Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Campbell Hall Rehabilitation Center Inc during CMS and state inspections, most recent first.
A resident with impaired mobility and multiple health conditions developed a Stage 2 pressure ulcer that was not properly assessed or monitored for nearly three weeks, resulting in progression to multiple Stage 3 ulcers. Despite physician orders for wound care and facility policy requiring regular RN assessments, there was no documentation of wound monitoring or care plan revision during this period. The resident was eventually hospitalized for worsening pressure ulcers, and staff interviews confirmed lapses in assessment and documentation.
The facility did not maintain adequate nursing staff on multiple shifts, resulting in missed showers, residents being left in bed, and delays in care. Staff, residents, and family members reported that low staffing levels led to incomplete care and long wait times for assistance, especially on weekends and night shifts. Facility leadership confirmed awareness of these staffing shortages.
Surveyors found that the facility failed to ensure a clean, odor-free, and homelike environment, with strong urine odors, soiled floors, garbage in common areas, and clutter in resident rooms. Staff interviews revealed inconsistent cleaning practices, lack of deep cleaning schedules, and insufficient supervision following the departure of the housekeeping supervisor.
Three residents did not receive consistent assistance with ADLs, including scheduled showers and incontinence care, as required by facility policy. One resident dependent on staff for hygiene received only a fraction of scheduled showers, another was kept in bed and missed both showers and social activities due to staffing decisions, and a third was repeatedly observed in soiled clothing and bedding without evidence of refusals or adequate intervention. Staff interviews revealed that care was often deprioritized due to staffing shortages and lack of supervision, and documentation of refusals or alternative care was inconsistent.
Surveyors found multiple instances of unlabeled, undated, and expired food items in kitchen and pantry areas, including open containers of garlic, cheese, perogies, salad dressing, cookies, yogurt, and beverages. Staff interviews revealed confusion and lack of clarity regarding responsibilities for labeling, dating, and discarding food, with dietary, nursing, and maintenance staff each providing different accounts of their roles.
A resident with cognitive impairment and a history of wandering entered another resident's room and physically assaulted them, causing injury and removal of a medical device. Despite known behavioral risks, staff did not implement or document effective monitoring or interventions to prevent the incident or protect other residents, and care plans were not updated accordingly.
A resident with severe cognitive impairment and a history of wandering was not adequately supervised, allowing them to access an alarmed stairwell door and fall down the stairs in their wheelchair, resulting in serious injuries. Despite known risks and prior incidents, staff did not implement increased supervision or effective interventions to prevent the resident from leaving supervised areas, and the alarmed door could be opened after a delay, contributing to the incident.
Two residents experienced significant unplanned weight loss due to inadequate nutrition care, lack of individualized dietary interventions, and inconsistent monitoring of meal intake. One resident with a pressure ulcer did not receive supplemental protein or have food preferences documented, while another resident's dietary supplement was delayed despite ongoing poor intake. Staff interviews confirmed gaps in documentation and care plan updates, contrary to facility policy.
The facility did not consistently ensure that both outgoing and incoming nurses signed the narcotic count sheets at shift changes, resulting in 37 missing signatures over 104 days. Although narcotic counts were reportedly performed and no medication discrepancies were found, the absence of signatures meant there was no documented proof of reconciliation and transfer of responsibility for controlled drugs.
A resident with epilepsy and dementia missed five doses of Lamictal due to unavailability, and multiple LPNs failed to notify the physician or supervisor as required. The resident subsequently experienced a breakthrough seizure and was hospitalized. The facility's policy for reporting medication administration issues was not followed.
Insufficient nursing staffing: Staffing records showed the facility was repeatedly short of CNA coverage and also short of LPN/RN coverage on multiple shifts, despite staffing levels outlined in the Facility Wide Assessment. Residents reported long waits for call bell response, especially overnight, and said staff were rushed or did not always follow through. An RN said more LPNs and RNs were needed for meds and tx, while the DON and staffing coordinator said callouts and difficulty hiring LPNs/RNs contributed to frequent staffing shortages.
Incomplete CNA Annual In-Service Training: The facility did not provide evidence that 5 of 5 CNAs reviewed completed the required 12 hours of annual in-service training, including dementia education. The Staff Educator reported only partial training hours for each CNA and could not show any dementia in-service, and the DON acknowledged the annual in-service requirement had not been met.
A resident did not receive appropriate care for existing pressure ulcers, and the facility did not take adequate steps to prevent new ulcers from developing, as observed and documented by surveyors.
Unsecured AC casings and damaged wall surfaces were observed in multiple resident rooms. Surveyors found air conditioner casings loose, detached, or removable by a resident, along with unfinished plaster, scuff marks, and a hole in the wall behind beds. The DON/maintenance staff acknowledged the conditions and described the needed repairs and painting.
Incomplete care plans were identified for three residents. One resident with dementia, anxiety, and mood disorder had orders for Buspar and Lexapro but no documented care plan for anxiety or depression. Two residents with severe cognitive impairment had weight loss and therapeutic diets, yet no active nutrition care plans were in place despite diet orders, supplements, swallowing precautions, and recent hospitalization-related changes. Interviews with the DON and LPNs confirmed the missing or inactive care plans.
Care plans were not kept current for three residents. One resident with osteomyelitis, amputation, and PVD had no documented discharge planning in the care plan or progress notes despite stated plans to go home. A resident with vascular dementia, DM2, and repeated falls had a physician order to offload heels in bed, but the skin care plan did not include that intervention. Another resident with Alzheimer’s disease, schizoaffective disorder, and diabetes had a fall with head injury and a later order for neuro-checks, but the fall care plan was not updated to reflect it.
Failure to assess and monitor nutrition and hydration needs: one resident receiving oral intake and tube feedings had no nutritional assessment completed on admission or afterward, despite severe malnutrition, impaired cognition, and repeated observations of dry lips, dry tongue, and limited fluid intake. A second resident with dementia and diabetes had 12.49% weight loss, but the record lacked an active nutrition care plan and new interventions, and staff interviews confirmed the weight loss was known without documented physician follow-up or updated nutrition orders.
No Qualified Dietician on Staff: The facility did not have a licensed dietician on staff full time, part time, or as a consultant for a period of time, leaving Nursing to monitor residents’ nutritional status and any weight loss concerns. The Administrator said the prior dietician had left and a new part-time dietician had not yet started, and the DON later confirmed a dietician had just returned. An NP stated the facility usually relied on the dietician to be informed of resident weight loss.
Meal tickets were not followed for multiple residents. One resident with CVA, HTN, and DM received a lunch tray that did not match the ticket, another resident received skim milk when whole milk was listed, and a resident with vascular dementia and DM was served a magic cup that was not ordered or documented on the meal ticket. Staff interviews confirmed the tray contents should match the ticket and that the extra item was an assembly line error.
A resident with multiple medical conditions was recorded and exposed on social media when a CNA inadvertently live streamed video during care, violating facility policies prohibiting cell phone use and unauthorized recordings. The resident felt violated and humiliated by the incident, which was discovered after a report to the facility.
A resident with a history of anxiety and cognitive intactness reported to staff that they had been raped and was found disoriented on the floor. Although the resident later recanted the allegation, the facility did not report the initial abuse claim to the state health department as required, resulting in a deficiency for failure to immediately report suspected abuse.
A resident who required staff assistance was found disoriented and sitting on the floor in their room after a fall, with the incident initially reported by the resident's relative. Although staff responded and assessed the resident, no incident or accident report was completed or documented as required by facility policy, and no investigation into the cause of the fall was conducted.
Two residents reported ongoing mouse activity in their rooms, but there was no documented evidence that these rooms were inspected or that targeted pest control measures were implemented. Staff interviews revealed inconsistent awareness and documentation of the complaints, and a significant wall hole was observed in one room. The facility's pest control program did not ensure resident rooms were specifically addressed, resulting in a deficiency.
Grievances about missing resident property were not promptly acted on or responded to for two residents. One resident with moderately impaired cognition reported missing shorts and completed a form, but there was no documented grievance, no follow-up, and no replacement. Another resident with severe cognitive impairment had missing sneakers reported by a representative, but the grievance was not routed to Social Work, no investigation was completed, and no reimbursement or outcome was provided.
A facility failed to ensure resident assessments accurately reflected resident status for two residents. One resident was observed with multiple decaying and broken teeth, yet MDS assessments documented no oral or dental issues despite prior dental consults and treatment orders. Another resident, identified as a smoker and care-planned for smoking, was not documented as a tobacco user on the annual MDS; the MDSC stated the resident was missed as a smoker.
A resident with Down Syndrome, severe protein calorie malnutrition, and heart disease had an inaccurate PASARR preadmission screen that did not follow the screen instructions. Facility admissions and SW staff stated the screen should be reviewed for accuracy, but they were not certain it had been completed correctly and acknowledged an error in the screen.
Improper Foley Catheter Positioning and Missed Catheter Care Documentation: A resident with an indwelling Foley catheter, urinary tract-related diagnoses, and severe cognitive impairment was repeatedly observed with catheter tubing routed up over the waistband and the drainage bag on or touching the floor. The facility’s catheter care policy required downhill urine flow, yet CNA catheter care documentation showed multiple omissions, and staff interviews confirmed the bag should not be on the floor and the tubing should not be positioned over the waistband.
Oxygen Therapy Not Provided as Ordered: A resident with chronic respiratory failure and an order for O2 via nasal cannula at 2 L/min was repeatedly observed with the concentrator running at 4 L/min, and no oxygen signage was posted outside the room. An RN stated they were unaware of the ordered rate until reviewing the EMR, and the DON stated O2 should be set as ordered and signage should be on room doors.
Medication storage and labeling were not maintained for a resident whose bedside table held three cups of red Colace capsules, with 31 capsules counted by an RN. The resident said the stool softeners were left at the bedside and that they only took one instead of two to avoid diarrhea. The resident was cognitively intact and needed help with medication administration, while staff stated medications should not be left at the bedside and that nurses were expected to stay with residents during med pass.
Failure to ensure timely dental care for a resident with HF, anxiety, and depression. In-house dental consults repeatedly documented the need for extractions and outside follow-up, including bleeding, pain, and badly broken-down dentition, but there was no documented outside dental treatment after the resident could not be seen at an oral surgeon’s office because the wheelchair would not fit. The resident reported a long wait, a sore mouth, and use of pain meds, and was observed with multiple decaying and broken teeth.
QAPI committee meetings did not include the Medical Director or designee as required. Attendance sheets for multiple monthly meetings showed no signature from the Medical Director or designee, and the Administrator stated the MD did not attend in person, by phone, or by Zoom. The MD stated they sometimes attended and could be reached by phone if needed.
Failure to use PPE during care for two residents on enhanced barrier precautions. A CNA provided dressing and toileting care to one resident without a gown, and an RN provided wound care to another resident without a gown. Both residents had orders and care plans for enhanced barrier precautions, and both staff members acknowledged they should have worn gowns during hands-on care.
A resident with CHF, COPD, and morbid obesity had an electrical bed that was not working, despite orders and a care plan directing head-of-bed elevation. The resident said the bed had been broken for over a year and pillows were used instead, while maintenance later found the bed was unplugged, had no remote, and still would not function after being plugged in; the motor was then found not to be working. Staff said they were unaware the bed was broken and the maintenance log showed an unresolved entry about the bed not moving up and down.
A resident with severe cognitive impairment and dementia was physically struck on the arm by a CNA during care after becoming combative. The CNA had not received abuse prevention training, and the resident's care plan had not been updated. The DON confirmed that staff had not received required abuse or behavioral health education, and both the physician and medical director were not promptly notified of the incident.
A resident with severe cognitive impairment was involved in an incident where a CNA allegedly struck the resident after being hit during care. The facility's investigation was incomplete, lacking review of camera footage, missing required signatures, and failing to notify law enforcement and the medical team in a timely manner, contrary to facility policy.
A resident with severe cognitive impairment and multiple diagnoses was inaccurately assessed on the MDS as having no behaviors, despite CNA and nursing documentation of physically aggressive incidents during the assessment period. The error resulted from conflicting CNA entries and an oversight by the MDS Coordinator, leading to an incomplete and inaccurate resident assessment.
Two residents with significant behavioral and mental health diagnoses did not have comprehensive care plans in place to address their aggressive behaviors, despite repeated documentation of incidents and physician orders for behavioral monitoring. Gaps in communication and documentation review among staff led to the absence of required care plans, contrary to facility policy and regulatory requirements.
Two residents with dementia and behavioral disturbances did not have individualized care plans addressing their aggressive behaviors, despite repeated incidents and physician orders for behavior documentation and intervention. The care plans were not reviewed or revised to include specific interventions, and the DON could not explain the lack of appropriate updates, even after documented incidents of aggression and abuse.
A nurse aide was not provided with required training in abuse prevention and dementia care, as confirmed by missing documentation and staff interviews. The facility lacked evidence of completed in-services, and the staff educator position was vacant, resulting in no recent training for staff.
The facility failed to supervise residents who smoked, despite being a non-smoking facility. A resident with impaired cognition started a fire on the patio by discarding a cigarette butt into dry leaves, with no staff present. The facility's inconsistent smoking policy and lack of safety assessments or supervision resulted in substandard care and immediate jeopardy.
The facility failed to implement comprehensive care plans for several residents, including those with dementia, diabetes, and smoking habits. A resident with Alzheimer's lacked care plans for dementia and diabetes management, while another at risk for pressure ulcers had no preventive care plan. Additionally, a resident with schizophrenia was observed smoking unsupervised without a care plan addressing smoking. Staff interviews revealed lapses in care plan initiation and updates.
The facility failed to supervise residents who smoked, leading to a fire incident, and did not enforce its non-smoking policy. Staff were not adequately trained in fire procedures, and required fire drills were not conducted. The facility also lacked sufficient nursing staff and did not ensure staff received updated COVID-19 vaccinations. Emergency preparedness plans were outdated, and staff training was insufficient.
The facility failed to supervise and manage smoking activities among residents, leading to a fire incident in a non-smoking facility. Despite being aware of the issue, the facility did not document a Quality Assurance Performance Improvement plan or hold meetings to address the problem. Key staff, including the Administrator, Director of Nursing, and Medical Director, were either unaware or did not communicate the issue effectively, resulting in a deficiency cited under Immediate Jeopardy.
The facility failed to document and offer COVID-19 vaccination to staff, including a RN Supervisor, a Receptionist, several CNAs, a Physical Therapist, and Maintenance staff. The facility's policy required education on the vaccine's benefits and risks, but this was not followed. The Director of Nursing admitted to not tracking or organizing vaccine offerings due to staffing issues, resulting in a lack of declination forms.
The facility failed to support resident self-determination by not providing a designated smoking area or offering smoking cessation programs after changing its policy to prohibit smoking. This affected five residents who were known smokers at admission, with no evidence of cessation support or staff training provided. The facility's administrator admitted that the needs and preferences of these residents were not considered.
During a survey, several maintenance and cleanliness issues were identified, including dusty fans, stained fixtures, and nonfunctional fans in nurse station toilets. Additionally, a janitor's room door did not close properly, compromising the safety and comfort of the environment.
The facility failed to update Comprehensive Care Plans for four residents, leading to deficiencies in care planning. A resident involved in a fire incident did not have their Smoking Care Plan updated. Another resident's Respiratory Care Plan lacked interventions for oxygen use, and their Psychotropic Medication Care Plan was incomplete. A third resident was discharged without an updated Discharge Care Plan, with no documentation of discharge planning.
The facility failed to maintain sufficient staffing levels, as evidenced by a review of staffing from 11/20/2024 to 12/20/2024, resulting in a 1-star rating. Residents experienced delays in call bell responses, with some waiting up to two hours. Despite recruitment efforts and using agency staff, the facility struggled to meet required staffing levels, impacting resident care.
The facility failed to maintain infection control practices, lacking a Water Management Plan for Legionella and not conducting required testing in 2024. Additionally, there was no effective tracking of infections among residents, and staff immunization records for influenza and pneumococcal vaccines were incomplete. The DON admitted to not knowing the current infection status and falling behind on immunization documentation due to staffing issues.
The facility failed to notify two residents or their representatives in writing about the bed hold policy during hospital transfers. Despite requests, documentation could not be provided, and interviews with the Director of Social Work and DON confirmed the notifications were not given.
Failure to Provide Timely Pressure Ulcer Assessment and Care
Penalty
Summary
A resident with multiple comorbidities, including diabetes, acute kidney failure, and impaired mobility, was identified as being at risk for pressure ulcers and was dependent on staff for bed mobility. The resident was initially assessed as having no pressure ulcers and was placed on a care plan that included regular skin assessments, use of pressure-reducing devices, and frequent repositioning. On a later date, a Stage 2 pressure ulcer was identified on the resident's sacrum, along with deep tissue injuries to the upper posterior thighs. Physician orders were obtained for wound care, including cleansing, foam dressing, turning every two hours, and use of a gel cushion. However, there was no documented evidence of wound assessments or monitoring from the time the ulcer was first identified until nearly three weeks later, despite facility policy requiring regular RN wound assessments. During this period, the resident's condition was not adequately monitored or reassessed by a registered nurse, and the wound care team did not evaluate the resident until a significant delay had occurred. Progress notes from nurse practitioners documented visits for unrelated issues, but did not mention the resident's skin condition or pressure ulcers. When the wound care physician finally assessed the resident, two Stage 3 pressure ulcers were identified, indicating a progression of the wounds. There was also a lack of documentation regarding wound progression for an additional week, and no evidence that the care plan was reviewed or revised in response to the resident's deteriorating skin condition. The resident was eventually hospitalized for worsening pressure ulcers, with hospital records describing extensive wounds with both partial and full thickness ulcerations, necrotic tissue, and a large affected area. Interviews with facility staff revealed uncertainty about wound assessment responsibilities, frequency, and documentation requirements. Staff acknowledged that wound assessments were not performed as required and that the wound care team visit was delayed, in part due to a COVID-19 outbreak. The delay in assessment and lack of documentation resulted in actual harm to the resident, as the pressure ulcers progressed in severity before appropriate interventions were implemented.
Insufficient Nursing Staff Resulting in Missed Care and Delays
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by staffing levels falling below the facility's own assessment of desired staffing on eleven out of ninety shifts during the review period. Documentation from daily staffing sheets showed multiple instances where the number of certified nurse aides and nurses on duty was significantly less than what was outlined in the facility assessment. As a result, residents did not receive showers as scheduled, were left in bed for extended periods, and were not able to participate in planned activities. Staff, residents, and family members consistently reported that low staffing led to delays in care, with some residents waiting up to two hours for assistance, and staff being unable to take breaks due to the workload. Interviews further confirmed the impact of inadequate staffing, with residents stating they missed showers and were left in bed because staff were too busy. Staff members reported that on certain shifts, especially weekends and nights, the number of aides was insufficient to provide care for all residents, sometimes leaving only three aides to care for forty residents. The Human Resource Director and Administrator acknowledged awareness of staffing shortages, particularly on weekends, and confirmed that the daily staffing sheets accurately reflected these deficiencies.
Failure to Maintain Clean, Odor-Free, and Homelike Environment
Penalty
Summary
Surveyors identified multiple failures by the facility to maintain a safe, clean, and homelike environment for residents. Observations revealed persistent strong urine odors in various areas of Unit 2, including hallways, a specific resident room, and the dining room, with the smell extending into surrounding areas. Floors in Unit 2 hallways and dining room were visibly soiled or stained, and garbage was found on the floors in the shower room, dining room, and hallways. The Unit 1 dining room cabinet drawer contained garbage, and clutter was observed in resident rooms, including an unused oxygen concentrator and boxes of supplies stored on the floor. The Unit 2 shower room had used linens left on shower chairs, bagged linens outside of receptacles, and other items left out of place. Interviews with staff indicated a lack of routine deep cleaning schedules and inconsistent supervision, especially following the recent absence of a housekeeping supervisor. Housekeeping aides reported cleaning shared spaces and resident rooms daily, but there was no established schedule for deep cleaning or for providing additional attention to rooms with persistent odors. The facility's provided cleaning policy addressed only terminal cleaning, not routine cleaning. The Administrator confirmed that rooms and floors should be cleaned daily and that clutter and unused equipment should not remain in resident rooms, but acknowledged that deep cleaning had not occurred recently and that oversight of housekeeping rounds was lacking.
Failure to Provide Consistent ADL Assistance and Hygiene Care
Penalty
Summary
Surveyors identified that the facility failed to provide necessary assistance with activities of daily living (ADLs) for three out of six residents reviewed. One resident, who was dependent on staff for showering and transfers due to physical and cognitive limitations, did not receive scheduled showers as required by facility policy. Documentation showed that out of 20 scheduled opportunities, only five showers were provided, with most other instances recorded as bed baths and no consistent documentation of refusals. The resident expressed a preference for showers and dissatisfaction with the inconsistency, noting that staff found it burdensome due to the need for a mechanical lift and two-person assistance. Staff interviews confirmed that showers were often missed due to staffing challenges and that the resident required regular hygiene due to incontinence. Another resident with severe cognitive impairment and extensive ADL needs was observed in bed throughout multiple days, missing scheduled social activities and not receiving showers as scheduled. Staff interviews revealed that decisions to keep the resident in bed and forego showers were made by CNAs based on staffing levels and workload, without consultation with nursing staff. Documentation indicated that showers were frequently replaced with bed baths, and refusals were not consistently documented. Nursing staff acknowledged that supervision of CNAs was lacking due to competing responsibilities, such as medication administration, and that communication between CNAs and nurses regarding care delivery was insufficient. A third resident, who had self-care deficits and was occasionally incontinent, was repeatedly observed in soiled clothing and bedding with a strong odor of urine present in their room and on their person. Despite care plans indicating the need for regular incontinence care and hygiene assistance, there was no documented evidence of refusals, education, or social work support related to hygiene. Staff interviews confirmed that the resident did not consistently refuse care and that soiled conditions persisted for extended periods. Supervisory staff were aware of the ongoing hygiene issues but could not provide evidence of recent interventions or consistent follow-up to address the resident's needs.
Failure to Properly Label, Date, and Discard Food Items
Penalty
Summary
Surveyors observed that the facility failed to ensure food was distributed and served in accordance with professional standards for food service safety. During the recertification survey, multiple instances of unlabeled and undated food items were found in both the kitchen and unit pantries, including open jars of chopped garlic and ricotta cheese, a defrosted turkey breast, and an open bag of perogies. Expired food items, such as salad dressing, cookies, and yogurt, were also found in various storage areas and pantries. Additionally, an unlabeled open vanilla pudding with mold and a jar containing an unknown substance were observed. Open and undated beverages, including thickened liquids and milk, were present in the second-floor pantry refrigerator. Interviews with staff revealed confusion and lack of clarity regarding responsibilities for labeling, dating, and discarding food items. The Maintenance Director, Certified Nurse Aide, DON, and Food Service Director each provided differing accounts of who was responsible for monitoring and maintaining food safety in the pantries and refrigerators. The Food Service Director acknowledged that dietary staff were responsible for labeling and discarding food after three days but admitted that some items may have been missed. There was also uncertainty about who stocked certain cabinets and who was responsible for discarding liquids used for medication pass if they were undated or expired.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with a history of hemiplegia, diabetes, and major depressive disorder, who was assessed as having intact cognition and at risk for abuse, was subjected to physical abuse by another resident. The incident involved a second resident with severe cognitive impairment, dementia, schizophrenia, and a history of wandering and resistance to care. This resident entered the first resident's room, struck them with a Reacher, scratched their arm causing a Dexcom sensor to be dislodged, and threatened them with scissors. The incident resulted in visible red scratch marks and the removal of the glucose monitoring device. Prior to the incident, the resident who committed the abuse had documented behaviors of wandering and resistance to care, with care plans indicating the need for monitoring while up in their wheelchair. However, there was no evidence that interventions were implemented to address these behaviors or to protect other residents from potential harm. Staff interviews revealed a lack of awareness regarding specific monitoring interventions for the resident after the incident, and care plans were not updated to reflect new risks or necessary precautions. Facility video footage confirmed that the resident continued to wander unsupervised after the incident, including moving through exit doors undetected. Multiple staff members, including nurses and certified nurse aides, reported being unaware of any additional interventions or monitoring put in place following the altercation. The failure to implement and document appropriate interventions to prevent further incidents contributed to the deficiency in protecting residents from abuse.
Failure to Prevent Resident Accident Due to Inadequate Supervision and Door Security
Penalty
Summary
A deficiency occurred when a resident with a history of dementia, schizophrenia, falls, and wandering was not adequately supervised, resulting in the resident accessing an alarmed stairwell door and falling down the stairs in their wheelchair. The resident sustained two fractured vertebrae and a scalp hematoma. The resident's care plan documented wandering and elopement risk, and interventions included monitoring while in a wheelchair. However, after a prior incident involving resident-to-resident aggression and documented wandering, there was no evidence that increased supervision or additional interventions were implemented to address the resident's ongoing wandering behavior. On the day of the incident, the resident was placed in the Day Room by staff to be monitored but was observed multiple times moving independently in the hallway. Despite being redirected once, the resident was able to access the stairwell door, which was alarmed but could be opened after a period of continuous pressure. Staff were providing care in another room when the alarm sounded, and there was a delay in responding to the alarm. Video surveillance confirmed that the resident was able to open the stairwell door and enter the stairwell unaccompanied, leading to the fall. Interviews with staff revealed that they were aware the resident had a tendency to wander and approach doors, requiring redirection. The alarm system on the stairwell door was known to allow the door to open after a certain period, even while sounding. There was no evidence of additional visual cues or barriers, such as stop signs, on the stairwell doors as planned. The lack of timely supervision and effective interventions to prevent the resident from accessing the stairwell resulted in the resident's fall and injuries.
Failure to Provide Adequate Nutrition and Monitor Intake
Penalty
Summary
The facility failed to ensure adequate nutrition care and services for two residents, resulting in significant unplanned weight loss and insufficient monitoring of nutritional intake. One resident experienced a 12% weight loss over five months and had a Stage 3 pressure ulcer, yet their care plan lacked documentation of food preferences and did not include any nutritional interventions. Despite a history of poor appetite and refusal of supplements, meal intake was not consistently documented, with 13 out of 24 meals left unrecorded during the survey period. The resident frequently ordered take-out food due to dissatisfaction with facility meals, and there was no evidence of supplemental protein being provided to support wound healing, as would be expected for a non-healing wound. Another resident experienced a 9.8% weight loss in six weeks and consistently consumed less than 50% of meals during the survey period. The care plan for this resident included general interventions such as offering food preferences and between-meal nourishment, but did not specify a particular nutrition supplement. Although a dietary supplement (Magic Cup) was recommended and ordered by the dietitian, there was a delay of several days before the supplement was actually started. Intake documentation showed that the resident continued to eat poorly, and observations revealed difficulty with meal consumption, including spitting out food despite being served a preferred diet texture. Interviews with staff, including the registered dietitian, speech therapist, and LPN, confirmed gaps in documentation of food preferences and inconsistent implementation of dietary interventions. The facility's policies required daily intake monitoring and immediate care plan updates for weight changes, but these procedures were not consistently followed for the affected residents. The lack of timely and individualized nutritional interventions contributed to ongoing weight loss and inadequate support for residents with complex medical needs.
Missing Nurse Signatures on Narcotic Count Logs
Penalty
Summary
The facility failed to ensure that drug records were properly maintained and that an account of all controlled drugs was periodically reconciled, as required by policy. Specifically, over a 104-day period, there were 37 instances where nurse signatures were missing from the change of shift narcotic count log out of 624 opportunities. The facility's policy mandates that a complete count of all narcotics must occur at every change of personnel, with both the outgoing and incoming nurses signing the narcotic count sheet to indicate agreement with the count and transfer of responsibility. Review of narcotic count sheets revealed missing signatures, indicating that the narcotic count was not always completed before the transfer of narcotic keys. Observations and interviews confirmed that the count process was generally followed, with nurses stating that the count was performed between shifts and that they could not leave until it was completed. However, the missing signatures were attributed to nurses forgetting, being rushed, or needing to return to the floor quickly. Despite the absence of medication count discrepancies, the lack of signatures meant there was no documented proof that reconciliation and transfer of responsibility had occurred as required by policy.
Significant Medication Error: Missed Anti-Seizure Medication Doses
Penalty
Summary
A resident with diagnoses including epilepsy, dementia, and headaches had a physician's order for Lamictal, an anti-seizure medication, to be administered twice daily. Over several days, five doses of Lamictal were missed due to the medication not being available. Multiple LPNs involved in the resident's care did not administer the medication as ordered, signed the Medication Administration Record as if it had been given, and failed to notify the physician or nursing supervisor about the missed doses. The pharmacy delivered only a partial supply of Lamictal due to concerns about drug interactions, but this information was not effectively communicated to the clinical team responsible for the resident's care. As a result of the missed doses, the resident experienced a breakthrough seizure and required transfer to the hospital. Documentation and interviews confirmed that the facility's policy required all medication administration issues to be reported to supervisory staff before the end of the shift, but this was not done. The facility's investigation did not address all missed doses, and the physician was not notified of the medication errors at the time they occurred.
Insufficient Nursing Staffing
Penalty
Summary
The facility did not ensure there was sufficient nursing staff to meet the needs of every resident and have a licensed nurse in charge on each shift. During recertification review from 7/29/25 to 8/5/25, surveyors reviewed staffing records from 6/27/25 through 8/4/25 and found the facility was not consistently staffed according to its Facility Wide Assessment updated 5/23/25. The assessment called for one RN on day and evening shifts, five LPNs on weekdays and four on weekends, twelve CNAs on weekdays and ten on weekends, and on night shift one RN, three LPNs on weekdays and two on weekends, and six CNAs every night. The staffing records showed the facility was understaffed on 34 of 39 days for CNAs, short-staffed on 28 of 39 days for CNA coverage during various shifts, and short-staffed on 15 of 39 days for LPN or RN coverage during various shifts. During interviews, residents stated they had to wait extended periods after ringing call bells, that overnight staffing was the worst, and that some staff were rushed, did not always do a thorough job, or did not return when they said they would. One resident said the facility was understaffed and staff were overworked. An RN stated the facility could use more LPNs and RNs because medication administration and treatments left no time for other tasks such as updating care plans. The staffing coordinator and administrator stated callouts were a problem, staffing goals for LPNs and RNs were difficult to meet, recruitment was ongoing, and the facility frequently did not have enough staff available, especially LPNs and RNs. An LPN stated staffing had recently improved but had become shorter again over the past few weeks, and a CNA stated weekend staffing could be low at times.
Incomplete CNA Annual In-Service Training
Penalty
Summary
The facility did not ensure certified nurse aides received the required 12 hours of annual in-service training, including dementia training, to support safe delivery of care. During record review and interviews, the facility was unable to provide evidence that 5 of 5 certified nurse aides reviewed (#15, #26, #27, #28, and #29) had completed the mandatory annual in-service hours required by facility policy and regulation. The Corporate Facility Policy titled, Continuing Education In-Service and Competence Training, stated in-service training must be sufficient to ensure continuing competence of nurse aides and be no less than 12 hours per year. The Staff Educator Resident Nurse reported providing only three hours of annual in-services for CNA #15, one hour and 10 minutes for CNA #26, one hour for CNAs #27 and #28, and two hours and 45 minutes for CNA #29, and stated they were not aware of annual in-services completed before April 2025. The Staff Educator also stated they could not provide evidence of a dementia in-service for these nurse aides. The DON stated the requirement for 12 hours of annual in-services for CNA staff would improve with the recent hiring of a Staff Educator.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that the necessary interventions to manage existing pressure ulcers and prevent additional ones were not consistently carried out for affected residents.
Unsecured AC Casings and Damaged Wall Surfaces in Resident Rooms
Penalty
Summary
The facility did not ensure a safe, clean, comfortable, and homelike environment in multiple resident rooms during the recertification survey. Surveyors observed air conditioner casings that were not secured, loose, or detached in resident rooms 120, 124, 130, and 131. During an observation on 7/30/2025 at 10:06 AM, the air conditioner casing in one room was off the wall and not secured. On 07/31/2025 at 12:50 PM, another room had a loose and unsecured air conditioner casing, and Resident #93 was able to remove the panel. On 08/04/2025 at 8:25 AM, air conditioner casings in additional rooms were observed loose and not secured. Surveyors also observed unfinished wall conditions in several rooms. In room 2-206-D, five unfinished plaster areas were observed behind the resident's bed. In room 2-220-W, scuff marks were observed on the closet door and an approximate 2.5-foot area of unfinished plaster was observed on the right side of the resident's bed. In room 2-209-P, an approximately 5-inch by 3-inch hole was observed near the baseboard behind the resident's bed. The Director of Maintenance stated that the air conditioner units should be enclosed in the casing and that the casings should be secure, and also stated that the walls in room 2-206-D should be painted, room 2-220-W needed painting including the unfinished plaster and closet scuff marks, and the hole in room 2-209-P should be repaired and plastered.
Incomplete Care Plans for Medications and Nutrition
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans with measurable goals, time frames, and interventions for 3 residents reviewed for care plans. The deficiency was identified during the recertification survey from July 29, 2025, to August 5, 2025, based on observation, record review, and interviews. Facility policy required residents with poor intake and/or unintentional weight loss to be assessed and have care plans developed addressing their clinical condition and risk factors, and the comprehensive care plan policy required care plans by the 21st day of admission and updates with significant changes of condition. Resident #13 had diagnoses including dementia, generalized anxiety disorder, and mood disorder, and the quarterly MDS documented severe cognitive impairment. Physician orders included Buspar 10 mg three times daily for anxiety and Lexapro 10 mg once daily for depression, but there was no documented care plan for anxiety or depression. During interview, the DON stated all nurses were responsible for care plans, RNs initiate them, LPNs can update them, and Resident #13 should have a care plan in place for all medications. An RN also stated all nurses were responsible for care plans. Resident #2 had diagnoses including unspecified dementia, major depressive disorder recurrent, generalized anxiety disorder, and bipolar disorder unspecified, and the reentry MDS documented severe cognitive impairment, set-up/clean-up assistance with eating, and a therapeutic diet. The record showed no active nutrition care plan, despite physician orders for no added salt, regular diet, thin liquids, and Ensure Plus three times daily, and documented weight loss of 5.7% from 05/02/2025 to 08/01/2025. Resident #34 had diagnoses including vascular dementia, type 2 diabetes mellitus, and repeated falls, and the quarterly MDS documented severe cognitive impairment, weight loss of 5% or more in the last month or 10% or more in the last six months, and a therapeutic diet. The record showed no active nutrition care plan, despite physician orders for no concentrated sweets, ground consistency, general swallow precautions, no oral intake if lethargic, and upright positioning, and documented weight loss of 12.49% from 03/28/2025 to 08/01/2025. Interviews with nursing leadership confirmed the absence of active nutrition care plans and that the plans had not been re-activated or updated after hospitalization.
Care Plans Not Updated for Discharge Planning, Heel Offloading, and Neuro-Checks
Penalty
Summary
The facility did not ensure that comprehensive care plans were reviewed and revised to reflect changes in residents’ status for three residents. The report cited failures involving discharge planning for one resident, a pressure ulcer-related intervention for another resident, and a fall-related intervention for a third resident. The facility policy stated that comprehensive care plans must be individualized, remain up to date, and be updated within seven days of each comprehensive assessment and after any new event, order, or condition change. For Resident #93, who had diagnoses including osteomyelitis, amputation, and peripheral vascular disease, the record showed intact cognition and varying levels of assistance with activities of daily living across assessments. The resident’s assessments documented that discharge planning was not active at one point and later that there was no discharge planning to return to the community, although the resident was involved in goal setting. The comprehensive care plan contained no documented evidence of discharge planning or discussion, the last care plan meeting was documented on 3/6/2025, and social work notes also lacked evidence of discharge planning. During interview, the resident stated care plan meetings were not happening routinely and that there had been no discussion or planning for discharge; the Director of Social Work stated the resident’s goal was to go home and that discharge planning had been worked on, but the care plan and progress notes did not reflect this. For Resident #34, who had vascular dementia, type 2 diabetes mellitus, and repeated falls, the quarterly assessment documented severe cognitive impairment and dependence for transfers. A physician’s order directed heel offloading in bed, but the resident’s skin integrity care plan, last updated after that order, did not include that intervention. For Resident #11, who had Alzheimer’s disease, schizoaffective disorder, and diabetes mellitus, the fall history included a fall from the floor in the resident’s room with head bruising, pain, and a skin tear to the right lower leg. After the fall, the resident returned from the emergency room and a physician’s order was entered for neurological checks, but the fall care plan did not include an intervention for neuro-checks.
Failure to Assess and Monitor Nutrition and Hydration Needs
Penalty
Summary
The facility did not ensure adequate nutrition and hydration management for a resident who received both oral intake and tube feedings. The resident had diagnoses including Down Syndrome, severe protein calorie malnutrition, and heart disease, and the admission MDS documented severely impaired cognition, dependence for all ADLs, a feeding tube, a mechanically altered diet, and that most calories and more than 500 mL of fluid were received through tube feeding daily. Although a care plan noted risk for weight loss/gain and altered nutrition and hydration, the record did not contain a nutritional assessment completed on admission or afterward to evaluate adequate intake. Staff observations during the survey repeatedly documented dry lips, dry flaky skin, dry tongue, and a dry cough, and staff interviews indicated the resident took limited oral fluids despite receiving tube feedings and water with medications and feedings. The facility also did not maintain an active nutrition care plan with updated interventions for a second resident who had significant weight loss. This resident had diagnoses including vascular dementia, type 2 diabetes mellitus, and repeated falls, and the quarterly MDS documented severe cognitive impairment, weight loss of 5% or more in the last month or 10% or more in the last six months, and a therapeutic diet. Weights showed a 12.49% loss from 3/28/25 to 8/1/25. The record contained no documented evidence of an active nutrition care plan, and there were no physician orders for a supplement, meal assistance, or weight monitoring. The dietary note from 6/19/25 stated the resident was at risk for malnutrition related to altered mental state and included a plan to encourage intake, assist as needed, and monitor weight trends, but survey findings showed the plan was not active in the electronic record after the resident’s hospitalization. During observations, the resident was assisted with meals by a CNA and by the resident’s representative, and one tray included a vanilla magic cup that was not documented on the meal ticket. Interviews with the resident’s representative, the DON, the Administrator, and the NP confirmed staff were aware of the weight loss, but the DON could not provide evidence of an active nutrition care plan or a physician visit addressing the weight loss, and the NP stated they were not aware of the weight loss because the facility had not had a dietician for a few months.
No Qualified Dietician on Staff
Penalty
Summary
The facility did not ensure that a licensed dietician was employed from 6/28/2025 until 8/4/2025, leaving no qualified dietician on staff full time, part time, or as a consultant during that period to oversee residents’ dietary needs. During an interview on 07/31/2025, the Administrator stated that the facility dietician had left employment over a month earlier and that a new part-time dietician had been hired but had not yet started, while Nursing was monitoring residents’ nutritional status in the meantime. During an interview on 08/05/2025, the DON stated that a dietician started again at the facility that day and that Nursing had been monitoring nutritional issues or concerns while there was no dietician. During a telephone interview on 08/05/2025, Nurse Practitioner #1 stated they were usually made aware of resident weight loss by the facility dietician and that the facility had not had a dietician for a few months.
Meal tickets and tray contents did not match for multiple residents
Penalty
Summary
The facility did not ensure that menus were followed for residents receiving meals and supplements. Resident #73, who had diagnoses including cerebrovascular accident, hypertension, and diabetes mellitus and was documented on the MDS as cognitively intact and needing set-up assistance for eating, stated during interview that the food was terrible and that the dietician was always changing. During a lunch observation, the resident’s tray ticket and tray did not match: the ticket listed a no concentrated sweets diet with Italian sausage and peppers, white rice, saltine crackers, apple slices, whole milk, coffee, creamer, and assorted juice, along with specific preferences and restrictions, but the tray contained a pot pie, yogurt, four ounces of juice, coffee, four ounces of milk, apple slices, two equal, two salt, and two creamers. Resident #37’s breakfast tray also did not match the meal ticket, as the ticket listed whole milk but skim milk was on the tray. Resident #34, who had vascular dementia, type 2 diabetes mellitus, repeated falls, and severely impaired cognition with set-up assistance for eating, was observed with a magic cup vanilla ice cream container on the tray even though there was no physician order or meal ticket documentation for it. An LPN reviewed the record and could not locate an order or care plan intervention for the magic cup, and the Food Service Director stated that additional items should not be added unless documented on the ticket and that the magic cup on the tray was an assembly line kitchen aide error.
Resident Exposed on Social Media Due to Unauthorized Live Streaming by CNA
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) used a personal cell phone to live stream video while providing care to a resident, resulting in the resident being recorded and exposed on social media without consent. The CNA entered the resident's room and performed care while the phone, carried in their pocket, inadvertently activated a live stream, capturing the resident's head, chest, and legs while they were wearing only a brief. The incident was discovered after the facility received a call about the live stream, and the CNA stopped recording when approached by the nursing supervisor. The resident, who had diagnoses including atrial fibrillation, major depressive disorder, and hemiplegia, was cognitively intact and later expressed feeling violated and humiliated by the event. Facility policies strictly prohibited the use of cell phones in resident care areas and the unauthorized capture or dissemination of photos or videos of residents. Despite in-service training and clear policies, the CNA admitted to carrying the phone in violation of these rules and was unaware that live streaming was occurring. Staff interviews confirmed that monitoring cell phone use during care was challenging, but efforts were made to intervene when observed. The administrator acknowledged that the staff member's actions constituted abuse, regardless of intent, as the resident's privacy and dignity were compromised.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
A deficiency occurred when the facility failed to immediately report an allegation of abuse, specifically rape, to the New York State Department of Health as required. The incident involved a resident with diagnoses including asthma, osteoarthritis, and anxiety, who was assessed as cognitively intact and requiring assistance with activities of daily living. On the morning in question, the resident's relative contacted the facility after the resident reported being on the floor and having been raped. Facility staff, including the Registered Nurse Supervisor, responded and found the resident disoriented and confused, expressing that they had been raped and needed help. The resident was alert but required repeated orientation to their surroundings. Despite the resident's later recantation of the rape allegation and clarification that no rape had occurred, the initial allegation was not reported to the state health department as mandated. The Registered Nurse Supervisor informed the Nurse Practitioner, DON, and physician about the incident, but the Administrator confirmed that the allegation was not reported to the authorities. The failure to report the alleged abuse immediately, regardless of the subsequent recantation, constituted a violation of reporting requirements.
Failure to Document and Investigate Resident Fall Incident
Penalty
Summary
A resident with diagnoses including asthma, osteoarthritis, and anxiety, who was cognitively intact and required staff assistance for activities of daily living, was found sitting on the floor of their room. The incident was initially reported by the resident's relative, who received a call from the resident stating they were on the floor, naked, and needed help. Facility staff, including a Registered Nurse Supervisor and floor nurses, responded and found the resident alert but disoriented, expressing confusion about their surroundings and alleging rape. Subsequent medical assessment found no injuries or changes in the resident's baseline condition. Despite facility policy requiring documentation and investigation of all accidents and incidents, there was no documented evidence that an incident/accident report or investigation was completed for the resident's fall. Interviews with facility staff confirmed that while the incident was verbally reported to supervisory staff and medical providers, no written report or investigation could be located. The Administrator stated that the allegation of rape took precedence over the fall, resulting in the lack of documentation for the accident as required by policy.
Failure to Maintain Effective Pest Control in Resident Rooms
Penalty
Summary
The facility failed to maintain an effective pest control program to prevent and address the presence of mice in resident rooms, as evidenced by complaints from two residents about mice in their rooms. Despite the facility's pest control policy requiring findings of pest activity to be reported and addressed, there was no documented evidence that the affected resident rooms were inspected or that specific pest control measures were implemented in response to these complaints. Observations revealed a cluttered room and a significant hole in the wall behind a resident's bed, which could facilitate rodent entry. Staff interviews confirmed that while pest control services were utilized for the facility overall, resident rooms were not specifically inspected by pest control professionals, and reports of mice were not consistently documented or addressed. Multiple staff members, including maintenance and nursing staff, were either unaware of the ongoing mouse issues in the specific resident rooms or did not have documentation of the complaints. The maintenance log book contained reports of mice in other areas but lacked entries for one of the affected rooms, despite resident complaints. The Director of Maintenance acknowledged the presence of a hole in the wall and the need for food storage precautions but was not aware of all resident-specific pest issues. The lack of targeted inspection and intervention in response to resident reports led to the deficiency in maintaining a pest-free environment as required by regulation.
Grievances for Missing Resident Property Were Not Promptly Addressed
Penalty
Summary
The facility did not ensure that resident grievances about missing property were acted on promptly or responded to for two residents. Resident #7, who had moderately impaired cognition, reported a missing pair of shorts that were labeled with their name and completed a form, but the shorts were never found and the resident never received follow-up about the grievance. The facility grievance log had no documented evidence of a missing-item grievance for Resident #7, and the Director of Social Work stated the department had not been aware of the missing shorts or received a grievance for the resident. Resident #34, who had vascular dementia, urinary retention, and type 2 diabetes mellitus and was assessed as having severe cognitive impairment, had a pair of sneakers go missing from the room in April 2025. The resident’s representative stated the missing sneakers were reported to nursing staff and believed to social work staff, but no follow-up information or reimbursement was provided. The facility grievance log also had no documented evidence of a missing-item grievance for Resident #34. Staff interviews indicated that missing-item reports were supposed to be routed to Social Work, but the Director of Social Work stated the report had been given to a staff member who was no longer employed and Social Work was not informed, so no investigation was completed.
Inaccurate resident assessments for oral/dental status and tobacco use
Penalty
Summary
The facility did not ensure that resident assessments accurately reflected resident status for two residents reviewed during the recertification survey. One resident had diagnoses including heart failure, gastro-esophageal reflux, and fibromyalgia, and was observed with multiple decaying and broken teeth. However, the resident’s comprehensive assessment and quarterly assessment both documented no oral or dental issues. The record also showed an in-house dental consult on 12/29/2024 identifying teeth #9 and #10 as needing extraction, no documented dental consultations after that date, and physician orders for dental consultation and tooth ache treatment, including Orajel for disorders of the teeth and supporting structures. The second resident had diagnoses including incomplete paraplegia, schizoaffective disorder, and nicotine dependence, and had been identified as a smoker since admission. The resident’s annual assessment did not document tobacco use, even though the care plan titled Smoking stated the resident was a grandfathered smoker and could continue smoking tobacco or chewing tobacco on facility grounds in the designated area. During interview, the MDS Coordinator stated the resident was missed as a smoker and should have been documented as a tobacco user in the annual MDS. The facility’s MDS policy stated the MDS is to be comprehensive, accurate, standardized, and reproducible, and that Section L oral/dental status and Section J tobacco use are completed by nursing/MDS Coordinator staff.
Inaccurate PASARR Screening for a Resident with Down Syndrome
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed accurately for one of 28 residents reviewed. Resident #6, who had diagnoses including Down Syndrome, severe protein calorie malnutrition, and heart disease, had a preadmission screen dated 6/16/2025 that did not follow the screen instructions and contained inaccurate answers. The facility’s Screen/PASSAR policy stated that Admissions and Social Work review preadmission screens for accuracy and may not admit if components are not completed properly. During interviews, the Director of Social Work and the Director of Admissions stated that the screen is reviewed for accuracy by admissions, social work, and nursing, but they were not certain whether Resident #6’s screen had been completed correctly and acknowledged that the screen contained an error.
Improper Foley Catheter Positioning and Missed Catheter Care Documentation
Penalty
Summary
The facility did not ensure appropriate treatment and services were provided for Resident #19, who had an indwelling Foley catheter and diagnoses including urinary tract infection, bacteriuria, and dementia. The resident’s 5-Day MDS documented severely impaired cognition, dependence on staff for toileting, frequent bowel incontinence, and an indwelling catheter. The care plan identified bladder incontinence with an indwelling catheter and included interventions to monitor for signs and symptoms of infection and report to the physician. Physician orders included a urology consult, a 16 French Foley catheter, catheter care every shift, and catheter bag changes as needed. During multiple observations, Resident #19’s catheter tubing was seen coming up and over the waistband of the pants while the resident was seated in a wheelchair, and the catheter collection bag was observed on the floor or with the bottom touching the floor while the resident was in bed. One observation noted cloudy yellow urine draining from the catheter. The facility’s catheter care policy required non-obstructed downhill urine flow at all times. Certified Nurse Aide documentation for catheter care from 6/12/2025 through 7/31/2025 showed thirty-five omissions. During interviews, a CNA, an LPN, and the DON stated the catheter bag should not be on the floor and the tubing should not be positioned over the waistband because it may impede urine flow.
Oxygen Therapy Not Provided as Ordered
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not ensured for Resident #66. The resident had diagnoses including Parkinson's disease without dyskinesia, chronic respiratory failure with hypoxia, and type 2 diabetes mellitus without complications. The quarterly MDS documented the resident was cognitively intact and received oxygen therapy. A physician's order dated 6/7/25 directed oxygen via nasal cannula at 2 liters per minute, and the care plan stated the resident required 2 liters/minute oxygen due to episodes of shortness of breath, with interventions to provide oxygen as ordered by the physician. During multiple observations, Resident #66 was seen in bed with a nasal cannula in place and the oxygen concentrator running at 4 liters per minute rather than the ordered 2 liters per minute. These observations occurred on 07/29/25, 07/30/25, and 8/1/25. There was also no signage outside the resident's door indicating oxygen use. During an observation and interview on 8/1/25, an RN observed the concentrator at 4 liters per minute and stated they were not aware of the ordered rate, then reduced it to 2 liters per minute after reviewing the electronic medical record. Other staff interviewed stated they were not aware of why the oxygen was set at 4 liters per minute or why no oxygen signage was posted, and the DON stated oxygen should be set as ordered and signage should be placed on resident room doors.
Medication Left at Bedside and Improperly Stored
Penalty
Summary
Drugs and biologicals were not stored and labeled in accordance with accepted professional principles for one resident. During observations on 7/29/25, 7/30/25, and 7/31/25, three medication cups containing red capsules were seen on the bedside table of Resident #79, and a registered nurse counted 31 capsules identified as Colace 100 mg on the over-bed table. The resident stated the capsules were stool softeners and said the nurse leaves two stool softeners, but the resident only took one because they did not want diarrhea. Resident #79 was admitted with hypertension, constipation, and anxiety, and the quarterly MDS dated 7/18/25 documented the resident as cognitively intact with no behavioral issues and needing assistance with activities of daily living, including medication administration. The physician’s order dated 7/3/25 directed Colace 100 mg, two capsules by mouth once daily, and the MARs showed the medication was administered as ordered in June and July 2025. During interviews, RN #5 stated no medications should be left at the bedside and that 31 red capsules identified as Colace were found in three cups on the over-bed table. The DON stated nurses were expected to remain with residents during medication administration and acknowledged being informed of the Colace capsules found at the bedside.
Failure to Ensure Timely Dental Follow-Up
Penalty
Summary
Provide routine and 24-hour emergency dental care for each resident was not ensured for one resident who had diagnoses including heart failure, anxiety, and depression. The resident’s annual and quarterly MDS assessments documented intact cognition and supervision needed for oral hygiene, with no oral issues or mouth pain noted in the assessments. The facility could not provide a dental policy. The resident’s dental care plan identified actual impairment and included goals to remain free of dental infection and pain, with interventions to assess chewing, oral hygiene needs, dentition, and oral mucosa, and to refer to a dietician as needed. In-house dental consultations over a two-year period documented that the resident needed extractions and follow-up with an outside dentist. One consultation noted bleeding and teeth that had died, another noted pain and badly broken-down dentition beyond what could be done at the facility, and another documented pain and the need for x-rays and outside treatment. There was no documented evidence of outside dental consultations except verbal statements that the resident went to a local oral surgeon for a consult but could not be seen because the wheelchair would not fit into the office. During the survey, the resident stated they had been waiting a long time for follow-up and a procedure, had a sore mouth, and were taking medication for oral pain. The resident was observed with multiple decaying and broken teeth. Staff stated the resident had an oral surgery appointment months later, that the office offered urgent visits but same-day transportation was difficult, and the DON and NP stated they were not concerned about the delay.
QAPI Committee Lacked Medical Director Participation
Penalty
Summary
The facility did not ensure that the Quality Assurance & Performance Improvement and Quality Assessment & Assurance committees included, at a minimum, the Medical Director or the Medical Director’s designee, and that this member attended quarterly meetings. During record review, the Monthly Meeting Attendance Sheets for the Quality Assurance and Performance Improvement meetings for February 25, 2025; March 13, 2025; March 26, 2025; April 24, 2025; May 29, 2025; and June 26, 2025 showed that the Medical Director or designee did not sign the attendance sheets. The facility’s Quality Assurance and Performance Improvement policy, revised December 27, 2024, listed multiple areas of care and services to be evaluated through the program, including Medical Director and Physician Services, Nursing Services, Dietary Services, Recreation Services, Environmental Services, Human Resources, Rehabilitative Services, Social Services, Maintenance Services, Resident Care, and Care Transitions. During interview, the Administrator stated the facility held QAPI meetings every month, but the Medical Director did not attend in person, by phone, or by Zoom, and stated the Medical Director should be part of the team. The Medical Director stated they sometimes attended the meeting and could be reached by phone if needed.
Failure to Use PPE During Care for Residents on Enhanced Barrier Precautions
Penalty
Summary
The facility did not ensure infection prevention and control practices were maintained for two residents on enhanced barrier precautions. Resident #34 had diagnoses including vascular dementia, urinary retention, and type 2 diabetes mellitus, was assessed as having severe cognitive impairment, and required substantial to maximal assistance for toileting and bathing and was dependent for transfers. A care plan and physician order documented enhanced barrier precautions, with staff instructed to don appropriate personal protective equipment during direct care. During observation, a CNA provided dressing and toileting care to Resident #34 without wearing a gown, and stated they had been aware the resident was on enhanced barrier precautions but forgot to don a gown. Resident #66 had diagnoses including Parkinson’s disease without dyskinesia, chronic respiratory failure with hypoxia, and type 2 diabetes mellitus without complications, and was dependent for toileting, bathing, and transfers. A care plan and physician order documented enhanced barrier precautions. During observation, an RN provided wound care to Resident #66 without donning a gown, and stated they knew the resident was on enhanced barrier precautions and should have worn a gown. The DON stated staff should don gown and gloves for all residents on enhanced barrier precautions while providing hands-on care, including wound care and toileting/bathing cares.
Electrical Bed Not Maintained in Working Order
Penalty
Summary
The facility did not maintain resident-use equipment in a safe operating condition when Resident #71’s electrical bed was not functioning. Resident #71 had diagnoses of heart failure, COPD, and morbid obesity, and a quarterly MDS dated 7/18/25 documented the resident was cognitively intact and independent in dressing, bed mobility, and transfers. The resident care plan for CHF and a physician order both directed that the head of bed be elevated 30-45 degrees while in bed, but during an interview on 7/29/25 the resident stated the bed’s electrical component had not worked for over a year and that pillows were being used to elevate the head while in bed. Resident #71 stated staff had been informed about the broken bed and nothing had been done to repair it. During an interview and observation on 8/1/25, Maintenance Assistant #20 initially found the bed was not plugged in and there was no remote control; after obtaining a remote and plugging in the bed, the bed still did not function, and the assistant stated the original motor was not functioning. During an interview on 8/4/25, RN #5 stated maintenance requests were entered in a unit logbook and checked daily, but staff were not aware the bed was broken. The maintenance book showed the bed had been fixed on 10/2/24 when the electrical plug came out, and an entry dated 11/11/25 documented the bed would not move up and down and was not checked as completed.
Resident Subjected to Physical Abuse by CNA During Care
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of dementia, encephalopathy, and Parkinson's Disease was subjected to physical abuse by a Certified Nurse Aide (CNA) during care. The incident took place while two CNAs were assisting the resident, who became combative and struck one of the aides. In response, the other CNA hit the resident on the arm. Documentation and staff statements confirmed the occurrence of the physical altercation, and the involved CNA was subsequently removed from the schedule. The resident's care plan identified them as being at risk for abuse due to dementia, but there had been no review or revision of the care plan since its creation. Further review revealed that the CNA involved in the incident had not received any abuse prevention training during their employment at the facility. Additionally, the Director of Nursing acknowledged that abuse and behavioral health education had not been provided to staff, and there was no staff educator in place to conduct such training. Both the attending physician and the medical director were not informed of the incident in a timely manner, despite expectations to be notified of all abuse allegations and incidents to ensure proper assessment and intervention.
Failure to Thoroughly Investigate and Document Alleged Abuse Incident
Penalty
Summary
The facility failed to thoroughly investigate an alleged incident of staff-to-resident abuse involving a resident with severe cognitive impairment and multiple diagnoses, including dementia, encephalopathy, and Parkinson's disease. The incident occurred when two certified nurse aides were providing care and the resident became combative, resulting in one aide allegedly hitting the resident in response to being struck. The facility's investigation did not include a review of available camera footage, and the internal investigative documentation was incomplete, missing required signatures from the Administrator, the medical provider, and the nurse manager. Additionally, the facility did not provide documented evidence that law enforcement was notified regarding the alleged abuse, as required by policy. The Administrator stated that law enforcement was not contacted because the resident did not wish to press charges, and a referral to the Certified Nursing Aide Registry was not made for the staff member involved. The Director of Nursing was not involved in initiating the investigation, and the medical director, as well as the primary physician, were not notified of the incident until several days after it occurred. Facility policy required that all elements of an abuse investigation be completed within 48 hours and that completed investigations be reviewed and signed off by the Administrator, Medical Director, Director of Nursing, and Social Services. In this case, the investigation was not coordinated as per policy, and key personnel were not informed or involved in a timely manner. The lack of a nurse manager and staff educator contributed to the incomplete documentation and review process.
Inaccurate MDS Assessment of Resident Behaviors
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) 3.0 assessment accurately reflected a resident's status at the time of assessment. Specifically, the MDS documented that the resident had no behaviors, despite Certified Nurse Aide (CNA) documentation and nursing progress notes indicating multiple physically aggressive behaviors, such as kicking and hitting, during the assessment period. The resident in question had diagnoses including dementia, encephalopathy, and Parkinson's disease, and was noted to have severely impaired cognition. The MDS Coordinator confirmed that the assessment was completed using a 7-day look-back period, during which CNA documentation showed conflicting entries for the same day—one indicating no behaviors and another documenting aggressive behavior. The oversight occurred when the MDS Coordinator failed to capture the documented behaviors in the MDS, resulting in an inaccurate assessment. This discrepancy was identified during the survey through record review and staff interviews.
Failure to Develop and Implement Comprehensive Behavior Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans to address behavioral needs for two residents with significant mental health diagnoses. One resident, admitted with dementia with behavioral disturbances, Parkinson's disease, and major depressive disorder, exhibited multiple documented incidents of aggressive behaviors such as kicking, hitting, pinching, scratching, spitting, biting, and abusive language. Despite repeated documentation of these behaviors by Certified Nurse Aides and nursing staff, there was no behavior care plan in place until after a resident-to-staff incident occurred. Physician orders required behavior notes and interventions to be documented each shift, but the care plan was not initiated on admission, and the abuse care plan was not updated following a subsequent incident. Another resident, admitted with schizoaffective disorder, Alzheimer's disease, and major depressive disorder, also demonstrated verbal and physical aggression, including an incident where the resident attempted to throw a television at another resident. This resident had physician orders for behavior documentation each shift, and multiple behavioral incidents were recorded in nursing notes. However, there was no documented evidence of a behavior or abuse care plan in the electronic medical record. Staff interviews revealed that interventions such as redirection and reapproach were used, but these were not formalized in a care plan, and communication gaps between nursing and Certified Nurse Aides contributed to incomplete documentation and lack of care plan initiation. The facility's policy required comprehensive care plans to be developed by the 21st day of admission and updated with any significant change in condition. However, failures in communication, documentation review, and interdisciplinary coordination led to the absence of required care plans for residents with documented behavioral issues. This resulted in the facility not meeting regulatory requirements to maintain residents' highest practicable physical, mental, and psychosocial well-being.
Failure to Individualize Dementia Care Plans for Residents with Aggressive Behaviors
Penalty
Summary
The facility failed to ensure that residents diagnosed with dementia received appropriate treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being. Specifically, two residents with dementia and behavioral disturbances did not have individualized care plans with interventions to address their verbal and physically aggressive behaviors. For one resident with severe cognitive impairment and a history of behaviors such as kicking, hitting, biting, abusive language, and threatening actions, there was no documented evidence that the care plan was reviewed or revised to include specific approaches for managing these behaviors, despite multiple documented incidents and a physician order requiring behavior notes and interventions each shift. Another resident, diagnosed with Alzheimer's disease and schizoaffective disorder, also exhibited verbal and physical aggression, as well as rejection of care. Although this resident had a general cognitive/dementia care plan, it did not include individualized interventions to address the aggressive behaviors. Multiple behavior incidents were documented in nursing notes, and a physician order was in place for behavior documentation and intervention, but the care plan was not updated to reflect these needs. Interviews with the Director of Nursing revealed that care plans are expected to be initiated and updated by the appropriate discipline, and that staff documentation should prompt the initiation of behavior management care plans. However, the Director of Nursing was unable to explain why behavior care plans were not initiated or updated for these residents, even after incidents of aggression and abuse were reported and documented.
Failure to Provide Required Abuse and Dementia Training to Nurse Aide
Penalty
Summary
The facility failed to ensure that a Certified Nurse Aide received required training in dementia management and abuse prevention, as mandated by facility policy and state regulations. Record review and staff interviews revealed that there was no documented evidence of such training for the aide in question. The only training record provided was for behavioral health, but the aide did not work on the date listed, and the in-service sign-in sheet lacked essential details such as the date, duration, and instructor's name. The Human Resources Director was unable to locate the aide's training folder, and both the Director of Nursing and the Administrator confirmed that the staff educator position was vacant, with no one currently performing the function. Further interviews indicated that the aide had not received in-services on abuse, behavioral health, or dementia care, only on fire safety. The Director of Nursing acknowledged that no in-services had been conducted since assuming responsibility for staff education, due to the absence of a staff educator. The facility's policy requires all staff to be trained on abuse identification and dementia care at hire and annually, but this was not met for the aide in question.
Inadequate Supervision of Smoking Residents Leads to Fire Hazard
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents related to smoking for six residents identified as smokers. Despite being a non-smoking facility, the facility did not complete safety assessments or develop and implement a plan of care to ensure the safety of these residents. Resident #41, a known smoker with moderately impaired cognition, was involved in an incident where a fire was started on the outside patio after they threw a cigarette butt into dry leaves. There was no staff supervision during this smoking activity, and the fire was only noticed by the Director of Human Resources from their office window. The facility's smoking policy was inconsistent and did not address how to accommodate residents who smoked prior to the policy change. Residents were observed smoking on the patio without supervision, and there were no ashtrays or cigarette receptacles available. Resident #54 was found with cigarettes and lighters in their room, and a strong odor of cigarette smoke was present. The facility was aware of the residents' continued smoking but did not complete safety assessments or provide supervision, resulting in substandard quality of care with immediate jeopardy. Interviews with staff and residents revealed that the facility was aware of the smoking activities but did not have a formal list of smokers or a system to supervise them. The facility's administration acknowledged the issue but did not implement new systematic interventions to prevent unsupervised smoking. The lack of supervision and failure to update care plans after the fire incident contributed to the deficiency, posing a likelihood for serious adverse outcomes to all residents in the facility.
Removal Plan
- The Smoking Policy was reviewed and updated to include that residents admitted to the facility prior to the implementation of the nonsmoking policy would be given smoking privileges. These residents who desired to smoke would be permitted to do so if the facility Interdisciplinary Team determined that the practice was safe for the residents, and they do so in the facility designated area.
- A nursing assessment by a Registered Nurse was done for all smokers. They examined the residents and clothing for any burns.
- All residents that currently smoke were assessed to determine if they were safe to smoke or require supervision and or assistance.
- Safe smoking contracts were established for residents that smoke.
- A safe smoking area 30 feet from the building was established.
- Appropriate receptacle for cigarettes butts was installed. A small metal step-on garbage can that self-closed was installed.
- Sign for supervised smoking area was posted.
- Smoking aprons were placed by exit to patio for those residents assessed to need an apron. Two smoking aprons were observed stored in two tier plastic storage bins by the [NAME] room door.
- A standard size all-purpose fire extinguisher was located near the patio door.
- Smoking materials for all residents were removed from resident rooms and placed in a locked medication cart.
- Supervised smoking times were assigned for 10:00 AM, 2:00 PM and 6:30 PM; doors were locked when smoking was not in session.
- Schedule of staff supervision was completed.
- Care plans for all 6 smokers were completed for safe smoking.
- Physician orders for each smoker documented residents were care planned to smoke in facility designated area only.
- The facility employs 109 staff members. Of these, 102 completed the in-service training, including supervisors. A sample of staff members from Nursing, Rehabilitation, Administration, and Recreation were interviewed and verified they received the education.
- All supervisor staff were educated on facility procedures particularly their role to call 911 in the event of a fire.
- An hourly smoking monitoring log was maintained to check resident rooms for signs of smoking.
- The patio door was locked and remained locked except during the smoking times. Staff was observed supervising the smokers, unlocking the door to allow the residents into the smoking area and locking the door when smoking was completed.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for four residents, leading to deficiencies in meeting their medical, nursing, mental, and psychosocial needs. Resident #15, who was admitted with diagnoses including traumatic brain injury, diabetes, and Alzheimer's, did not have care plans for dementia care, psychotropic drug use, or diabetes management. Despite receiving medications such as Lorazepam, Seroquel, and insulin, the care plans lacked documented goals or interventions. Interviews with staff revealed a lack of awareness and completion of necessary care plans for residents with dementia or Alzheimer's. Resident #84, admitted with dementia, hip fracture, and respiratory failure, was at risk for pressure ulcers but did not have an appropriate care plan in place. Observations noted the resident's feet were not offloaded, and there was no care plan for pressure ulcer prevention despite a Braden Score indicating risk. The Director of Nursing and other staff acknowledged the oversight, noting that the care plan was not reactivated upon the resident's readmission from the hospital, and protocols for skin breakdown prevention were not implemented. Resident #29, diagnosed with schizophrenia, diabetes, and anxiety disorder, was observed smoking unsupervised on the facility's patio, yet had no care plan addressing smoking or non-compliance. The resident's electronic health record lacked a smoking assessment, and staff interviews indicated that care plans should be initiated and updated routinely, but this was not done. The facility's failure to develop and implement these care plans resulted in deficiencies in providing adequate care and supervision for the residents involved.
Deficiencies in Supervision, Fire Safety, Staffing, and COVID-19 Protocols
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents related to smoking for residents identified as smokers. Specifically, a resident known to smoke in a non-smoking facility was not properly assessed or provided with a care plan to ensure their safety. This oversight led to a fire incident on the outside patio when the resident discarded a cigarette butt into dry leaves, with no staff present to supervise the activity. Additionally, the facility did not enforce its non-smoking policy, as smoking was observed during the survey. The facility also failed to ensure that employees were periodically instructed and followed general fire procedures according to the facility's Fire Emergency Plan. During a fire emergency, staff did not activate the fire alarm or contact the fire department. Furthermore, the facility did not conduct the required number of fire drills per quarter, and records did not include details of simulated emergency conditions, violating the NFPA 101: Life Safety Code. Moreover, the facility did not maintain adequate nursing staffing levels to meet resident needs, as documented in their facility assessments. This was evident in 17 out of 90 shifts reviewed, resulting in a 1-star rating in the payroll-based journal report. Additionally, the facility did not ensure that staff were offered updated COVID-19 vaccinations, with no documented evidence of immunization records for several staff members. The facility's emergency preparedness plans were not updated, and staff were not trained annually, further compromising resident safety and care.
Inadequate Supervision of Smoking Activities in Non-Smoking Facility
Penalty
Summary
The facility was found to have a deficiency related to inadequate supervision and management of smoking activities among residents, despite being a non-smoking facility. During the survey, it was observed that residents were smoking on the patio and gazebo, which are unsupervised areas, leading to a fire incident caused by a discarded cigarette butt. The facility failed to establish and implement a process for the Administrator to report to the governing body, and there was no documented evidence of a Quality Assurance Performance Improvement (QAPI) plan or meetings to address the smoking issue. The Administrator acknowledged the non-compliance with the facility's smoking policy and identified six residents as smokers, but no actions were taken to address the issue through the QAPI committee. Interviews with the Director of Nursing, Medical Director, and the facility owner revealed a lack of awareness and communication regarding the smoking activities and the fire incident. The Director of Nursing was unaware of residents smoking in their rooms, and the Medical Director was not informed about the smoking-related fire. The facility owner admitted awareness of the smoking issue but stated it was not brought to the QAPI committee's attention. The deficiency was cited under Tag F 689 at Immediate Jeopardy scope and severity J, indicating a serious lapse in ensuring resident safety and compliance with facility policies.
Failure to Document and Offer COVID-19 Vaccination to Staff
Penalty
Summary
The facility failed to ensure that all staff members were screened, offered the COVID-19 vaccine, and provided education regarding the benefits, risks, and potential side effects associated with the vaccine. During the recertification survey, it was found that there was no documented evidence of immunization records for COVID-19 vaccines for ten staff members, including a Registered Nurse Supervisor, a Receptionist, several Certified Nurse Aides, a Physical Therapist, and Maintenance staff. The facility's policy, dated May 15, 2021, required that all staff be educated about the COVID-19 vaccine before it was offered, but this was not adhered to. Additionally, a Dear Administrator Letter dated September 13, 2023, reminded nursing homes of the expectation to ensure all eligible residents and staff remain up to date with CDC-recommended COVID-19 vaccine doses. The facility did not have documentation of screening, education offering, current COVID-19 vaccine booster status, or signed declination forms for the staff members in question. The Director of Nursing, who is also the Infection Preventionist, admitted during an interview that they had not been offering or keeping track of COVID-19 vaccines for staff due to staffing issues and had not organized the offering of vaccines, resulting in a lack of declination forms for the COVID-19 vaccine.
Failure to Support Resident Smoking Preferences
Penalty
Summary
The facility failed to honor residents' rights to self-determination and choice by not providing a designated smoking area or offering a smoking cessation program when it changed its policy to prohibit smoking. This deficiency affected five residents who were known smokers at the time of their admission. The facility's policy initially allowed smoking in designated areas, but a subsequent policy change prohibited smoking entirely without considering the needs and preferences of the residents who smoked. There was no documented evidence that these residents were offered smoking cessation counseling, nicotine replacement options, or that staff received training on smoking cessation programs. Resident #29, who was cognitively intact and admitted with diagnoses including schizophrenia, diabetes, and anxiety, was not assessed for smoking habits or offered cessation support. Similarly, Resident #41, also cognitively intact and admitted with paraplegia, borderline personality disorder, and schizophrenia, reported that no accommodations were made for smokers after the policy change. Resident #54, with quadriplegia and major depressive disorder, had care plans that mentioned smoking but lacked evidence of cessation support being offered. The facility administrator acknowledged that the needs and preferences of residents who smoked were not considered when the policy changed.
Facility Maintenance and Cleanliness Deficiencies
Penalty
Summary
During the recertification survey conducted from December 15 to December 22, 2024, several deficiencies were observed in the facility's maintenance and cleanliness, compromising the safety and comfort of the environment for residents, personnel, and the public. On December 17, 2024, a dusty fan was found in the soiled room on the second floor. In a resident's room, the tub had a brown stain around the drain, and a green-colored substance was present around the sink faucet. Stained ceiling tiles were noted in the second-floor corridor. Additionally, the toilets in the nurse stations on both the first and second floors had nonfunctional fans, and another resident's room had a toilet with a dusty fan. Furthermore, the janitor's room door in the service corridor on the second floor did not close properly. These observations were made in the presence of the Director of Maintenance.
Deficiencies in Comprehensive Care Plan Revisions
Penalty
Summary
The facility failed to ensure that the Comprehensive Care Plans were revised for four residents, leading to deficiencies in care planning. Resident #41, who had diagnoses including Paraplegia and Schizoaffective Disorder, was involved in a fire incident after extinguishing a cigarette in dry leaves. Despite this incident, the Smoking Care Plan was not updated to include new interventions for safe smoking practices. The resident had previously been counseled on the facility's non-smoking policy, but there was no documented evidence of updates to the care plan following the fire incident. Resident #89, diagnosed with conditions such as Unspecified Atrial Fibrillation and Chronic Obstructive Pulmonary Disease, had a physician's order for oxygen use as needed, but this was not reflected in their Respiratory Care Plan. Observations noted the resident using oxygen at 3 liters, yet the care plan lacked interventions or goals related to oxygen therapy. Additionally, the Psychotropic Medication Care Plan for this resident did not include interventions or goals for monitoring behavior or the effectiveness of psychotropic medications, despite the resident's severely impaired cognition and ongoing medication adjustments. Resident #48, with diagnoses including Unspecified Dementia and Generalized Anxiety Disorder, was discharged without an updated Discharge Care Plan. The care plan still indicated the resident as a long-term care resident, and there were no documented notes or goals related to discharge planning. Despite the resident being discharged home, there was no evidence of nursing or social services documentation regarding the discharge process. Interviews with staff revealed a lack of documentation and communication regarding the discharge planning for this resident.
Insufficient Staffing Levels in LTC Facility
Penalty
Summary
The facility failed to ensure sufficient nursing staff to meet the needs of residents, as evidenced by a review of staffing levels from 11/20/2024 to 12/20/2024. During this period, the facility did not meet the minimum staffing levels outlined in their Facility Assessment for 17 out of 90 shifts. Specifically, the facility was short on Certified Nursing Assistants (CNAs) and Licensed Practical Nurses (LPNs) during various shifts, which contributed to a 1-star rating in the payroll-based journal report. Observations and interviews with residents revealed that the lack of adequate staffing resulted in delayed responses to call bells, with some residents waiting up to two hours for assistance. Interviews with the Human Resource Director and the Administrator highlighted the challenges the facility faced in maintaining adequate staffing levels. Despite efforts to recruit staff through bonuses and the use of agency staff, the facility struggled to meet the required staffing levels. Agency staff often did not have set schedules, and the management team frequently had to assist on the units to ensure residents received care. The resident council also expressed concerns about staffing, noting that staff often did not return after turning off call bells, further indicating the impact of insufficient staffing on resident care.
Inadequate Infection Control and Immunization Documentation
Penalty
Summary
The facility failed to maintain proper infection control prevention practices, as evidenced by the absence of a Water Management Plan to prevent and control Legionella. There was no documented evidence of Legionella testing or completion of an Environmental Risk Assessment within the last year. The last recorded Legionella test was conducted in February 2023, with no subsequent testing in 2024. The facility's policy required annual Legionella culture sampling and analysis, but this was not adhered to. The Administrator confirmed the lack of testing in 2024, and the owner was unable to provide the necessary documentation for review. Additionally, the facility did not effectively track and monitor infections and outbreaks among residents. The Director of Nursing, who was responsible for the Infection Control Program, admitted to not knowing the current infection status within the facility. There was no documented tool to track infections, symptoms, lab results, or isolation precautions. Furthermore, the facility failed to maintain proper documentation of staff immunization records for influenza and pneumococcal vaccines. The Director of Nursing acknowledged falling behind on tracking immunization records due to staffing issues, resulting in incomplete records for several staff members.
Failure to Notify Residents of Bed Hold Policy
Penalty
Summary
The facility failed to ensure that residents or their representatives were notified in writing of the facility's bed hold policy during hospital transfers. This deficiency was identified during a recertification survey conducted from December 15 to December 22, 2024. Specifically, two residents, identified as Resident #49 and Resident #93, were transferred to the hospital, and the facility could not provide evidence that written notice of the bed hold policy was given to them or their representatives. The facility's policy, revised in June 2019, requires notification to the private insurance carrier when a resident is transferred to the hospital or is on therapeutic leave. Resident #49, who was admitted with diagnoses including Sepsis, Dementia, and Bipolar Disorder, was discharged to the hospital on September 27, 2024, and admitted with Septic Shock on September 28, 2024. Resident #93, with diagnoses of Non-Alzheimer's Dementia, Huntington's Disease, and Parkinson's Disease, experienced hospitalizations on December 4-5, 2024, and November 29 to December 2, 2024. Despite requests for documentation on December 22, 2024, the facility could not verify that written notifications were provided. Interviews with the Director of Social Work and the Director of Nursing confirmed that the notifications were not given, and they were unable to provide copies of the notifications.
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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 Campbell Hall
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sapphire Nursing And Rehab At Goshen | 4.8 mi | ★★★★★ | 0 | 0 |
| Glen Arden Inc | 4.8 mi | ★★★★★ | 11 | 0 |
| Middletown Park Rehab & Health Care Center | 5.2 mi | ★★★★★ | 1 | 0 |
| Montgomery Nursing And Rehabilitation Center | 6.7 mi | ★★★★★ | 0 | 0 |
| Highland Rehabilitation And Nursing Center | 7.1 mi | ★★★★★ | 3 | 0 |
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