Below average — CMS composite of the measures below.
The next survey window likely opens around May 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 Baptist Health Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with dysphagia and a puree diet was given an egg salad sandwich after requesting an alternate meal, then choked, became cyanotic, and required the Heimlich maneuver. In addition, bedside meds were left unattended for multiple residents who were not approved to self-administer, including Nystatin powder and OTC diphenhydramine, despite assessments and care plans indicating they could not keep meds at the bedside.
Insufficient staffing left units without adequate coverage when a resident’s call bell was answered only after a delay and staff were found in the break room while one CNA remained on the floor. On another unit, multiple residents were observed with no staff present for several minutes, and a CNA stated they were alone while other staff were off the floor on break and residents were still being prepared for lunch. The DON and RN stated that one CNA alone on the unit was not acceptable, and the DON also stated that having only one LPN on the floor led to late medication administration and showed the unit was not adequately staffed.
Food was not stored, prepared, and served according to professional standards in the kitchen and all nourishment stations. Pureed muffins were stored below raw beef patties, staff did not know the reheating temperature for the food, the dish machine final rinse was below manufacturer specs, the 3-bay sink sanitizer measured 0 ppm instead of the required 200 to 400 ppm, and multiple kitchen and nourishment station surfaces, equipment, floors, walls, and ceilings required cleaning or repair.
Failure to maintain infection prevention and control practices. Staff did not clean hands between resident rooms, did not offer residents hand hygiene before dining, transported dirty linen improperly, placed wound care supplies on an unclean surface and on the floor, and allowed urinary catheter drainage bags to rest on the floor. The Infection Preventionist and Administrator both described expected infection control practices that were not followed.
The facility failed to maintain resident dignity during meals and catheter care. Residents were observed being served plastic utensils instead of metal silverware during lunch, despite the facility’s expectation for appropriate silverware and its policy discouraging routine use of plastic cutlery. In addition, two residents with urinary catheters had drainage bags visible from the hallway and not covered with dignity bags; one resident was cognitively intact and the other had severe cognitive impairment. Staff, including the DON, stated catheter bags should be covered and not visible.
Failure to obtain informed consent for psychotropic medications: Three residents had psychotropic orders without timely or documented consent. One resident had multiple psychotropics with consents obtained after the medications were already ordered, another had no documented psychotropic consent, and a third had psychotropic orders with consents also obtained after the fact. Staff interviews confirmed psychotropic consent was not being completed prior to starting medications.
Housekeeping and maintenance services were ineffective across multiple resident units and service areas. Surveyors observed an open drain and standing water in the kitchen, leaking pipes and standing water in the Boiler Room, heavily soiled locker room surfaces, stained ceiling tiles, unpainted wall repairs, scratched handrails, rusty heat registers, and dust balls on resident room floors.
Missing controlled substance count signatures and delayed narcotic documentation. Review of narcotic count books showed multiple missing signatures on two units, including periods with no signatures for several shifts. During a med pass, an LPN did not immediately sign the narcotic record after giving two narcotic meds. Staff, including the DON, stated the count should be signed each shift and narcotics should be documented when administered.
Unsecured medication storage and incomplete refrigerator temperature logs. A pain-relieving cream was left unattended on top of a med cart, insulin pens were not bagged, loose tablets were found inside a cart, and an inhaler was undated and unlabeled. Treatment carts and a med cart were observed unlocked and unattended, and temperature logs for med room refrigerators were incomplete. Staff interviews confirmed carts should be locked and refrigerator temps documented by the overnight shift.
Food and drinks were not consistently served at appetizing temperatures. In a resident council meeting, all residents said meals were cold by the time they were served, and cognitively intact residents reported that hot food was served cold or sometimes cold. During one meal observation, a resident's lunch items were measured at lukewarm to cool temperatures, and the resident said the food was cold. The DSD and Administrator acknowledged complaints that hot foods were not hot enough.
Unmaintained Exterior Grounds and Landscaping: Surveyors observed weeds growing between the asphalt and building foundation, along with weeds, grape vines, and tree saplings in the landscaping at the facility entrances and in the resident garden sanctuary courtyard. A large tree sapling was also growing over the pad-mounted electrical transformer. The Director of Facilities stated they would address the landscaping overgrowth.
Failure to notify the resident representative before a room change. A resident with vascular dementia, encephalopathy, and severe cognitive impairment was moved to another unit, but the family was not given prior notice or the new room number. Staff interviews confirmed that the transfer occurred before Social Services was aware of it, despite the facility’s usual process of contacting families before room changes.
Failure to report an abuse allegation within the required timeframe and failure to keep resident medications secured. A resident on a puree diet was given an egg salad sandwich by a CNA, began choking, and required the Heimlich maneuver after appearing cyanotic. In separate findings, two residents who were not approved for self-administration had medications at bedside, including Nystatin powder and an OTC sleep aid.
Care plans were not fully developed or followed for three residents. One resident on continuous O2 had no respiratory or oxygen care plan, another resident with significant weight loss had no nutrition/weight-loss care plan, and a third resident’s suprapubic catheter dressing changes were not carried out as planned for multiple days.
Two residents did not receive needed ADL assistance with hygiene and meals. One resident with Alzheimer’s disease was observed with dirty fingernails and unshaven, while the record did not show a bath or shower during the reviewed period and CNA documentation was incomplete. Another resident with dementia was left in bed with an untouched breakfast tray out of reach, despite being awake, wanting to eat, and having care plan directions for out-of-bed meals and supervised eating; staff confirmed breakfast was not offered and the resident was not assisted until later.
A resident with constipation risk did not receive the ordered bowel protocol after several days without a documented BM, and the ordered laxative was not administered. Another resident with a suprapubic catheter had a dressing change order that was not followed for days, the family’s concern was not promptly escalated, and a wound culture was mislabeled, leading to delayed care and empiric antibiotics.
Medication Pass Error Rate Exceeded Allowed Threshold: An LPN administered several scheduled meds to a resident with dementia, anemia, HTN, and atrial fibrillation more than 2 hours late, resulting in an observed med error rate of 12.5% and exceeding the required threshold. Staff interviews showed inconsistent expectations and communication about notifying the nurse manager, NP, MD, and DON when meds were late or missed.
Unsafe meal service and unattended bedside medications
Penalty
Summary
The facility failed to keep the environment free from accident hazards when Resident #17, who had dysphagia, moderate cognitive impairment, and an order for a puree texture diet with thin liquids, was given an egg salad sandwich after requesting an alternate meal. The resident’s care plan included puree textures, and the physician’s order remained puree texture diet, thin consistency related to dysphagia. During the meal, the resident began choking in the dining room, could not speak, pointed to their throat, appeared cyanotic, and the nurse performed the Heimlich maneuver until a large piece of egg salad sandwich was expelled. Resident #17’s choking episode occurred after Certified Nurse Aide #5 provided the sandwich and stated that a nurse had said it was okay when asked if the resident could have it. The incident report documented that the resident was eating in the dining room when choking began and that the Heimlich maneuver was performed with successful removal of food. The resident’s record also showed the event was investigated as a care plan violation. The facility also left medications unattended at the bedside for multiple residents who were not approved to self-administer. Resident #80 had two bottles of Nystatin powder on the shelf next to the bed throughout the survey, despite a self-medication assessment showing the resident was not approved to self-administer or keep medications at bedside. Resident #162 had a half-full bottle of diphenhydramine nighttime sleep aid on the overbed table; the resident stated the spouse brought it in and that they took it when unable to sleep. The resident’s assessment documented the resident was not approved for self-administration and could not keep medications at the bedside. Similar bedside medication observations were made for Resident #151 and Resident #161 during the survey period.
Insufficient staffing left units without adequate coverage
Penalty
Summary
The facility failed to provide sufficient nursing staff on a 24-hour basis to meet resident care needs and to ensure a licensed nurse was in charge on each shift. On 06/09/2026, an observation on Unit H2 showed Resident #87 using a call bell at 11:04 AM, and LPN #5 answered at 11:07 AM before looking for an available CNA to assist the resident. At that time, two CNAs and one LPN were in the break room across the hall from the resident’s room. During an interview that same day, LPN #5 stated that staff in the break area were on break and explained that there were four CNAs and two LPNs on the unit for the shift, with one CNA and one LPN off the floor on break and two CNAs and one LPN in the staff breakroom, leaving one CNA on the floor. On 06/11/2026 at 11:45 AM, an observation on Unit H1 found multiple residents in the common area with no staff observed on the unit until 11:52 AM. CNA #9 stated during interview that they were alone on the unit while one other CNA and one LPN were both off the floor on break, and that they were still getting residents up for lunch with no one supervising the common area. CNA #9 also stated there had been difficulty getting everyone up before lunch because of increased residents needing two-person assistance. The DON stated that one CNA alone on the unit during the day shift was not acceptable, and later stated that late medication administration due to only one LPN on the floor for the shift was not acceptable and indicated the unit was not adequately staffed. RN #1 also stated it was not acceptable for one CNA to be on the unit with all other staff on break.
Food Storage, Sanitizing, and Kitchen Cleanliness Deficiencies
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards in the main kitchen and 6 of 6 nourishment stations. During observation, pureed breakfast muffins were stored below raw beef patties in the walk-in refrigerator. The Director of Dining Services stated the pureed muffins were fully cooked but would be reheated before serving, and [NAME] #1 did not know the temperature required to reheat the food. The automatic dishwashing machine was observed with a final rinse temperature of 120 degrees Fahrenheit at zero pounds per square inch of water pressure, although the machine data plate stated the final rinse should be 180 degrees Fahrenheit at 15 to 25 pounds per square inch. The quaternary ammonium compound in the 3-bay sink sanitizing rinse measured zero parts per million, while the label directions required 200 to 400 parts per million. Kitchen coving tiles and the floor by the service entrance were cracked and/or broken, the bottom cover was missing from the stove exposing electronic and control mechanisms, and multiple kitchen items and surfaces required cleaning, including equipment, floors, walls, ceilings, and the food service office. Six of six nourishment station refrigerators, sinks, floors, and/or cabinetry also required cleaning.
Failure to Maintain Infection Prevention and Control Practices
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program in accordance with professional standards of practice. During observations, staff did not perform hand hygiene between resident rooms, including a CNA who entered three rooms to deliver meal trays without cleaning hands between rooms. At a dining observation, staff did not offer to sanitize or clean residents’ hands before dining, and the posted enhanced barrier precautions sign stated that everyone was to clean hands before entering and when leaving the room. Additional observations showed indwelling urinary catheter drainage bags resting on the floor on multiple occasions. A CNA was observed transporting a dirty linen bag that was open, with an incontinence garment and gloves falling out, and stated the bag had been brought from another room. During wound care, an LPN placed dressing change supplies on an overbed table without cleansing the surface or placing a drape, and another LPN placed dressing supplies on the floor. The Infection Preventionist stated catheter drainage bags should not touch the floor, dirty linen and garbage bags should not be transported from one resident’s room to another, and dressing change supplies should be placed on a clean surface with a drape.
Failure to Maintain Resident Dignity During Meals and Catheter Care
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect during dining and while managing urinary catheter drainage bags. During lunch observations on 06/08/2026, residents on the Homeward Bound unit were served plastic spoons with metal fork and knife, and residents on the H-1 unit were served a plastic bag containing a plastic knife, spoon, and fork instead of metal silverware. The facility policy stated that dignity in dining included avoiding day-to-day use of plastic cutlery and paper/plastic dishware, and the Director of Dining Services and Administrator both stated that plastic utensils were not expected during meals and were not appropriate for dining. Resident #65 had diagnoses including type 2 diabetes mellitus, chronic obstructive pulmonary disease, and obstructive and reflux uropathy. The resident’s MDS documented that the resident was cognitively intact and able to understand and be understood. During observations on 06/08/2026, 06/09/2026, 06/10/2026, and 06/12/2026, Resident #65’s urinary catheter drainage bag was visible from the door and not covered with a dignity bag. When interviewed, Resident #65 stated they were not aware the drainage bag should be covered and did not remember being offered a cover. Resident #201 had diagnoses including dementia, chronic kidney disease, and urinary tract infection. The resident’s MDS documented severe cognitive impairment, though the resident could usually be understood and usually understand others. During observations on 06/08/2026, 06/09/2026, 06/10/2026, 06/12/2026, and 06/15/2026, Resident #201’s urinary catheter drainage bag was visible from the door and not covered with a dignity bag. Staff interviews confirmed that catheter drainage bags should be covered, including a CNA, an LPN, and the DON, who stated the bags should not be visible from the hallway and should be covered.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents were informed in advance of the risks and benefits of proposed psychotropic treatment and given the opportunity to choose the option preferred by the physician or other practitioner for three of five residents reviewed. Resident #12 had diagnoses including bipolar disorder, anxiety disorder, and an infection related to an indwelling urethral catheter. The MDS documented that the resident could usually be understood, could understand others, and was mildly cognitively impaired. Provider orders showed multiple psychotropic medications, including doxepin, quetiapine, paroxetine, divalproex sodium, and lithium carbonate. Psychotropic medication consents were requested on 06/10/2026 and 06/11/2026 and received by the facility on 06/12/2026; the consents were signed and dated 06/11/2026. Resident #19 had provider orders for mirtazapine, prazosin, Seroquel, and sertraline, but there was no documented evidence of psychotropic medication consent. Resident #87 had diagnoses including major depressive disorder, recurrent, chronic respiratory failure with hypoxia, and dependence on supplemental oxygen. The MDS documented that the resident could be understood, could understand others, and was mildly cognitively impaired. Provider orders included escitalopram 10 mg and 20 mg, trazodone, and Klonopin for anxiety for 14 days. Psychotropic medication consents were requested on 06/10/2026 and 06/11/2026 and received by the facility on 06/12/2026; the consents were signed and dated 06/11/2026. During interviews, an LPN stated she had never been made aware until the day before that psychotropic consents needed to be obtained, the Medical Director stated consent was required prior to starting or changing psychotropic medication, and the DON stated psychotropic medication consents were not being completed prior to 06/11/2026.
Housekeeping and Maintenance Deficiencies in Resident and Service Areas
Penalty
Summary
The facility failed to provide effective housekeeping and maintenance services on six resident units and in service areas, with observations showing floors, walls, ceilings, dining tables, and plumbing were not clean or maintained. During surveyor observations, the main kitchen had an open drain and standing water under the pre-rinse sink, and the pre-rinse sink was plumbed to a sump pump system in the Boiler Room. The S unit Boiler Room had leaking pipes with standing water on the floor, trash on the floor, and a sump pump system with an open wastewater collection tub. Additional observations showed the dietary employee locker room floors, walls, doors, and lockers were heavily soiled, and the walls below the sinks in the men's room had unfinished and unsealed repair work. Other areas had dirt, grime, food particles, or black build-up on service area door thresholds, undersides of dining room tables, and ceiling vents. Ceiling tiles were stained in the H-1 unit nurse station and throughout the S-2 unit, where corridor walls also had small holes, scratch marks, unpainted patched repairs, scratched handrails, and rusty heat registers in resident rooms. In the N unit, walls and doors were scraped and patched repairs were not painted, and floors in rooms 2269 and 3369 were covered with dust balls.
Missing Controlled Substance Count Signatures and Delayed Narcotic Documentation
Penalty
Summary
The facility failed to ensure drug records were in order for controlled substances. During review of narcotic shift-to-shift count books, one unit had multiple missing signatures with no signatures for any shift from 06/08/2026 to 06/10/2026, and another unit had multiple missing signatures between 06/02/2026 and 06/10/2026. The facility policies stated that controlled substances were to be counted and signed by two nurses at the beginning and end of each shift, and that each narcotic dose removed from the package was to be documented with the date, time, dose, balance remaining, and name/title. During an observed medication pass, an LPN did not immediately sign the narcotic record after administering two narcotic medications. Staff interviews confirmed that the narcotic books should be signed every shift and that narcotic medications should be documented when given. The DON stated the count should be done and signed every time the narcotic keys were exchanged, and the books should be signed with every medication administration at that time.
Unsecured medication storage and incomplete refrigerator temperature logs
Penalty
Summary
Drugs and biologicals were not consistently stored in locked compartments under proper temperature controls. During observations, a pain-relieving cream was left unattended on top of a medication cart on H-1, insulin pens were not in bags, and five tablets were loose inside the medication cart. An inhaler on a medication cart on H-2 was observed to be undated and unlabeled. Treatment carts on H-3 and a medication cart on H-1 were observed unlocked and unattended during multiple observations, including while an LPN was in a resident's room and could not see the medication cart. Medication refrigerator temperature logs were incomplete in the medication rooms on H-1 and H-3. The facility policy titled Storage of Medications stated that drugs and biologicals were to be stored in locked compartments under proper temperature, light, and humidity controls, and nurses were responsible for maintaining medication storage and preparation areas in a clean, safe, and solitary manner. During interviews, an LPN stated refrigerator temperatures were checked by the overnight shift, another LPN stated medication and treatment carts should always be locked when not in use, the DON stated medication and treatment carts should be locked and temperature log sheets should be filled out as directed, and an RN stated the overnight shift should be checking and documenting refrigerator temperatures.
Food and Drinks Served at Unappetizing Temperatures
Penalty
Summary
The facility failed to ensure residents were provided food and drink that was palatable, flavorful, and at an appetizing temperature. During a surveyor-led resident council meeting, five of five residents stated that by the time food was served, it was cold. Resident #80, who had diagnoses of dysphagia, type 2 diabetes mellitus, and unspecified diastolic heart failure and was cognitively intact, stated that cold food was served at room temperature and hot food was served cold. Resident #99, who had diagnoses of Parkinson's Disease without dyskinesia, pulmonary hypertension, and unspecified diastolic heart failure and was cognitively intact, stated that sometimes the food was served cold. During an observation of Resident #110's lunch meal, the entree and side items were measured at lukewarm to cool temperatures, including barbeque chicken thighs at 118.8 degrees Fahrenheit, rice pilaf at 114.3 degrees Fahrenheit, sauteed zucchini at 105.8 degrees Fahrenheit, orange juice at 68.4 degrees Fahrenheit, whole milk at 56.1 degrees Fahrenheit, and a frosted banana cupcake at 67.5 degrees Fahrenheit. After tasting the meal, the entree was described as lukewarm, the orange juice as barely chilled, and the milk as slightly cooler than the orange juice. Resident #110, who had diagnoses of iron deficiency anemia, GERD without esophagitis, and hypertension and was cognitively intact, stated that food was served cold and that hot food or drinks were not received at the facility. The Director of Dining Services and the Administrator both acknowledged resident complaints that hot foods were not hot enough.
Unmaintained Exterior Grounds and Landscaping
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public because the exterior building and grounds were not maintained. During observation on 06/12/2026 at 11:35 AM, surveyors found weeds growing in the gap between the asphalt and the building foundation, and weeds, grape vines, and tree saplings growing in the landscape gardening at the facility entrances and in the resident garden sanctuary courtyard. A large tree sapling was also observed growing over the pad-mounted electrical transformer. During an interview on 06/12/2026 at 12:09 PM, the Director of Facilities stated that they would address the landscaping overgrowth.
Failure to Notify Resident Representative Before Room Change
Penalty
Summary
The facility failed to promptly notify the resident and the resident representative when there was a room change for one resident reviewed. Resident #138 had diagnoses of vascular dementia, encephalopathy, and adjustment disorder, and the Minimum Data Set dated 5/01/2026 documented severe cognitive impairment. A social work progress note dated 4/29/2026 documented that Family Member #1 understood the resident might be moved to another room on the S2 unit if staff determined it was best, and that the family was agreeable to a move if appropriate. However, there was no documented evidence that Family Member #1 was provided prior notice of the actual room change or the resident's new room number before the transfer occurred. A late entry health status note documented that the resident was transferred to S2 on 5/28/2026. During interviews, Social Worker #1 stated that families were normally contacted and informed of the unit and room number before a room change, but in this case the resident was transferred without prior notification and the social worker was unaware of the transfer until after the resident had arrived. The Administrator stated that designated responsible parties should be notified prior to a room change and that no resident should be moved until Social Services had distributed an email confirming the room change and any necessary consent.
Failure to Report Abuse Allegation and Control Resident Medications
Penalty
Summary
The facility failed to ensure that an allegation of sexual abuse involving two residents was reported immediately, or no later than two hours after the allegation was made. The report identifies this as one of four incidents reviewed for abuse in which the required reporting timeframe was not met. The report also describes a choking incident involving a resident with dysphagia, congestive heart failure, moderate cognitive impairment, and a puree diet order. The resident was in the dining room when a CNA gave the resident an egg salad sandwich after asking a nurse if it was okay. The resident began choking, appeared cyanotic, could not speak, and the nurse performed the Heimlich maneuver until a large piece of the sandwich was expelled. The facility’s records documented that the sandwich was given in violation of the resident’s care plan, and the medical director stated that a resident on a puree diet who received an egg salad sandwich and required the Heimlich maneuver had been harmed. The report further documents that two residents had medications at the bedside despite not being approved for self-administration. One resident had two bottles of Nystatin powder on a shelf next to the bed, and another resident had a half-full bottle of diphenhydramine nighttime sleep aid on an overbed table. Both residents had assessments indicating they were not approved to self-administer medications or keep medications at bedside, and staff interviews confirmed that residents not approved for self-administration should not have medications in their rooms.
Care Plans Not Developed or Implemented for Respiratory Needs, Weight Loss, and Catheter Care
Penalty
Summary
Comprehensive care plans were not developed and implemented for three residents reviewed. Resident #87 was admitted with major depressive disorder recurrent, chronic respiratory failure with hypoxia, and dependence on supplemental oxygen. The Minimum Data Set documented that the resident could be understood and understand others and was mildly cognitively impaired. Prescriber orders directed oxygen continuously at 2 liters via nasal cannula every shift for hypoxia, but the comprehensive care plan contained no documented respiratory care area or oxygen therapy plan. Resident #15 was admitted with pulmonary hypertension, protein-calorie malnutrition, and chronic atrial fibrillation. The Minimum Data Set documented that the resident could be understood and understand others and was moderately cognitively impaired. The weight summary documented a 16.25% weight loss over the identified period, and a nutrition/dietary note documented significant weight loss for 6 months, but the comprehensive care plan contained no care plan for actual weight loss or alteration in nutritional status. Resident #12 had a suprapubic urinary catheter care plan that included daily dressing changes, but in 10/2025 the dressing was not changed for multiple days and the plan was not implemented as written.
Failure to Provide Needed ADL Assistance With Hygiene and Meals
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living received needed assistance with eating, personal hygiene, and grooming. The deficiency involved two residents. One resident had diagnoses including type 2 diabetes, Alzheimer’s disease, and hypertension, and was documented as having severe cognitive impairment, requiring substantial assistance with bathing and partial assistance with personal hygiene. The resident was observed sitting in a wheelchair with brown material under all fingernails, and later was again observed with brown material under the bilateral fingernails and was unshaven. The record did not show a bath or shower provided during the reviewed period, and the CNA documentation lacked entries for some dates and did not show documented hygiene care. The second resident had diagnoses including unspecified dementia, heart failure, and spinal stenosis, and was documented as having moderate cognitive impairment and requiring supervision or touching assistance with eating, along with substantial or maximal assistance with toileting hygiene, bathing, dressing, and transfers. The care plan and Kardex directed staff to ensure the resident was out of bed before breakfast and out of bed for supervised intake in the room. On observation, the resident remained awake in bed with a breakfast tray left in the room, not within reach, untouched, and unopened, while the room was dark and the resident was confused about the time of day. The resident stated wanting to eat breakfast. Staff interviews confirmed the breakfast was not offered and the resident did not refuse it. The assigned CNA stated the resident needed assistance with meals, could not reach the tray independently, and required set-up assistance, but breakfast was not delivered and the resident was not offered breakfast or assisted out of bed until lunchtime when the surveyor pointed it out. Another CNA stated the tray was typically left at bedside until the resident got up, and if the resident was still in bed when lunch arrived, the breakfast tray was removed and replaced with lunch. The DON stated staff should observe what was left on the meal tray and that the resident was required to be out of bed for meals.
Missed bowel protocol and delayed suprapubic catheter care
Penalty
Summary
Resident #208 did not receive the facility’s bowel protocol as ordered after more than three days without a documented bowel movement. The resident was admitted with diagnoses including fracture of the left fibula, rhabdomyolysis, and hypertension, and the Minimum Data Set documented intact cognition. The care plan identified the resident as at risk for constipation related to decreased mobility and directed staff to administer bowel medication per physician orders, follow the facility protocol for bowel management, and record bowel movement patterns daily. Certified nurse aide documentation showed a bowel movement on 06/03/2026, followed by multiple entries on 06/04/2026 through 06/07/2026 documenting no bowel movement. The medication administration record included an order for magnesium hydroxide 30 cc by mouth every 24 hours as needed for constipation as per bowel program on day 3 of no bowel movement, to be given on the 3:00 PM to 11:00 PM shift, but it was not marked as administered from 06/03/2026 through 06/08/2026. The resident stated they were having constipation issues and had only been given prune juice, not other medications or treatments. Staff interviews confirmed that the bowel protocol should have been initiated after three days without a bowel movement, and the DON stated the protocol was initiated after three days and magnesium hydroxide was to be administered on the evening shift. Resident #12 had a suprapubic catheter site dressing that was ordered to be changed daily, but the dressing was not changed for 10 days. The resident had diagnoses including bipolar disorder, anxiety disorder, and infection and inflammatory reaction due to an indwelling urethral catheter, and the Minimum Data Set documented that the resident could usually be understood, could understand others, and was mildly cognitively impaired. A nurse practitioner visit documented drainage at the suprapubic catheter site after the family reported blood-tinged drainage and foul-smelling purulent drainage under the dressing. The nurse practitioner ordered a culture and close monitoring with dressing changes as ordered. The facility incident report documented that the suprapubic catheter dressing was changed on 09/29/2025 and then not again until 10/08/2025. It also documented that a family member told RN #2 on 10/06/2025 that they were concerned about the surgical site and dressing, but the dressing was not changed and a provider was not notified. The wound culture was labeled incorrectly by RN #2 as coming from the right thigh, and the culture was considered of questionable integrity; the resident was then treated empirically with an antibiotic. Interviews with RN #1, the nurse practitioner, and the medical director confirmed that the dressing changes were not followed as ordered, the culture was mislabeled, and the delay in notifying the practitioner and obtaining the culture contributed to the delay in care.
Medication Pass Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to ensure a medication error rate of less than 5 percent, and the observed medication error rate was 12.5 percent. The facility policy titled "Administration of Medications - General," revised 09/2024, stated medications were to be administered within one hour before or after the prescribed time. During an observation, an LPN administered medications scheduled for 9:00 AM at 11:30 AM for a resident with dementia, anemia, and essential hypertension. The medications given late were amlodipine 10 mg daily for hypertension, sertraline 12.5 mg daily for depression, ferrous sulfate 325 mg twice daily, and metoprolol tartrate 12.5 mg twice daily for atrial fibrillation. During interview, the LPN stated the medications were late because they had arrived on shift at 8:30 AM and guessed they would notify the nurse manager, but did not know when that would occur. The medical doctor stated they were notified by text or phone if a medication was not available or if a new medication was missed, but not when a medication pass was late, which they considered a nursing issue. The NP stated they had never been notified of a late medication pass or missed medications. The DON stated the expectation was that the provider and family would be notified if a medication was late, refused, or missed. An RN stated they expected to be informed of late, held, or unavailable medications and did not recall being informed of late medications over the last month. The medical director stated they were not always notified of late medications and expected an NP to be notified, with notification to them if there was an adverse outcome or missed medications.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Scotia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ellis Residential & Rehabilitation Center | 2.8 mi | — | 0 | 0 |
| Pathways Nursing And Rehabilitation Center | 3 mi | ★★★★★ | 0 | 0 |
| Schenectady Center For Rehabilitation And Nursing | 3 mi | ★★★★★ | 0 | 0 |
| Glendale Home-schdy Cnty Dept Social Services | 3.8 mi | ★★★★★ | 22 | 0 |
| Kingsway Arms Nursing Center Inc | 4.6 mi | ★★★★★ | 0 | 0 |
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