Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Crest Manor Living And Rehabilitation Center during CMS and state inspections, most recent first.
Missing personal property reports were not properly investigated or documented for two residents. One resident with CKD, chronic pain, and DM reported a missing jacket after giving it to laundry staff, but the facility form was incomplete and no documented investigation, findings, or resolution were available. Another cognitively intact resident with an AKA, HTN, and post-stroke hemiparesis/hemiplegia reported a missing wallet given to staff for safekeeping; only an email was sent, no missing item report was completed, and there was no documented follow-up with the resident or family.
Failure to Provide Needed Grooming and Personal Hygiene Assistance: Two residents who required staff help with ADLs were observed with poor grooming and hygiene. One resident with severe cognitive impairment and diagnoses including HF, CKD, and hepatic encephalopathy had facial hair, dirty fingernails, broken nails, and stained clothing, with no documented showers, nail care, or grooming in the record. Another resident with COPD, HF, and CKD was repeatedly observed with chin hair, long fingernails, and greasy hair despite care plans calling for staff-assisted showers and grooming, and the record did not show follow-up when hygiene care was missed.
The facility failed to provide appropriate care for two residents, leading to deficiencies in treatment and documentation. One resident did not have documented bowel movements for over three days, and no bowel medications were ordered or administered per protocol. Another resident with nephrostomy tubes experienced inadequate care, resulting in hospitalization for pyelonephritis. Staff lacked training in nephrostomy tube care, contributing to the resident's condition worsening.
Two residents in an LTC facility experienced significant weight loss due to inadequate assistance with meals, as outlined in their care plans. One resident developed a stage three pressure ulcer following the weight loss, while the other did not consistently receive their prescribed nutritional supplement. Observations showed that staff failed to provide the necessary assistance, and there was a lack of communication and documentation regarding the residents' nutritional needs.
A facility failed to ensure that nursing staff had the necessary competencies to care for a resident with nephrostomy tubes. Despite having a policy for nephrostomy tube care, there was no documented evidence of training or competencies for the staff. Interviews revealed that several LPNs and the Nurse Educator had not received training on nephrostomy tube care. The resident had specific medical conditions requiring nephrostomy tube management, but the facility's staff lacked the documented training to perform these tasks competently.
The facility was found to have insufficient staffing levels, affecting resident care on both the second and third floors. Observations showed residents in bed late in the morning, some without meal assistance, and reports of long waits for help. Staffing records confirmed frequent shortages, with only one or two CNAs present on shifts needing more staff. Despite these findings, the Regional Administrator claimed staffing levels were met.
A survey revealed that a facility failed to address grievances from the Resident Council, affecting several residents. Concerns included delayed call bell responses, staff shortages, personal phone use by staff during care, and issues with food and laundry services. Despite these issues being raised over several months, the facility did not provide responses or rationales, and the residents were unsure of the Grievance Official's identity.
The facility did not ensure baseline care plans were reviewed or provided to residents or their representatives within 48 hours of admission, as required by policy. This issue was identified during a survey involving ten residents, with staff interviews revealing a lack of documentation and communication. The nursing department was responsible for this task, but no evidence was available to confirm compliance.
The facility failed to maintain safe operating conditions for mechanical lifts, with a lift missing a wheel and insufficient assistive equipment for resident transfers. Residents and staff reported faulty and inadequate equipment, causing delays in care. Maintenance issues were known but not addressed due to approval requirements, and leadership was unaware of the problems.
The facility's nurse call system on the second floor was found to be deficient, lacking a central panel and audible alerts. Staff had to rely on visual indicators to respond to call bells, leading to potential delays in resident care. The system's deficiencies were not documented in weekly checks, and staff interviews confirmed the challenges faced due to the outdated system.
A survey revealed a medication error rate of 6.38% in an LTC facility, exceeding the acceptable threshold. Two residents did not receive prescribed medications due to unavailability. An LPN confirmed the absence of lamotrigine for a resident with bipolar disorder, while another LPN noted the lack of gabapentin and cyanocobalamin for a resident with neuropathy and vitamin B12 deficiency. Staff interviews indicated awareness of ongoing medication availability issues due to pharmacy delivery delays.
Three residents in the facility experienced significant medication errors due to the unavailability of prescribed medications. A resident with bipolar disorder and anxiety did not receive lorazepam and lamotrigine, while another with chronic pain missed doses of tramadol. A third resident with multiple health issues faced unavailability of metoprolol, clopidogrel, trazodone, and Humalog insulin. The facility's Medical Director and DON acknowledged ongoing issues with pharmacy communication and medication management.
The facility failed to implement comprehensive care plans for two residents at risk of falls. One resident, with severe cognitive impairment and mobility dependency, was observed with their bed not in the low position and the call bell out of reach. Another resident, at high risk for falls, had a fall mat improperly placed. Staff interviews confirmed that care plans were not followed, compromising resident safety.
A resident with a stage 3 pressure ulcer did not receive recommended wound care treatment due to a failure in transcribing the Wound Care Nurse Practitioner's recommendations into the electronic medical record. This resulted in a lack of active treatment orders, leaving nurses without guidance on the necessary care.
A resident at high risk for falls did not receive adequate supervision or a hazard-free environment, as required fall prevention measures like a fall mat and low bed position were not consistently implemented. An unwitnessed fall occurred without a Registered Nurse's assessment, and subsequent injuries were not properly investigated or documented.
A resident was prescribed Seroquel without proper documentation of necessity or effectiveness, contrary to facility policy. The resident, diagnosed with major depressive disorder, showed no significant behaviors or distress, yet was on antipsychotic medication. The facility lacked evidence of acceptance or rejection of pharmacy recommendations, and documentation supporting the medication's use was insufficient.
A resident with a history of falls sustained a patella fracture while being assisted in the bathroom. The facility failed to conduct a thorough investigation, as required by policy, by not obtaining necessary statements from involved staff and the resident. The Director of Nursing acknowledged the investigation was incomplete, and it was unclear if the care plan was followed.
Two residents in the facility were found with unclean and uncut fingernails over multiple days, despite being dependent on staff for assistance with daily living activities. One resident, with a history of stroke and other conditions, had a care plan requiring weekly nail care, yet their nails remained dirty. Another resident, requiring assistance with hygiene, also had long, dirty nails despite their care plan. Staff interviews revealed inconsistencies in nail care provision and documentation.
A resident with chronic pain did not receive their prescribed tramadol on multiple occasions due to pharmacy delivery issues, and the medical provider was not notified. Despite the resident's high pain levels, the facility failed to manage their pain in accordance with the care plan.
A resident with multiple health issues, including an amputation, did not receive necessary assistance for personal hygiene, resulting in unclean hair and soiled clothing. Despite a care plan requiring staff to offer and reattempt showers, the resident reported not having a shower since March. Facility logs lacked documentation of showers or refusals, and staff interviews revealed a failure to follow protocols, leading to a deficiency in care.
Missing Personal Property Reports Were Not Properly Investigated or Documented
Penalty
Summary
The facility failed to ensure reported concerns regarding missing personal property were investigated, documented, and addressed in accordance with its policy for two residents. The undated policy for Missing/Damaged Property/Suspected Crimes Reporting stated that when missing property is reported, Social Work or the weekend designee is to be notified, a form completed and sent to appropriate disciplines, the facility is to investigate the missing property, and Social Work with nursing assistance is to complete a closure report within five days. One resident, who had chronic kidney disease, chronic pain syndrome, and diabetes and was cognitively intact, reported a missing blue fabric zip-up jacket without a hood. The facility form documented searches of the resident’s closet, hamper, dresser drawers, roommate’s belongings, and shower rooms, and noted the resident said the jacket had been given to a laundry staff member and that laundry and housekeeping searched unclaimed items. However, the sections for who completed the report, who investigated it, and the closure report were blank, and the facility could not provide documented evidence that an investigation was completed, findings were determined, or resolution was communicated to the resident. A second resident, who had left above-the-knee amputation, hypertension, and left-sided hemiparesis and hemiplegia following a stroke and was cognitively intact, reported a missing wallet that had been given to staff for safekeeping. The Director of Social Work stated an email was sent regarding the missing wallet, but a missing item report was not completed and there had been no follow-up communication with the resident or family. The Director of Nursing confirmed that sending an email alone did not constitute a complete investigation, and the electronic record contained no nursing or social work notes documenting family notification regarding the missing wallet.
Failure to Provide Needed Grooming and Personal Hygiene Assistance
Penalty
Summary
The facility failed to ensure residents who were unable to perform activities of daily living received the necessary assistance to maintain good grooming and personal hygiene for two residents. The cited deficiency involved Resident #73 and Resident #15, both of whom required staff help with bathing, grooming, dressing, and personal hygiene. Facility policies stated staff were to assist residents with bathing, hair care, nail care, and dressing as needed, and residents had the right to care that supported dignity and a positive self-image. Resident #73 had diagnoses including heart failure, stage 3 CKD, and hepatic encephalopathy, and the MDS documented severely impaired cognition with staff assistance needed for personal hygiene and dressing. The care plan directed extensive assistance with grooming and total assistance with bathing and dressing. However, progress notes from late March through mid-May did not document showers, nail care, personal grooming, or refusals. On multiple observations, Resident #73 had a significant amount of facial hair, unclean fingernails with dark debris underneath, broken and jagged fingernails, and stained clothing; the resident stated staff had not offered to shave them and that they wanted to be shaved. The resident was also observed wearing the same stained sweatpants on consecutive days and was noted to have tremors in both hands. Resident #15 had diagnoses including COPD, chronic systolic HF, and CKD, and the MDS documented moderate cognitive impairment with staff assistance needed for showering and personal hygiene. The care plan and Kardex directed weekly showers with assistance and grooming support, and the TAR showed showers recorded on two dates during the review period. Despite this, Resident #15 was observed with visible chin hair, long fingernails, and greasy hair on multiple occasions, and stated the facial hair had not been shaved since the previous week and that a bath had not been received on one of the scheduled shower days. Additional record review did not show documentation that nursing staff recognized missed hygiene care or followed up to ensure completion of care.
Deficiencies in Resident Care and Documentation
Penalty
Summary
The facility failed to provide appropriate treatment and care for two residents, leading to deficiencies in care. Resident #13 did not have documented evidence of a bowel movement for more than three days, and there was no indication that bowel medications were ordered or administered per the facility's protocol. Additionally, there was no evidence that a medical provider was notified of the resident's condition. This lack of documentation and adherence to protocol resulted in a failure to address the resident's constipation effectively. Resident #59, who had nephrostomy tubes, experienced frequent lapses in documentation indicating that medical orders were completed. The resident was hospitalized and treated for pyelonephritis, a kidney infection, due to inadequate care and monitoring of the nephrostomy tubes. The facility staff had not received special training to care for nephrostomy tubes, which contributed to the resident's condition worsening. The facility's failure to ensure that nursing staff were trained and competent in nephrostomy tube care resulted in actual harm to the resident. Interviews with facility staff revealed a lack of training and competencies regarding nephrostomy tube care. Licensed Practical Nurses (LPNs) and other staff members were not adequately informed or trained to handle the specific needs of residents with nephrostomy tubes. The Director of Nursing acknowledged the absence of documented competencies or training for nephrostomy tube care, highlighting a significant gap in the facility's ability to provide appropriate care for residents with specialized medical needs.
Failure to Provide Nutritional Assistance Leads to Harm
Penalty
Summary
The facility failed to ensure acceptable nutritional parameters for two residents, leading to significant weight loss and the development of pressure ulcers. Resident #38, diagnosed with Alzheimer's dementia and moderate protein-calorie malnutrition, did not receive the necessary assistance during meals as outlined in their care plan. Despite being care planned for extensive assistance, observations revealed that the resident's meal trays were often left out of reach, and staff did not provide the required help, resulting in poor meal intake and a significant weight loss of 14.3% in one month. This weight loss was not timely reassessed, and the resident subsequently developed a stage three pressure ulcer. Resident #11, with diagnoses including dementia and dysphagia, was also care planned to receive extensive assistance with meals. However, observations showed that the resident was left to eat independently without staff assistance, and their prescribed nutritional supplement, Mighty Shake, was not consistently provided. The resident's weight decreased from 100 pounds in April to 88 pounds by October, with no documented evidence of a re-weight being obtained despite significant weight loss. The lack of staff intervention and failure to provide the nutritional supplement contributed to the resident's inadequate nutritional intake. Interviews with facility staff, including CNAs and LPNs, revealed a lack of understanding and adherence to the care plans regarding the level of assistance required for these residents. Staff failed to provide the necessary hands-on assistance and cueing during meals, as required for residents needing extensive assistance. Additionally, there was a lack of communication and documentation regarding the residents' weight loss and nutritional needs, further exacerbating the situation and leading to harm for the residents involved.
Lack of Competency in Nephrostomy Tube Care
Penalty
Summary
The facility failed to ensure that licensed nurses possessed the necessary competencies and skills to care for residents with specific medical needs, as evidenced by the case of a resident with nephrostomy tubes. The facility's assessment tool did not address conditions related to obstructive and reflux uropathy, chronic obstructive pyelonephritis, and the presence of urogenital implants, which were relevant to the resident's care. Despite having a policy for the care of nephrostomy tubes, the facility could not provide documented evidence of training or competencies for nursing staff regarding nephrostomy tube care. Interviews with various nursing staff, including Licensed Practical Nurses and the Nurse Educator/Infection Preventionist, revealed that they had not received any training or competencies related to nephrostomy tube care. The resident in question had diagnoses including obstructive and reflux uropathy, chronic obstructive pyelonephritis, and the presence of urogenital implants, with a care plan that required specific interventions for nephrostomy tube management. Despite physician orders detailing the necessary care procedures, such as flushing the nephrostomy tubes under sterile technique, the facility's staff lacked the documented training to perform these tasks competently. The Medical Director acknowledged the rarity of nephrostomy tubes in long-term care settings and emphasized the importance of following medical orders to prevent complications. However, the Director of Nursing and the Regional Administrator confirmed the absence of documented competencies or training for nephrostomy tube care, and the Quality Assurance committee was unaware of any related concerns.
Insufficient Staffing Levels Impact Resident Care
Penalty
Summary
The facility was found to have insufficient staffing levels during a recertification survey and complaint investigations, impacting the care and well-being of residents on both the second and third floors. Observations revealed that several residents remained in bed wearing hospital gowns during late morning hours, with some residents not receiving assistance with meals as care planned. Interviews with residents indicated dissatisfaction with the timing of assistance, with some residents expressing that they were not helped out of bed until much later than their preferred time. Additionally, residents reported that they were often left without assistance for extended periods, leading to episodes of incontinence. The staffing plan outlined by the facility included eight Certified Nursing Assistants (CNAs) for the day and evening shifts and four for the night shift. However, actual staffing levels frequently fell short of these numbers, with documented instances of only one or two CNAs being present on shifts that required more staff. This shortage was corroborated by interviews with staff members who acknowledged the heavy workload and the inability to meet residents' needs adequately. The Director of Nursing and other staff members admitted that when minimum staffing levels were not met, it resulted in delays in getting residents up and postponing scheduled showers. Residents voiced their concerns during a special Resident Council meeting, highlighting frequent short-staffing issues, particularly during evening shifts. They reported instances where they were told to remain in bed due to insufficient staff to assist them. The facility's staffing records from August to October 2024 further confirmed the recurring issue of inadequate staffing, with multiple days showing fewer CNAs than required. Despite these findings, the Regional Administrator claimed that the facility had met their staffing levels, contradicting the evidence gathered during the survey.
Failure to Address Resident Council Grievances
Penalty
Summary
During a Recertification Survey conducted from October 7 to October 15, 2024, it was found that the facility failed to address grievances and recommendations made by the Resident Council, affecting seven residents. The residents expressed concerns during a special Resident Council meeting about issues such as delayed call bell responses, staff shortages leading to missed showers, staff using personal phones during care, missing laundry items, and receiving cold food. Despite these grievances being raised in meetings over the previous three months, the facility did not provide responses or rationales for the issues brought up by the resident group. The residents were uncertain about the identity of the Grievance Official, although they frequently reported their concerns to the Director of Social Work. Meeting minutes from June, July, and September 2024 showed repeated concerns about call bell delays, difficulty finding aides, staff phone use during care, and issues with food and laundry services. However, these minutes lacked follow-up actions or rationales from the staff. Interviews revealed that the Director of Social Work and the Regional Administrator were unaware of the grievances and the lack of responses, and there was uncertainty about whether the Activities Director had been trained to take proper notes during Council meetings.
Failure to Provide Baseline Care Plans to Residents
Penalty
Summary
The facility failed to ensure that baseline care plans were reviewed or provided to residents or their representatives within 48 hours of admission, as required by their policy. This deficiency was identified during a recertification survey conducted from October 7 to October 15, 2024, involving ten residents. The facility's policy, dated June 2018, mandates that a baseline care plan be developed within 48 hours of admission and shared with the resident or their representative. However, the facility could not provide evidence that this was done for any of the ten residents reviewed. Interviews with staff revealed a lack of documentation and communication regarding the baseline care plans. The Licensed Practical Nurse Manager and the Director of Social Work indicated that the nursing department was responsible for reviewing and providing the care plans, but this was not consistently documented. The Director of Nursing confirmed that nurse managers were tasked with this responsibility, yet no documentation was available to verify compliance. The President of Operations acknowledged the inconsistency in reviewing baseline care plans with residents and their representatives.
Deficiency in Equipment Maintenance and Availability
Penalty
Summary
The facility failed to maintain mechanical, electrical, and patient care equipment in safe operating condition on both the Second and Third Floors. Specifically, a mechanical lift on the Third Floor was missing the rubber around one of its wheels, causing it to tilt and drag across the floor. Additionally, the facility did not have enough assistive equipment, such as mechanical lifts and sit-to-stand lifts, to meet the transfer needs of the residents. The monthly preventative maintenance logs and annual electrical inspection vendor logs did not match the lifts currently in use, indicating a lack of proper equipment tracking and maintenance. Interviews with residents and staff revealed that the equipment was faulty and insufficient. Residents reported that the lifts were not working well and were dirty, while staff confirmed that there were not enough lifts available, causing residents to wait for assistance. The Maintenance Director acknowledged the issues with the equipment but stated that repairs could not be made without approval. The Director of Nursing and Regional Administrator were unaware of the equipment issues and the shortage of lifts, indicating a communication gap between staff and leadership.
Deficiency in Nurse Call System Functionality
Penalty
Summary
The facility failed to maintain a functional nurse call system on the second floor, as observed during the Recertification Survey. The system lacked a central nurse call panel, and the audible component was non-functional. The facility's policy required all mechanical, electrical, and patient care equipment to be in safe operating condition, with immediate reporting and repair of any non-functioning equipment. However, the weekly nurse call system checks did not document the absence of a control station or the non-functionality of the audible component on the second floor. The manufacturer's manual indicated that the system was originally designed to have both audible and visual components, but these were not present or functioning. Interviews with staff revealed that there was no central call bell panel on the second floor, and staff had to rely on visual indicators, such as overhead corridor lights, to respond to call bells. The Maintenance Director confirmed that the second-floor system was outdated and lacked a panel and audible function, unlike the updated system on the third floor. Staff, including a CNA, reported difficulties in identifying which room's bathroom call bell was activated, as there was no audible alert, and they had to visually check each room. The Regional Administrator was unaware of the absence of a central call station and mistakenly believed the system was audible.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
During a Recertification Survey and complaint investigations, it was found that the facility did not maintain a medication error rate below five percent, resulting in a rate of 6.38 percent. This deficiency was observed in two residents during medication administration. For one resident with bipolar disorder, anxiety disorder, and major depressive disorder, the prescribed dose of lamotrigine was unavailable for administration. The LPN involved confirmed that the medication was not available in the Pyxis system. Another resident, diagnosed with neuropathy, vitamin B12 deficiency, and hypertension, did not receive their prescribed doses of gabapentin and cyanocobalamin due to unavailability. The LPN stated that the pharmacy had been contacted to reorder the cyanocobalamin, but it had not been delivered, and the gabapentin was not available in the Pyxis. Interviews with staff, including the Director of Nursing and the Regional Administrator, revealed that the facility was aware of ongoing issues with medication availability due to untimely pharmacy deliveries.
Significant Medication Errors Due to Unavailability
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the unavailability of prescribed medications for three residents. Resident #1, diagnosed with bipolar disorder and anxiety, was frequently unable to receive their prescribed medications, lorazepam and lamotrigine, due to them being unavailable in the facility. This was confirmed during a medication administration observation and through a review of the Medication Administration Record, which showed multiple instances where the medications were not administered as they were on order and awaiting arrival from the pharmacy. Resident #2, who suffered from chronic pain, also experienced significant medication errors due to the unavailability of their prescribed narcotic pain medication, tramadol. The Medication Administration Record indicated several occasions where the medication was not administered because it was either on order, awaiting a provider signature, or simply unavailable. This lack of medication availability was documented in the progress notes, highlighting a recurring issue with the pharmacy's supply chain. Resident #53, with multiple diagnoses including major depressive disorder and diabetes, faced similar issues with the unavailability of several critical medications, such as metoprolol, clopidogrel, trazodone, and Humalog insulin. The Medication Administration Record and progress notes revealed that these medications were often on order and not available for administration. Interviews with the Medical Director and Director of Nursing confirmed that there were ongoing issues with medication availability, communication with the pharmacy, and the management of medication orders, which contributed to these significant medication errors.
Failure to Implement Comprehensive Care Plans for Residents at Risk of Falls
Penalty
Summary
The facility failed to implement comprehensive person-centered care plans for two residents, leading to deficiencies in their care. Resident #38, who had diagnoses of dementia, depression, anxiety, and a right above the knee amputation, was care planned to have a low bed and a call bell within reach due to their severely impaired cognition and dependency on staff for mobility. However, observations revealed that the resident's bed was not consistently in the low position, and the call bell was not within reach, compromising their safety. Interviews with staff confirmed that the care plan was not followed, as the bed height and call bell placement were not checked as required. Similarly, Resident #19, with diagnoses of dementia, epilepsy, and osteoporosis, was care planned to have a fall mat placed next to their bed due to their high risk for falls. Observations showed that the fall mat was improperly placed, folded on the floor, and not next to the bed as required. Staff interviews indicated a lack of adherence to the care plan, as the fall mat was not checked or positioned correctly. These failures in implementing the care plans for both residents highlight deficiencies in ensuring the safety and well-being of residents at risk for falls.
Failure to Implement Wound Care Recommendations
Penalty
Summary
The facility failed to provide necessary care and treatment for a resident with a stage 3 pressure ulcer, as per professional standards and the recommendations of the Wound Care Nurse Practitioner. The resident, who had diagnoses including diabetes, high blood pressure, and end-stage kidney disease, did not receive the recommended wound care treatment for a sacral pressure ulcer from 09/27/2024 to 10/09/2024. The Wound Care Nurse Practitioner had recommended a specific treatment regimen on 09/26/2024, but this was not transcribed into the electronic medical record, resulting in a lack of documented evidence that the treatment was provided during this period. Interviews with facility staff, including LPNs and the Director of Nursing, revealed that there was a lapse in entering the wound care recommendations as orders in the electronic medical record. This oversight meant that there were no active orders for the resident's pressure ulcer care, leaving nurses without guidance on the necessary treatment. The facility's policy required that wound care treatments be ordered and documented, but this was not adhered to, leading to a deficiency in the care provided to the resident.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure adequate supervision and a hazard-free environment for Resident #19, who was at high risk for falls due to conditions such as dementia, epilepsy, and weakness. The resident's care plan required a fall mat on the floor and a low bed position, but these interventions were not consistently implemented. An unwitnessed fall occurred, and there was no documented assessment by a Registered Nurse following the incident, nor was there evidence that the bed was in a low position at the time of the fall. The facility's policies on falls and fall risk were not adhered to, as there was no comprehensive documentation of the fall incident, including the absence of a Registered Nurse's assessment. Additionally, the resident's medical record lacked information regarding the fall, and subsequent injuries such as skin tears and hematomas were not properly investigated or documented. The Director of Nursing noted that the resident's medications and conditions could contribute to bruising, but there was no formal investigation into the fall or notification to medical staff. Observations during the survey revealed that the fall mat was not in place as required by the care plan, and staff interviews confirmed that the care plan was not consistently followed. The Director of Nursing acknowledged the importance of investigating unwitnessed falls and ensuring proper documentation and assessment, but the facility failed to provide evidence of such actions for Resident #19's fall.
Inadequate Documentation for Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was not given psychotropic drugs unless necessary to treat a specific condition as diagnosed and documented in the clinical record. Specifically, a resident was prescribed an antipsychotic medication, Seroquel, without documentation of behavioral symptoms that presented a danger to the resident or others, symptoms of significant distress, or monitoring for the effectiveness of the medication. The consultant pharmacist made recommendations regarding the antipsychotic in August and September 2024, but the facility could not provide evidence that these recommendations were accepted or rejected by a medical provider. The resident, who had diagnoses including major depressive disorder and anxiety disorders, was first prescribed the antipsychotic on August 17, 2024, but a comprehensive care plan with measurable goals and interventions for its use was not developed until October 14, 2024. The facility's policy stated that antipsychotic medications should only be used for specific conditions and required detailed documentation of symptoms and effectiveness, which was not adhered to in this case. The resident's Minimum Data Set assessments indicated they were cognitively intact, had no or minimal depression, and did not exhibit behaviors, yet were taking both antidepressant and antipsychotic medications. Observations and interviews revealed that the resident appeared comfortable and did not show signs of depression, anxiety, or distress. The Medical Director and Director of Nursing acknowledged the lack of proper documentation and the need for better nursing documentation of behaviors. The Medical Director also noted that the provider who prescribed the Seroquel had passed away unexpectedly, leaving no note related to the order. Despite the facility's monthly psychotropic medication review meetings, there was no clear documentation supporting the use of Seroquel for the resident's condition.
Incomplete Investigation of Resident Fall Incident
Penalty
Summary
The facility failed to thoroughly investigate an incident involving a resident who sustained a major injury. The incident occurred when the resident, who had a history of falling and was cognitively intact, fell while being assisted in the bathroom by a staff member, resulting in a patella fracture. The facility's policy required a comprehensive investigation, including obtaining statements from all involved parties, but this was not completed. The Accident-Incident report for the fall did not include statements from the involved staff members or the resident, and the Certified Nursing Assistant present during the fall was not identified. The Director of Nursing acknowledged that the investigation was incomplete without the Certified Nursing Assistant's statement, which was missing and could not be located as the employee was no longer with the facility. Interviews with staff, including the Licensed Practical Nurse Manager and the Director of Nursing, revealed that the investigation process was not followed as required. The Director of Nursing admitted that the investigation was not complete and that it was unclear if the resident's care plan was followed during the incident.
Failure to Provide Adequate Nail Care for Residents
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living received necessary services to maintain good grooming and personal hygiene. Specifically, two residents were observed with unclean and uncut fingernails over multiple days. Resident #53, who had a history of stroke with left-sided hemiplegia, diabetes, and anxiety, was dependent on staff for assistance with all activities of daily living. Despite having a care plan that required weekly nail care on shower days, Resident #53's fingernails were observed to be long and unclean with a dark substance underneath them over several days. The resident expressed a desire for their nails to be cleaned, and there was no documented evidence of refusal of nail care in their medical record. Similarly, Resident #25, who had diagnoses including diabetes, high blood pressure, and end-stage kidney disease, required assistance with hygiene. Despite being cognitively intact and having a care plan that required extensive assistance with grooming, Resident #25 was observed with long fingernails and dark debris under them. The resident stated that no one had helped them with nail care, and observations confirmed that their nails remained unclean even after their scheduled shower day. Interviews with staff revealed inconsistencies in the provision and documentation of nail care, contributing to the deficiency.
Failure to Administer Pain Medication as Prescribed
Penalty
Summary
The facility failed to manage the pain of Resident #2 in accordance with the comprehensive assessment and plan of care. Resident #2, who had chronic pain due to conditions such as osteoporosis and polymyalgia rheumatica, did not receive their prescribed pain medication, tramadol, on multiple occasions. The Medication Administration Record for October 2024 showed that doses were not documented as administered on several dates and times, and there was no evidence that the medical team was notified about the unavailability of the medication. Interviews and record reviews revealed that the pharmacy had not delivered the tramadol, and the nursing staff, including Licensed Practical Nurse #3 and the Nurse Manager, were aware of the situation. Despite contacting the pharmacy and notifying the nurse manager, there was no documented evidence that the medical provider was informed about the medication's unavailability. Resident #2 consistently reported high levels of pain, rating it between eight and nine out of ten, and expressed that their pain was not alleviated by the medications provided. The Director of Nursing acknowledged the importance of administering pain medication to keep residents out of pain and stated that the process for obtaining medications should be automatic. However, issues with obtaining narcotic medications from the pharmacy were noted, as orders required a doctor's signature before being sent. The facility's policy required pain levels to be documented every shift, but the failure to ensure the availability and administration of pain medication led to the deficiency.
Resident Hygiene Neglect Due to Inadequate Shower Assistance
Penalty
Summary
The facility failed to ensure that a resident who was unable to perform activities of daily living independently received the necessary services to maintain good grooming and personal hygiene. Specifically, a resident with diagnoses including kidney disease, heart failure, and an above-the-knee left leg amputation, who required assistance with showering and bathing, was observed with unclean hair and soiled clothing over two days. The resident reported not having received a shower since March, despite their preference for showers and the facility's care plan indicating that staff should offer assistance with showers and reattempt if initially refused. The resident's shower logs showed only two showers in March and April, with no documentation of showers or refusals in May. Interviews with facility staff revealed a lack of documentation and follow-up regarding the resident's shower schedule. The unit Shower Log for May was blank, and staff could not recall the last time a skin assessment was completed for the resident following a shower. The Director of Nursing acknowledged that there was no excuse for a resident not receiving a shower and emphasized the importance of documenting refusals and reattempting to offer showers. Despite these protocols, the resident continued to wear the same soiled clothing and had not been offered a shower, highlighting a deficiency in the facility's care practices.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 153 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fairport
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aaron Manor Rehabilitation And Nursing Center | 1.3 mi | ★★★★★ | 0 | 0 |
| Fairport Rehabilitation And Nursing Center | 2.8 mi | ★★★★★ | 0 | 0 |
| Highlands Living Center | 3.2 mi | ★★★★★ | 2 | 0 |
| St John's Penfield Homes | 4 mi | — | 0 | 0 |
| Penfield Place | 4.8 mi | ★★★★★ | 0 | 0 |
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