and a preference for female caregivers for showers and bed baths to avoid re-traumatization. A care plan initiated in 2023 stated the resident required staff assistance with bathing and should have female caregivers for bed baths. Despite this, a facility-reported incident dated 07/23/2025 documented that the resident received a bed bath from a male CNA and reported feeling that the CNA had been invasive when cleaning around the resident's anus. The resident also stated the resident had reminded the CNA that only female CNAs were supposed to provide bed baths. Resident #12 was admitted with multiple sclerosis, neuromuscular dysfunction of the bladder, major depressive disorder, a stage III pressure ulcer of the back, contracture, and pain in both hands. The MDS documented severe functional dependence, including dependence for eating, hygiene, bathing, dressing, toileting, and rolling in bed, and the resident was unable to use a scooter or wheelchair. The resident used a flat round call light device operated with the chin because the resident had no functional use of the upper extremities. The comprehensive care plan did not include interventions for the placement, monitoring, or availability of the call light, and the resident reported that the device often slid out of reach and staff would forget to place it within reach before leaving the room. Resident #5 was admitted and readmitted with diagnoses including GERD, major depressive disorder, and a stage III sacral pressure ulcer. A PT evaluation and plan of treatment documented the resident's objective was to roll side to side in bed using a trapeze, and a trapeze was observed above the bed. However, the comprehensive care plan lacked documented goals and interventions addressing the trapeze, its use for mobility in bed, or pressure-relieving tactics. The Administrator and PT Manager confirmed the resident used the trapeze for increased independence with mobility in bed and to relieve pressure, but the care plan did not contain documented evidence for this device use.
Failure to Follow Trauma-Informed Bathing Preferences
Penalty
Summary
The facility failed to ensure a resident with a documented history of trauma received trauma-informed care based on the triggering factors identified in the resident’s trauma assessment. Resident #11 was admitted and later readmitted with diagnoses including bipolar disorder, major depressive disorder, and schizophrenia. A facility-reported incident documented that the resident reported receiving a bed bath from a male CNA and felt the CNA was invasive when cleaning around the resident’s anus. The resident stated the CNA had been reminded that only female CNAs were supposed to provide bed baths, and a staff member reported the resident seemed less lively than usual after the incident. The resident’s Trauma Informed Care assessment documented a history of intimate partner violence, that the resident did not trust men, and that female staff were preferred for showers to avoid triggers and prevent re-traumatization. The care plan also documented that the resident required staff assistance with bathing and should have female caregivers for bed baths. Despite this, the DON confirmed the resident received a bed bath from a male CNA and should not have had a male CNA provide that care. A Social Services progress note documented the resident had difficulty sleeping after the incident, and the resident later stated the event was too upsetting to discuss and that the resident had requested no male caregivers before the bath occurred.
Missing Hospice Morphine and Inaccurate Controlled Substance Logs
Penalty
Summary
The facility failed to ensure a morphine order was available for a resident receiving hospice services who had diagnoses including dysphagia following cerebral infarction, cerebrovascular disease affecting the left non-dominant side, and anxiety disorder. The resident had a care plan documenting shortness of breath, and the hospice order specified morphine sulfate concentrate 20 mg/ml, 0.25 ml by mouth every four hours as needed for shortness of breath or pain, with hospice to provide the medication. During review, the morphine was not available on site, and the facility RN stated it should have been ordered and available in case the resident needed it for pain. The DON also stated the medication should have been ordered and available on site. The facility also failed to maintain accurate controlled substance logs for residents on Station B. For one resident with a history of a healed traumatic fracture, the Controlled Drug Record showed 21 capsules of pregabalin remaining, but no medication card or container could be located in the medication cart. For another resident with polyneuropathy, the CDR showed six capsules of pregabalin remaining and 10 tablets of oxycodone remaining, but neither medication card or container could be located in the cart. The ADON searched the controlled and uncontrolled medication drawers and confirmed the missing cards could not be found. For a third resident with bipolar disorder and anxiety disorder, the CDR showed one diazepam tablet remaining, but the medication card was empty. The ADON stated the nurse had administered the medication but did not sign it out on the CDR. On Station A, a resident with unspecified osteoarthritis had a hydrocodone-acetaminophen order for increased pain; the CDR documented 36 tablets remaining, while the medication card contained 37 tablets. The ADON stated the concern was that the resident requested but did not receive the medication. The facility policy required controlled medications to be reconciled and documented accurately.
Antibiotic Stewardship Education Not Provided to Residents and Families
Penalty
Summary
The facility failed to ensure education regarding its Antibiotic Stewardship Program (ASP) was provided to residents and residents' representatives/families. During interview, the Infection Preventionist (IP) stated the purpose of the role was to facilitate the infection control program and provide education regarding the facility's policies and infection control plan. The IP explained that if an antibiotic was prescribed for a resident, the IP would visit the resident and later call the resident's representative/family member to provide verbal education regarding the ASP, but the IP denied having documented evidence that the education was provided. The IP confirmed that education regarding the ASP was only provided to residents and representatives/families of residents who were prescribed an antibiotic, and that education was not currently being provided to all residents and resident representatives/families. The facility policy titled Antibiotic Stewardship, reviewed 04/2025, stated the facility would implement an ASP to promote appropriate use of antibiotics. The IP job description stated the IP was responsible for planning, organizing, developing, and directing the infection control program in accordance with federal, state, and local standards, and the CDC document on antibiotic stewardship for nursing homes stated educational resources should be provided to clinicians, nursing staff, residents, and families about antibiotic resistance and opportunities for improving antibiotic use.
Outdated Nursing Staff Posting
Penalty
Summary
The facility failed to ensure current nursing hours were posted for the facility. During observation on 12/11/2025 at 9:23 AM, the nursing staff posting was dated 12/10/2025. At 9:25 AM, the Administrator confirmed the posting was for 12/10/2025 and stated that it should be updated first thing at the start of the shift when staff arrive.
Facility Assessment Missing Staffing Requirements Based on Average Census
Penalty
Summary
The facility failed to ensure its Facility Assessment included staffing requirements based on the average census of the facility. The Facility Assessment dated 2025 lacked documented evidence for adequate staffing levels related to the average census, and the staffing plans did not include an average census or staffing levels per shift to show how the facility would meet resident care needs. During interview on 12/11/2025 at 8:26 AM, the Administrator confirmed the Facility Assessment staffing plans did not include an average census and staffing levels per shift. The facility policy titled Facility Assessment, originally dated 10/2017, stated staffing decisions were determined at the facility level to ensure there were enough staff with appropriate competencies and skill sets necessary to care for residents' needs as identified through resident assessments and plans of care.
Failure to Thoroughly Investigate Allegation of Neglect Following Resident Death
Penalty
Summary
The facility failed to thoroughly investigate an allegation of neglect involving one resident who was found deceased in their room. The resident, admitted with a history of vertebral fractures and orthopedic aftercare, was last reported to have had vital signs taken by a CNA at approximately 6:00 AM. The resident was later found unresponsive, cold to touch, and exhibiting signs of rigor mortis around 7:10 AM, with EMS pronouncing the resident deceased after arrival. There was a discrepancy between the reported time of the last vital signs and the timeline of the resident's death. The facility's investigation into the incident was incomplete. Documentation provided included initial and final incident reports, vital sign flowsheets, nursing progress notes, and statements from some staff. However, the investigation lacked interviews with the resident's roommate, other residents cared for by the accused CNA, and staff from other shifts who had contact with the resident or the accused CNA. The Administrator and ADON confirmed that not all relevant staff or residents were interviewed, and the facility's own policy requiring comprehensive interviews and documentation during investigations was not followed.
Failure to Administer Tube Feeding per Complete Physician Order and Accurate Documentation
Penalty
Summary
The facility failed to ensure that tube feeding was administered to a resident according to physician orders and that a complete physician order was in place prior to administration. One resident with a diagnosis of dysphagia following cerebral infarction had a tube feeding order that, prior to being updated, did not specify the type of formula to be administered. Staff confirmed that the resident had been receiving tube feeding since admission, but the order was incomplete until it was updated. The interim Director of Nursing acknowledged that the previous order lacked essential details, such as the formula type, which is necessary for safe administration. Additionally, on one occasion, a Licensed Practical Nurse documented that the resident received tube feeding when, in fact, the feeding was not administered as ordered. The nurse prepared the feeding and documented its completion before actually providing it, then failed to return to administer the feeding after the resident requested a short delay. The nurse did not document the resident's refusal or the missed administration. The facility's policy and the nurse's job description both require accurate documentation and adherence to physician orders for tube feeding, which were not followed in this instance.
Incomplete Documentation of Resident Bathing and Care Refusals
Penalty
Summary
A deficiency was identified when a clinical record review revealed that documentation for a resident was incomplete. The resident, who had multiple rib fractures and mild protein-calorie malnutrition, was admitted to the facility and was scheduled to receive showers twice weekly. Documentation showed that the resident received showers and a full-body bath on specific dates, but there were blank entries for several PM shifts. Additionally, after the resident tested positive for Covid-19, the facility limited the use of communal showers and was expected to offer bed baths instead. However, there was no documentation in the clinical record indicating that a shower or bed bath was provided, nor any record of refusals or alternative care offered during a specific period. Interviews with facility staff, including a CNA, the ADON, and the Administrator, confirmed that the expectation was for all care provided, refusals, and alternative offers to be documented in the electronic medical record. The Administrator acknowledged that the clinical record lacked documentation of bathing care or refusals for the resident during the period in question. Facility policy required that ADL support and resident performance be documented electronically, but this was not done for the identified dates.
Failure to Inform Residents of Leave Policies
Penalty
Summary
The facility failed to inform residents both orally and in writing about the rules related to leaving the premises on pass prior to or upon admission. This deficiency was identified during interviews and document reviews, revealing that residents were not made aware of the process for going out on pass until they requested to do so. Specifically, Resident #3, who was admitted with a primary diagnosis of type two diabetes mellitus without complications, expressed feeling confined and uninformed about the ability to leave the facility. Interviews with staff, including a CNA and an LPN, confirmed that a physician's order was required for residents to leave on pass, but this information was not communicated to residents at the time of admission. The Director of Nursing acknowledged that residents were not informed of the rules and processes for going out on pass during admission, which is a resident right that should have been included in the admission packet. The facility's admission packet lacked documentation of these rules, and the facility's policy on Resident Rights and Responsibilities stated that residents should receive a written copy of their rights and the facility's rules upon admission. The policy on Out on Pass or Leave of Absence required a physician's order and interdisciplinary team decision for a resident to leave, but this was not communicated to residents as part of their admission process.
Deficiencies in Ice Machine Cleanliness and Food Storage
Penalty
Summary
The facility failed to maintain cleanliness and proper food storage practices, as observed during a survey. The ice machine in the kitchen was found to have black buildup on the plastic visor above the ice, which was confirmed by the Dietary Manager (DM) who stated that the machine was cleaned every three months, but any visible buildup should have been addressed by the staff. Additionally, refrigerated foods were not properly covered, labeled, and dated. Specifically, three cups of fruit cocktail were found uncovered in the trayline refrigerator. The DM confirmed that the expectation was for all food stored in the refrigerator to be covered and labeled with the date.
Failure to Inform Resident of Menu Options
Penalty
Summary
The facility failed to ensure that a resident was informed in advance of menu options and alternative meal choices, which is a violation of the resident's right to self-determination. Resident #44, who is bedbound and has limited mobility, was not made aware of the daily menu or alternative meal options. The resident frequently had to send meal trays back to the kitchen and request a bowl of soup, as they were not informed of the menu in advance and could not see the menu posted on the wall due to their condition. The menu in the resident's room was outdated, and staff did not notify the resident of the menu items each day. The Dietary Manager confirmed that there was no process in place to ensure that residents with limited mobility could see the menu, and the Director of Nursing acknowledged that menus should be up to date and accessible to bedbound residents. A Certified Nursing Assistant also confirmed that the menu in the resident's room was from the previous week and not visible from the resident's bed. The facility's policy on Resident Rights states that residents have the right to make choices about aspects of their life in the facility, which was not upheld in this case.
Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an incident of resident-to-resident abuse to the State Agency (SA) within the required timeframes. Resident #23, who was admitted with severe vascular dementia and unspecified mood disorder, was involved in an incident with Resident #57, who has unspecified dementia with agitation. On 10/05/2024, Resident #57 was observed slamming their wheelchair into Resident #23's legs. However, the Facility Reported Incident (FRI) was not submitted to the SA until 10/07/2024, exceeding the 24-hour reporting requirement for abuse without serious bodily harm. The facility's policy, revised in 10/2022, mandates that allegations of abuse be reported within the applicable timeframes, which was not adhered to in this case.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, leading to potential adverse health outcomes. Resident #71, who was on anticoagulant medication, exhibited symptoms of gastrointestinal bleeding and had low hemoglobin and hematocrit levels. Despite these significant clinical changes, the resident's care plan did not include documentation of the anticoagulant use or the symptoms of gastrointestinal bleeding. Additionally, a stool sample collected for testing was mishandled, and the results were not tracked, leaving staff unaware of the resident's condition. The Director of Nursing confirmed the absence of a care plan addressing these issues, which was contrary to the facility's policy requiring updates to care plans following a change in medical condition. Resident #134, diagnosed with hypoxemia, was receiving oxygen therapy via a nasal cannula. However, the resident's clinical record lacked a care plan for the diagnosis of hypoxemia and the administration of oxygen. The Director of Nursing acknowledged this oversight, which was inconsistent with the facility's policy mandating the development of person-centered care plans with measurable objectives to meet residents' medical needs. These deficiencies highlight a failure in the facility's care planning process, potentially compromising the residents' health and safety.
Failure to Monitor Lab Results and Communicate Bleeding Symptoms
Penalty
Summary
The facility failed to ensure timely monitoring and communication of laboratory results for a resident on anticoagulant therapy, which could have led to severe adverse health outcomes. Resident #71, who was on apixaban for atrial fibrillation, exhibited signs of gastrointestinal bleeding, such as blood-streaked stool, which was reported by a CNA and observed by a licensed nurse. However, the resident's care plan did not document the use of apixaban or the symptoms of gastrointestinal bleeding, and the fecal occult blood test results were not included in the clinical record. Additionally, the LPN caring for Resident #71 was unaware of the resident's bleeding symptoms or any concerns with lab values. The DON confirmed that the resident's care plan lacked documentation for the blood thinner and the bleeding concern. The stool sample collected was sent to the lab in the wrong container, and a new sample was not sent, resulting in a lack of follow-up on the test results. The facility's policy required updates to the care plan after a change in medical condition, but this was not adhered to in this case.
Failure to Obtain Physician's Order for Oxygen Administration
Penalty
Summary
The facility failed to obtain a physician's order for the administration of oxygen for a resident diagnosed with hypoxemia. The resident was admitted to the facility and was observed receiving oxygen via a nasal cannula from an oxygen concentrator set at two liters-per-minute. However, the clinical record for the resident lacked documented evidence of a physician's order for this oxygen therapy. The resident expressed uncertainty about the need for oxygen, having not used it prior to admission. The Director of Nursing confirmed that the resident had been receiving oxygen since admission without a physician's order, which was against the facility's policy that required oxygen therapy to be administered as ordered by a physician or as an emergency measure until an order could be obtained. The deficiency was identified through clinical record review, observation, interview, and document review, highlighting a lapse in following the facility's policy on oxygen administration.
Unsecured Medication Cart Found Unattended
Penalty
Summary
The facility failed to ensure that medications were secured in a medication cart, which could have facilitated unauthorized access. During an observation, a medication cart located outside the nurse's station was found to be unlocked and unattended while a resident and visitors were present in the hallway. The Director of Nursing (DON) confirmed the cart was unlocked and acknowledged that the expectation was for medication carts to remain locked when unattended. The facility's policy on the storage of medication, dated 2007, specifies that only licensed nurses and those lawfully authorized to administer medications are allowed access to medication carts. It also states that medication rooms, cabinets, and supplies should remain locked when not in use or attended by authorized personnel.
Failure to Follow Resident's Diet Order
Penalty
Summary
The facility failed to adhere to a resident's prescribed diet order, resulting in a deficiency. Resident #134, who was admitted with acute kidney failure and chronic kidney disease, was observed receiving meals that did not align with the physician's order. The resident's diet was ordered as a regular diet with regular texture and thin liquid consistency, but the resident was served pureed and mechanically altered foods. The resident expressed confusion and dissatisfaction with the texture of the meals, as they had no swallowing issues and possessed their own teeth. The Dietary Supervisor admitted to a lack of understanding regarding the GI soft diet and incorrectly assumed it to be a mechanically altered diet after searching online. This misunderstanding was not communicated with the nursing staff for clarification. The Director of Nursing confirmed that a GI diet is not mechanically altered and acknowledged that the diet order should have been clarified. Additionally, it was revealed that the facility lacked a policy related to following diet orders, contributing to the oversight.
Failure to Conduct Legionella Testing as per Policy
Penalty
Summary
The facility failed to adhere to its water management policy by not conducting Legionella testing on a five-year basis. During an interview, the Director of Environmental Services acknowledged that the maintenance department was responsible for the water management program but admitted that the facility did not have results of Legionella testing and was unaware of when the last testing occurred. Furthermore, there was no plan in place to conduct future testing. This practice was not in compliance with the facility's policy, which required random water samples to be collected and submitted for Legionella testing every five years to a certified testing facility, with additional testing as needed based on results.
Failure to Complete Annual Elder Abuse Training
Penalty
Summary
The facility failed to ensure that annual elder abuse training was completed for one of its employees, a Registered Nurse hired in December 2015. The personnel record for this employee showed that elder abuse training was last completed in August 2023, but there was no documented evidence of the required annual training being completed in 2024. During an interview, the Human Resources Representative confirmed that all staff were required to complete elder abuse training upon hire and annually thereafter, and acknowledged the absence of the 2024 training documentation for this employee. The facility's policy on abuse prevention and prohibition, revised in May 2023, mandates training for new and existing nursing staff on preventing, identifying, recognizing, and reporting abuse.
Failure to Prevent Pressure Ulcer Development
Penalty
Summary
The facility failed to provide adequate care to prevent Moisture Associated Skin Damage (MASD) and a pressure injury for a resident who was admitted with a displaced intertrochanteric fracture of the left femur and type two diabetes mellitus with a foot ulcer. Initially, the resident's daily skilled note documented no active skin conditions. However, a few days later, a CNA noticed redness and an open area on the resident's coccyx, which was confirmed by a licensed nurse skin evaluation. Despite having a physician's order to apply barrier cream and assist in turning and repositioning every shift, the resident developed MASD and a pressure injury while in the facility. The facility's policy stated that residents who entered without a pressure injury should not develop one unless it was unavoidable due to their clinical condition. The Wound Nurse and the Director of Nursing confirmed that the resident did not have a pressure injury upon admission and that the MASD and pressure injury were acquired at the facility. The deficiency was identified through clinical record review, interviews, and document review, indicating a failure in the facility's skin and wound monitoring and management practices.
Failure to Address Tripping Hazard in Courtyard
Penalty
Summary
The facility failed to address a known tripping hazard in the courtyard, which resulted in a resident tripping over an irrigation sprinkler head and sustaining a fracture to the right elbow and patella. The incident was documented in the Facility Reported Incident (FRI) #NV00071929, but the final report did not include corrective measures to prevent future occurrences of tripping caused by the sprinkler heads. Observations confirmed that five sprinkler heads were raised above ground level, posing a potential tripping hazard. Interviews with facility staff, including the Director of Environmental Services, Director of Nursing (DON), and Operations Manager, revealed a lack of communication and awareness regarding the tripping hazard. The Director of Environmental Services was unaware of the incident, and the DON could not confirm if the information had been conveyed to Maintenance. The Operations Manager also confirmed that the FRI Final Report lacked corrective action to address the hazard. The facility's Fall Management System policy, revised in December 2023, stated that resident environments should be free from hazards, but this was not adhered to in this case.
Failure to Update Care Plan for Indwelling Catheter
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident with an indwelling catheter. The resident, who was admitted with chronic kidney disease and benign prostatic hyperplasia, had a physician's order for indwelling catheter care every shift and to change the catheter every 30 days. Despite these orders, the resident's care plan did not include any documentation related to the indwelling catheter or the necessary catheter care. The Director of Nursing (DON) confirmed that the care plan lacked updates to reflect the catheter placement and care requirements. The facility's policy required the interdisciplinary team to develop a comprehensive person-centered care plan that included measurable objectives and timeframes to meet the resident's needs. However, the care plan for this resident was not updated to include the catheter care, which was a responsibility of the DON and the Social Worker.
Dishwasher Malfunction and Expired Food Items
Penalty
Summary
The facility failed to ensure that a high-temperature dishwasher was operating correctly and that expired food items were discarded. During an initial kitchen tour, the dishwasher was observed making a noise, and its final rinse cycle was recorded at 178 degrees Fahrenheit, below the required 180 degrees Fahrenheit. A Cook mentioned that the lower dishwasher sprayers were not working correctly and would get stuck together, but was unsure if a work order had been submitted. The Dietary Supervisor confirmed that no work order had been submitted and acknowledged that the dishwasher was not sanitizing dishes properly due to the malfunctioning sprayers and insufficient rinse temperature. Additionally, expired food items were found in the kitchen. A container of homemade macaroni salad in the reach-in refrigerator was labeled with a prepared date that exceeded the facility's policy of using refrigerated leftovers within 48 hours. In the dry storage room, 12 containers of grits were found with a use-by date that had passed. The Dietary Supervisor confirmed that kitchen staff were responsible for discarding expired foods and acknowledged that the macaroni salad and grits should have been discarded according to the facility's policies.
Failure to Administer Pneumococcal and Influenza Vaccines
Penalty
Summary
The facility failed to ensure that two residents who requested a pneumococcal vaccine were administered the vaccine. Resident #308, who had diagnoses including orthopedic aftercare following surgical amputation, pulmonary hypertension, and heart failure, had a signed consent form for the pneumococcal vaccine, but the vaccine was not administered. Similarly, Resident #55, with a diagnosis of nontraumatic ischemic infarction of the right lower leg, also had a signed consent form for the pneumococcal vaccine, but the vaccine was not administered. The Infection Preventionist confirmed that both residents had signed consents and requested the vaccine, but it was not given to them. The facility's policy stated that pneumococcal immunizations should be offered and administered to eligible residents after obtaining consent, but this was not followed in these cases. Additionally, the facility failed to screen and offer the influenza vaccine to 25 out of 82 residents and did not administer the vaccine to 12 residents who had requested it. The facility received the influenza vaccine from the pharmacy, but the Infection Preventionist confirmed that not all residents were screened or offered the vaccine, and some who requested it did not receive it. The Administrator was unaware of the number of residents who had not been screened or who had requested but not received the influenza vaccine. The facility's policy required that all residents be screened and offered the influenza vaccine annually during flu season, but this was not adhered to, resulting in a significant portion of the resident population not being vaccinated as required.
Failure to Maintain Resident Health Information Privacy
Penalty
Summary
The facility failed to ensure the privacy of resident health information for three residents whose names were visible on an unattended computer screen. The computer, located on top of a treatment cart outside of room five, was logged into the electronic health record (EHR) and displayed the names of three residents under the wounds tab. This occurred while the computer was facing the hallway and unattended, allowing two visitors to walk by and potentially view the resident information. The residents involved had various medical conditions, including acute kidney failure, type two diabetes mellitus, metabolic encephalopathy, and respiratory failure. An LPN returned to the cart and acknowledged forgetting to lock the screen when walking away, which is against the facility's policy. The Director of Nursing (DON) confirmed that staff are expected to log out or lock the screen when leaving a computer unattended to maintain resident privacy. The facility's policy on the use and disclosure of protected health information, revised in March 2016, mandates that such information be used and disclosed in a secure and confidential manner.
Failure to Prevent Resident-to-Resident Abuse and Neglect
Penalty
Summary
The facility failed to prevent resident-to-resident abuse and neglect. In one incident, a resident with schizoaffective disorder and anxiety disorder attempted to hit another resident with cognitive communication deficit and dementia. The altercation was witnessed by staff, and the residents were separated, with one being moved to a different room. The facility's policy on abuse prevention was not effectively implemented to protect the residents from such incidents. In another incident, a resident with a history of traumatic subdural hemorrhage and memory deficit was found soaked in urine with the call light unplugged. The resident reported that staff had initially responded to the call light but eventually stopped coming into the room. A CNA discovered the resident in the same position as the previous day, indicating neglect. The facility's policy on abuse and neglect prevention was not followed, leading to the resident's needs being unmet and the staff member responsible being terminated.
Late Submission of FRI Final Report
Penalty
Summary
The facility failed to submit a Facility Reported Incident (FRI) final report to the State Survey Agency within the required five-day timeframe for one of seven FRIs investigated. Specifically, FRI# NV00069177, which involved an allegation that a Certified Nursing Assistant had force-fed a resident, was initially reported to the State on 08/09/23. However, the final investigation report was not submitted until 08/17/23, three days past the required deadline. The Director of Nursing (DON) confirmed responsibility for submitting the reports and attributed the delay to a miscalculation of the dates. The facility's policy, reviewed in 10/2022, mandates adherence to State and Federal reporting timeframes for all reports of resident abuse.
Failure to Transmit MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) 3.0 assessments were transmitted timely for five sampled residents. Resident #8, diagnosed with cerebral palsy, had a quarterly MDS assessment with a completion date of 10/16/23, which should have been transmitted by 10/23/23 but had not been transmitted by 11/02/23. Resident #9, diagnosed with dementia, had a quarterly MDS assessment completed on 10/10/23, which should have been transmitted by 10/17/23 but was transmitted 15 days late on 11/01/23. Resident #11, diagnosed with type II diabetes mellitus with hyperglycemia, had a quarterly MDS assessment completed on 10/21/23, which should have been transmitted by 10/28/23 but had not been transmitted by 11/02/23. Resident #41, diagnosed with type II diabetes mellitus with diabetic neuropathy, had a quarterly MDS assessment completed on 10/11/23, which should have been transmitted by 10/18/23 but had not been transmitted by 11/02/23. Resident #46, diagnosed with type II diabetes mellitus with hyperglycemia, had a quarterly MDS assessment completed on 10/11/23, which should have been transmitted by 10/18/23 but was transmitted 14 days late on 11/01/23. The MDS Coordinator confirmed the delays in transmission for all five residents and acknowledged that the facility's policy, which follows the Resident Assessment Instrument (RAI) Manual timelines, was not adhered to. The RAI Manual specifies that quarterly assessments must be transmitted within seven days after the completion of the assessment. Despite the facility's policy being in place, the assessments for the sampled residents were not transmitted within the required timeframe, leading to the identified deficiency.
Deficiencies in Care Planning and Communication
Penalty
Summary
The facility failed to ensure that care planned interventions related to cognitive functioning and communication were completed and person-centered for a resident with type II diabetes mellitus. The care plan lacked specific details and interventions for the resident's impaired cognitive function and limited English proficiency. Staff members, including a Hospitality Aide, LPN, and CNA, did not use the designated language line for communication, relying instead on family members and non-clinical staff, which could lead to inaccurate assessments. The Director of Nursing confirmed the care plan was incomplete and not person-centered. Another resident with major depressive disorder and schizoaffective disorder was prescribed Seroquel, but the care plan did not include specific details about the medication, behaviors to monitor, or the diagnosis associated with its use. The clinical record also lacked documented evidence of an assessment to determine the resident's change of condition and new diagnosis requiring psychotropic medication. The Director of Nursing confirmed the care plan was not medication-specific and missing necessary details to make it person-centered. Additionally, the facility failed to develop care plans related to the use of bedrails for a resident with cirrhosis of the liver and mobility issues, and for two residents following incidents of abuse and neglect. One resident's care plan did not include documentation of employee-to-resident neglect, while another resident's care plan lacked details of a resident-to-resident altercation and any changes in services or care to prevent further incidents. The Director of Nursing confirmed these deficiencies in the care plans, which should have included specific interventions and outcomes to ensure proper care and prevent further occurrences.
Medication Administration and Assessment Deficiencies
Penalty
Summary
The facility failed to ensure professional standards of practice were followed during medication preparation and administration for two residents. One resident, who was on pain medication therapy, received oxycodone without the LPN assessing the location and severity of the pain prior to administration. The LPN confirmed this oversight and acknowledged that the pain level should have been assessed before administering the medication. The Director of Nursing (DON) also confirmed that the pain level was supposed to be assessed prior to administration, as per the facility's policy on pain management. Another resident, who had diabetes mellitus, received insulin without the LPN scrubbing the rubber stopper with alcohol before applying the needle. The LPN believed the stopper was already sterile and administered the insulin after the resident had eaten breakfast, despite the insulin being ordered to be administered before meals. The DON confirmed that the rubber stopper should have been wiped with alcohol and that insulin should be administered before meals to ensure its effectiveness. Additionally, the facility failed to adhere to professional standards for assessing and diagnosing a resident with schizoaffective disorder. The resident's clinical record lacked documentation of an assessment to determine the need for psychotropic medication. The DON confirmed that an assessment was required prior to the administration of such medication, and the physician admitted to knowing the resident prior to admission but had no documentation of an assessment. The facility's policy on psychotropic drug use required a documented clinical rationale for administering medication based on an assessment of the resident's condition.
Failure to Provide Translation Services for Non-English Speaking Resident
Penalty
Summary
The facility failed to offer a non-English speaking resident a communication device and/or provide translation services. Resident #26, who had limited English proficiency and a diagnosis of type II diabetes mellitus, was admitted and readmitted to the facility. Despite the resident's Comprehensive Care Plan documenting the need for a language line, staff members, including a Hospitality Aide, a Certified Nursing Assistant, and a Licensed Practical Nurse, did not use the language line to communicate with the resident. Instead, they relied on hand gestures, short sentences, and assistance from family members who visited infrequently. The Director of Nursing confirmed that translation services were supposed to be used, especially during assessments, and acknowledged that using family and non-clinical staff for translation could lead to inaccurate assessments. The facility's Language Access Plan (LAP) outlined the requirement to provide equitable and meaningful access to services for individuals with Limited English Proficiency, in accordance with section 1557 of the Affordable Care Act. The LAP specified that staff should be trained to access written translations and oral language assistance services effectively. It also stated that individuals were not required to provide their own interpreters, and the facility should not rely on minors or adult friends and family for interpretation. Despite these guidelines, the facility did not adhere to the LAP, resulting in a failure to provide appropriate communication support for Resident #26.
Failure to Coordinate Care with Hospice Agency
Penalty
Summary
The facility failed to ensure coordinated care with a hospice agency for a resident receiving hospice services. Resident #34, who was admitted with diagnoses including tubulo-interstitial nephritis, quadriplegia, and a history of transient ischemic attack, expressed concerns that the facility did not follow hospice instructions. Despite a physician's order to admit the resident to hospice and a care plan indicating regular visits from hospice staff, there was a lack of documentation in the hospice binder and the electronic health record (EHR) regarding the care provided by hospice aides. The Licensed Social Worker (LSW) and Director of Nursing (DON) confirmed the absence of necessary documentation, which was supposed to be maintained as per the Hospice Services Agreement and facility policy. Interviews with the resident, Certified Nursing Assistant (CNA), Licensed Practical Nurse (LPN), and LSW revealed that hospice aides did not consistently report their visits or document the care provided. The LSW and DON acknowledged that the hospice agency was required to check in with facility staff and document care in the hospice binder, but this was not done. The most recent documentation from hospice in the EHR was dated 10/16/23, indicating a significant gap in record-keeping and communication between the hospice agency and the facility staff.
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What surveyors actually found near you
We read the 162 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Reno
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Advanced Health Care Of Reno | 1.8 mi | ★★★★★ | 12 | 0 |
| Caremeridian Llc, Dba Neurorestorative | 1.8 mi | ★★★★★ | 28 | 0 |
| Northern Nevada State Veterans Home | 2.7 mi | ★★★★★ | 13 | 0 |
| Hearthstone Health And Rehabilitation | 3.8 mi | ★★★★★ | 26 | 0 |
| Alpine Skilled Nursing And Rehabilitation Center | 4.1 mi | ★★★★★ | 16 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.