Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Daleview Care Center during CMS and state inspections, most recent first.
A resident with major depressive disorder, Parkinson’s disease, and severe cognitive impairment remained on quetiapine 100 mg BID even after psychiatry recommended lowering Seroquel to 25 mg BID for one week and then stopping it. The consult was misfiled in the EMR, so the primary provider did not see it, and the GDR was not implemented for over a month. Progress notes continued to list Seroquel, Remeron, ropinirole, supportive care, and psychiatry follow-up, while staff later stated the missed consult explained why the dose reduction was delayed.
Failure to implement a person-centered skin care plan: A resident with DM, PVD, CVA, moderate cognitive impairment, and a diabetic heel ulcer was ordered to have heels offloaded at all times, but repeated observations found the heels resting directly on a pillow while in bed. The RN UM stated this was considered offloading and did not readjust the pillow, while the Nursing Educator, wound MD, and DON stated the heels must not touch any surface.
A resident with cellulitis, DM, chronic venous insufficiency, and severe cognitive impairment had a CCP for skin integrity that did not include ordered compression socks, and staff observed ace wraps on both lower extremities during the day. An RN stated the ace wraps were omitted from the CCP, and the DON later stated they should have been included because the care plan should reflect the resident’s total care.
A resident with chronic bilateral elbow pain, CVA, Parkinson’s disease, and lumbar radiculopathy did not have pain medication ordered on admission despite pain noted in nursing and OT assessments. When the resident later reported severe bilateral elbow pain rated 8/10, the RN supervisor delayed treatment while waiting for the PA to assess the resident, and Tylenol was not given until more than two hours later. The record also showed no documented assessment of the OT-reported pain and no ordered elbow dressings were in place during observation.
Crushed Extended-Release Potassium Chloride: An LPN crushed an extended-release potassium chloride tablet and mixed it in applesauce before giving it to a resident with cancer, DM, and osteomyelitis. The blister pack stated do not crush and noted the tablet could be dissolved in water before administration. The LPN said they did not realize the label said not to crush it, and the pharmacist, nursing educator, and DON all confirmed the medication should not have been crushed.
Unlabeled and undated medications were found during survey observations. An open tube of hydrocortisone cream was left in a shower room, and an opened insulin pen plus opened eye drops on a med cart lacked dates showing when they were first opened. Staff stated the items should have been labeled and stored in medication or treatment carts, and the pharmacist confirmed the discard intervals for the insulin pen and eye drops.
Incomplete Documentation of Discontinued Contact Precautions: A resident with an indwelling catheter, neurogenic bladder, diabetes, and hemiplegia had contact isolation precautions documented in the care plan and physician orders for VRE, Klebsiella, and Pseudomonas. Staff stated the precautions were verbally discontinued when IV antibiotics were stopped, but the EMR was not updated for several days, no nursing progress note was written, and contact isolation signage was not posted outside the room during observations while EBP signage remained in place.
An LPN failed to maintain infection control during wound care for a resident with diabetic foot ulcers by not sanitizing the overbed table, not setting up a clean field, and not washing hands or changing gloves between wound care steps. In a separate observation, an LPN cleaned a glucometer with alcohol prep pads and hand wipes instead of the facility’s EPA-approved germicidal wipes after resident use.
Two residents in an LTC facility did not receive adequate pressure ulcer care. One resident developed a new Stage 2 ulcer without proper assessment or physician's order, and treatment was administered without authorization. Another resident's care plan was not updated to reflect necessary interventions, and staff failed to document or perform required care. Interviews revealed communication and documentation lapses among staff.
An unsecured oxygen E-Cylinder tank was found beside a resident's bed, contrary to facility policy requiring tanks to be secured. The resident, with a history of acute renal failure and COPD, was receiving oxygen therapy, although the physician's order had been discontinued. Staff interviews revealed a lack of awareness about the tank's presence and proper securing, with the DON confirming the need for securing to prevent hazards.
A facility failed to label enteral feeding equipment for a resident, leading to a deficiency. Observations showed the feeding bottle and water bag lacked labels with the resident's name, start time, and physician instructions. Interviews revealed that nurses forgot to label due to busyness and lack of supplies. The Unit Manager and DON confirmed labeling is required.
The facility failed to ensure proper documentation when a Nurse Practitioner disagreed with a Pharmacist's recommendations for two residents. The Nurse Practitioner did not provide clinical rationale for disagreeing with medication recommendations for residents with conditions like Orthostatic Hypotension and Multiple Myeloma. Interviews revealed the Nurse Practitioner was unaware of the documentation requirement.
An LPN at an LTC facility crushed and administered an extended-release Metoprolol tablet to a resident, despite a physician's order not to crush it. The facility's policy did not address extended-release medications, contributing to the error. The resident, with a history of hypertension, was not monitored for blood pressure changes post-administration, highlighting a significant oversight.
A resident with severe cognitive impairment was found with an unlabeled Albuterol inhaler on their bed, without a physician's order or assessment for self-administration. The facility's policy requires medications to be stored in locked compartments, which was not adhered to in this case. Nursing staff were unaware of the inhaler's presence, and the DON confirmed that the resident should not have had unsupervised access to medications.
A facility failed to maintain proper infection control practices for a resident with Influenza. Staff members were observed not wearing appropriate PPE, such as gowns, N95 masks, and eye protection, while cleaning the resident's room, despite the facility's policies requiring such precautions. Management confirmed that staff were expected to follow isolation precaution directions, but these were not adhered to, resulting in a deficiency.
A facility failed to complete a resident's Annual MDS assessment within the required 12-month period, resulting in a delay of 369 days since the last assessment. The delay was attributed to the MDS Director being on vacation, and the facility lacked a backup assessor to ensure timely completion. The resident had a history of cellulitis, hypertension, and dysuria, with mild cognitive impairment.
A facility failed to transmit a resident's MDS assessment to CMS within the required 14-day period. The assessment was completed but not submitted until 15 days later due to the MDS Director being on vacation. The facility's policy requires timely transmission, and a backup assessor should have been in place.
A resident with severe cognitive impairment and an elopement risk exited an LTC facility undetected through an unalarmed door. The resident was found by police 0.2 miles away, but staff did not notice the absence until hours later. The facility's policies on elopement prevention and Wander Guard monitoring were not effectively implemented, contributing to the incident.
Failure to Implement Psychiatry-Recommended GDR for Antipsychotic
Penalty
Summary
The facility failed to ensure that a resident was free from chemical restraints not required to treat medical symptoms. Resident #1 had diagnoses including diabetes mellitus, Parkinson’s disease, major depressive disorder, and severe cognitive impairment, with no behaviors documented on the admission MDS and mood indicators including little interest in doing things, feeling down or depressed, sleeping too much or trouble falling asleep, and feeling tired or having little energy. The resident was receiving quetiapine 100 mg twice daily for major depressive disorder with psychiatric symptoms. A psychiatry consultation on 03/31/2026 documented that the resident had intellectual disability/developmental delay, was a poor historian, had no psychosis, mania, suicidal or homicidal ideation, or hallucinations, and recommended starting Lexapro and lowering Seroquel to 25 mg twice daily for one week and then stopping it. The record showed that the consultation was misfiled in the wrong section of the electronic medical record and was not seen by the primary provider. During the period after the consult, the resident was seen multiple times by the physician assistant, and progress notes continued to document major depression/intellectual disability with Seroquel, Remeron, ropinirole, supportive care, and psychiatry follow-up. The recommended gradual dose reduction from the psychiatry consult was not implemented until 05/06/2026, more than a month after the consult. The physician assistant stated that on 05/04/2026 they noticed a gradual dose reduction had not been done and lowered quetiapine to 50 mg twice daily because the psychiatry consult had not been seen. The primary physician stated that if the consult had been seen, the dose would have been changed to 25 mg twice daily as recommended. The DON stated the primary doctor was expected to address consultant recommendations, but the consult had been stored in the wrong section of the EMR and therefore was not addressed.
Failure to Implement Heel Offloading in Care Plan
Penalty
Summary
The facility failed to ensure that a comprehensive person-centered care plan was implemented with measurable objectives and time frames to meet the resident’s medical and nursing needs identified in the comprehensive assessment. Resident #43 was admitted with diagnoses including diabetes mellitus, peripheral vascular disease, and cerebrovascular accident. The admission MDS documented a BIMS score of 10, indicating moderate cognitive impairment, and the resident had a diabetic ulcer and was at risk for pressure ulcer development. The Braden Scale dated 04/10/2026 documented a score of 14, indicating moderate risk for pressure ulcer development. The care plan effective 04/13/2026 for skin integrity documented interventions to monitor for signs and symptoms of infection and apply local treatments as ordered by the physician. A physician’s order dated 04/20/2026 documented to offload the heels at all times, and a later order dated 04/27/2026 documented treatment for the right heel diabetic foot ulcer. A wound consult on 04/27/2026 documented the right heel diabetic foot ulcer was resolved but the area remained tender, and recommended cleansing with normal saline, applying skin prep, covering with dry dressing, and offloading the heels at all times. During observations on 05/04/2026, 05/05/2026, and 05/06/2026, the resident was in bed with socks on and the heels were resting directly on a pillow and were not offloaded. During an observation with the RN Unit Manager on 05/05/2026, the RN Unit Manager stated that when the heels are resting on a pillow, it is considered offloading and did not readjust the pillow. The Nursing Educator, Wound Care Physician, and DON later stated that offloading heels means the heels are not touching any surface and the pillow must be placed under the lower legs so the heels are off the bed or pillow.
Care Plan Not Updated to Reflect Ordered Compression Therapy
Penalty
Summary
The facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team to reflect a resident’s preferences and status after assessment. Resident #117 was admitted with cellulitis, diabetes, and chronic venous insufficiency, and the annual MDS documented severe cognitive impairment with a BIMS score of 5 and an active diagnosis of peripheral vascular disease. The comprehensive care plan for skin integrity documented local treatment and monitoring for infection, but it did not include the physician-ordered compression socks for both legs in the morning and removal at bedtime. During observations, the resident was seen sitting in a wheelchair with ace wraps on both lower extremities on two separate occasions. A charge nurse stated the resident had a physician’s order for ace wraps and acknowledged they were not included in the comprehensive care plan, stating the omission was because of the resident’s chronic cardiac condition. A later comprehensive care plan for chronic venous insufficiency included applying ace wraps to both lower extremities daily at 9:00 AM and removing them daily at 9:00 PM. The DON stated the ace wraps should have been included in the resident’s comprehensive care plan and that nurses should be aware care plans are updated with any changes because the care plan reflects the total care of the resident.
Delayed Pain Medication for Resident with Severe Bilateral Elbow Pain
Penalty
Summary
Safe, appropriate pain management was not provided for a resident with chronic bilateral elbow pain. The resident was admitted with diagnoses including cerebrovascular accident, Parkinson’s disease, and radiculopathy of the lumbar region, and the admission nursing assessment documented mild joint pain with activities, facial grimacing, and verbal complaints. The comprehensive care plan included pain management interventions, but the record showed no documented assessment of the pain identified by OT and no pain medication ordered at admission. An OT assessment documented pain interfering with functional activity in both elbows and the right knee, and nursing was notified. The physician history and physical did not document non-surgical pain, and the medical record showed no pain medication order from admission until 05/05/2026. During an observation that morning, the resident was in bed with a RN supervisor present, complained of pain in both elbows, had no ordered dressings on the elbows, and rated the pain as 8 out of 10. The RN supervisor stated they would call the physician for pain medication, but did not address the missing dressings, the duration or characteristics of the pain, or factors that made it better or worse. The resident continued to report elbow pain later that morning, describing it as feeling like a constant “funny bone” pain in both elbows, and there were still no dressings present. The RN supervisor stated the resident did not have a pain medication order and that the PA wanted to see the resident first because this was a new pain complaint. A one-time Tylenol order was then written and administered more than two hours after the resident reported severe pain. Later that day, the PA documented chronic bilateral upper extremity pain and ordered IV acetaminophen for improved pain control. Interviews with the PA, DON, admission nurse, OT, and physician reflected that the resident had complained of pain and that severe pain should be medicated as soon as possible.
Crushed Extended-Release Potassium Chloride
Penalty
Summary
The facility failed to ensure pharmaceutical services were provided to meet resident needs when an LPN crushed an extended-release potassium chloride tablet during medication administration for a resident with cancer, diabetes mellitus, and osteomyelitis. The resident’s 05/06/2026 MDS documented a BIMS score of 13, indicating the resident was cognitively intact. A physician’s order dated 04/30/2026 directed potassium chloride extended release, 10 mEq, one tablet by mouth daily at 9:00 AM for hypokalemia, and another order stated that appropriate medications may be crushed unless contraindicated. During the medication administration observation on 05/05/2026 at 8:17 AM, the LPN crushed the extended-release potassium chloride tablet, mixed it in applesauce, and administered it to the resident. When the blister pack was later reviewed, it stated the tablet was to be given whole, do not crush, and that the whole tablet may be dissolved in four ounces of water prior to administration. The LPN stated they did not realize the label documented that the medication should not be crushed and acknowledged it should not have been crushed. The pharmacist stated the extended-release potassium chloride tablet should not be crushed, the nursing educator stated an extended-release medication should never be crushed, and the DON stated the nurse must read the blister pack label prior to administration and follow facility policy.
Unlabeled and Undated Medications Found in Storage Areas
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored and labeled in accordance with currently accepted professional principles. During the initial tour, an unlabeled open tube of 1% hydrocortisone cream was observed on the ledge in the Unit 3 shower room. A charge nurse stated that no medication should be left in shower rooms and did not know who had left the unlabeled hydrocortisone there, adding that treatment creams should be stored in medication or treatment carts. During medication storage review of the Unit 2 medication cart, an opened Lantus Solostar insulin pen and an opened bottle of latanoprost eye drops were both found without dates showing when they were first opened. The medication nurse stated they were not aware the items were missing opened dates and said the dates should have been written to determine discard timing. The unit manager and pharmacist stated the insulin pen should be discarded 28 days after opening, and the pharmacist stated the latanoprost eye drops should be discarded 42 days after opening. The DON stated nurses should document opened dates on medication bottles or pens with a set expiration date and that medications should be properly labeled and locked in medication or treatment carts.
Incomplete Documentation of Discontinued Contact Precautions
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for one resident reviewed for catheter care. Resident #28, who had diagnoses including neurogenic bladder, diabetes, and hemiplegia, had an indwelling catheter and was documented on the MDS as being on isolation or quarantine for active infectious disease while a resident. The resident’s care plan included contact isolation precautions, and a physician’s order renewed on 04/27/2026 documented contact isolation for VRE, Klebsiella, and Pseudomonas in the wound. Although the resident’s contact precautions were discontinued on 04/21/2026 according to staff interviews, the medical record was not updated to reflect that discontinuation until 05/05/2026. During observations on 05/04/2026 and 05/05/2026, Enhanced Barrier Precaution signage was posted outside the resident’s room, but contact isolation signage was not present. The Infection Preventionist stated the resident should have contact isolation signage outside the room, while the Unit Manager stated the precautions were discontinued verbally, but the order was not discontinued, the Infection Preventionist was not notified, and no nursing progress note was written. The PA stated they told the Unit Manager to discontinue the contact isolation precautions and should have documented it in the medical progress note and written an order to discontinue the precautions.
Infection Control Failures During Wound Care and Glucometer Disinfection
Penalty
Summary
The facility failed to maintain an infection prevention and control program during wound care for a resident with diabetes mellitus, peripheral vascular disease, cerebrovascular accident, and diabetic foot ulcers. The resident had a brief interview for mental status score of 10 on the admission MDS, indicating moderate cognitive impairment, and had care plans and physician orders for a right heel diabetic foot ulcer and a left 5th toe diabetic foot ulcer. The wound consultation documented the right heel ulcer as resolved but still tender, and the left toe ulcer remained open and required cleansing, betadine, and a dry dressing. During the wound care observation, an LPN placed wound care supplies on the resident’s overbed table without first sanitizing the table or setting up a clean field that fully covered the surface. Some supplies were directly touching the table, and other items, including a television remote control and a compression knee sleeve, were also on the table nearby. The LPN removed the old dressings from the foot wounds, then put on clean gloves without washing hands. After cleansing the right heel wound, the LPN applied the skin prep and dry dressing without changing gloves or sanitizing hands between steps. The facility also failed to use the correct cleaning agent for a glucometer during medication storage and labeling observations. An LPN stated they cleaned the glucometer between residents with alcohol prep pads and instant hand sanitizing wipes, and demonstrated that process. Facility records and staff interviews identified that the glucometer was to be cleaned and disinfected with EPA-approved germicidal wipes after each resident use, but the LPN used alcohol pads and hand wipes instead. Staff interviews confirmed that alcohol prep pads and hand wipes were not the approved cleaning agents for the glucometer, and that the EPA-approved germicidal wipes were the facility’s designated disinfectant for the device.
Inadequate Pressure Ulcer Care for Two Residents
Penalty
Summary
The facility failed to provide adequate pressure ulcer care for two residents, leading to deficiencies in treatment and prevention of new ulcers. Resident #90, who had multiple pressure ulcers, was observed with a new Stage 2 pressure ulcer on the right buttock during a wound care observation. There was no documented assessment or physician's order for this new ulcer, and treatment was administered without proper authorization. The wound care nurse and other staff members failed to communicate and document the presence of the new ulcer, leading to a lack of appropriate care. Resident #237, who was admitted with a Stage 2 pressure ulcer on the sacrum, did not receive the recommended treatment frequency as per the wound physician's orders. The care plan was not updated in a timely manner to reflect the necessary interventions, such as turning and positioning every two hours. The facility's staff did not document or consistently perform the required interventions, resulting in inadequate care for the resident's pressure ulcer. Interviews with facility staff revealed a lack of communication and documentation regarding the residents' conditions and care needs. The Director of Nursing Services and other staff members acknowledged the failures in following physician orders and updating care plans. These deficiencies highlight the facility's inability to ensure that residents with pressure ulcers receive necessary treatment and services consistent with professional standards of practice.
Unsecured Oxygen Tank Poses Hazard
Penalty
Summary
The facility failed to ensure that a resident's environment was free from accident hazards, as observed during a recertification survey. Specifically, an unsecured oxygen E-Cylinder tank was found on the right side of a resident's bed. The facility's policy requires that oxygen tanks be secured in a rolling safety stand, metal rack, or chained to the wall. The resident in question had a history of acute renal failure with hypoxia and chronic obstructive pulmonary disease (COPD) and was receiving oxygen therapy via an oxygen concentrator at the time of the observation. However, the resident's physician's order for oxygen therapy had been discontinued prior to the survey. Interviews with facility staff revealed a lack of awareness regarding the presence and proper securing of the oxygen tank. A Certified Nursing Assistant did not notice the tank during morning care, and both a Licensed Practical Nurse and a Registered Nurse were unaware of who placed the tank by the bed. The Unit Manager explained that the tank might have been brought in due to a power outage the previous day. The Director of Nursing Services confirmed that the tank should have been secured to prevent potential hazards, such as falling or exploding.
Failure to Label Enteral Feeding Equipment
Penalty
Summary
The facility failed to ensure proper labeling of enteral feeding equipment for a resident with a feeding tube, leading to a deficiency in care. During the recertification survey, it was observed that the enteral feeding bottle and water bag for a resident receiving tube feeding were not labeled with the resident's name, the time feeding was started, or the feeding directions as prescribed by the physician. This lack of labeling was noted during observations on two separate occasions on the same day. Interviews with nursing staff revealed that the labeling oversight was due to a combination of forgetfulness and lack of available supplies, such as a marker or pen. The Licensed Practical Nurse on the morning shift did not notice the missing labels, while the nurse from the previous evening shift admitted to forgetting to label the equipment due to being busy with other tasks. The Unit Manager and Director of Nursing Services confirmed that proper labeling is required and that it is the responsibility of the nursing staff on each shift to ensure compliance.
Failure to Document Pharmacist Recommendation Disagreements
Penalty
Summary
The facility failed to ensure that the Physician documented in the resident's medical record that the irregularity identified by the Pharmacist had been reviewed and what action had been taken to address it. This deficiency was identified during a Recertification Survey for two residents reviewed for unnecessary medications. Specifically, the Nurse Practitioner disagreed with the recommendations provided by the Consultant Pharmacist for both residents but did not document the reason for the disagreement in the residents' medical records. Resident #121, who had diagnoses including Atrial Fibrillation and Orthostatic Hypotension, was receiving both Midodrine and Fludrocortisone. The Consultant Pharmacist recommended evaluating the need for both medications and considering discontinuing one. The Nurse Practitioner disagreed with this recommendation but failed to provide a clinical rationale for the disagreement. Similarly, Resident #116, with diagnoses including Benign Prostatic Hyperplasia and Multiple Myeloma, was receiving multiple medications, including Haloperidol and Melatonin. The Consultant Pharmacist made several recommendations regarding these medications, but the Nurse Practitioner disagreed without documenting any clinical rationale. Interviews with the Nurse Practitioner and Primary Physician revealed that the Nurse Practitioner was unaware of the requirement to document the rationale for disagreeing with the Pharmacist's recommendations. The Primary Physician acknowledged that the Nurse Practitioner should have documented a response when disagreeing with the recommendations. This lack of documentation and communication led to the deficiency identified during the survey.
Medication Administration Error: Crushing Extended-Release Medication
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors during a recertification survey. Specifically, a Licensed Practical Nurse (LPN) crushed and administered Metoprolol Succinate Extended Release, a medication with a physician's order indicating it should not be crushed, to a resident diagnosed with Essential Hypertension. The facility's policy on medication administration did not specifically address the handling of extended-release medications, which contributed to the error. The LPN, unaware of the specific instructions not to crush the medication, relied on the medication blister pack label, which did not indicate the restriction, leading to the administration error. The resident involved had a recent admission with diagnoses including Joint Replacement Surgery, Diabetes Mellitus, and Hypertensive Heart Disease. The error was identified during a medication administration observation, and subsequent interviews with the LPN, Medical Director, Pharmacist, and other nursing staff confirmed the mistake. The Medical Director and Pharmacist highlighted the potential risks of crushing extended-release medications, such as a sudden drop in blood pressure. Despite the error, there was no documentation of monitoring the resident's blood pressure following the administration of the crushed medication, which was a significant oversight in the resident's care.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in locked compartments, as required by regulations. During a recertification survey, it was observed that a resident with severe cognitive impairment had an unlabeled Albuterol inhaler on top of their bed without any nursing staff present. The resident did not have a physician's order for the Albuterol inhaler and was not assessed to self-administer medication. The facility's policy mandates that medications be stored in locked compartments and that residents participating in a self-administration program have a locked medication cabinet in their room. The resident in question was admitted with chronic lung conditions, including Chronic Obstructive Pulmonary Disorder and Emphysema, and had a physician's order for a different inhaler, Breo Ellipta, to be administered once daily by nursing staff. Interviews with nursing staff revealed that they were unaware of the presence of the Albuterol inhaler and confirmed that the resident was not capable of self-administering medication due to confusion. The Director of Nursing Services acknowledged that the resident should not have had access to medications without supervision, highlighting a lapse in the facility's medication storage and handling procedures.
Inadequate Infection Control Practices for Influenza Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper use of Personal Protective Equipment (PPE) by staff members when dealing with a resident diagnosed with Influenza. Resident #283, who was readmitted to the facility with a positive diagnosis of Influenza, was placed under Contact and Droplet Precautions. However, during observations, staff members were seen cleaning the resident's room without wearing the appropriate PPE, such as gowns, N95 masks, and eye protection, as required by the facility's infection control policies. This oversight was noted during two separate observations involving different staff members. The facility's policies clearly outlined the need for droplet and contact precautions, including the use of specific PPE to prevent the transmission of infectious agents like the Influenza virus. Despite this, staff members failed to adhere to these protocols, as evidenced by one staff member exiting the room without removing PPE and another reaching out of the room to access additional PPE while still wearing contaminated gloves. Interviews with facility management confirmed that staff were expected to follow the isolation precaution directions provided on the signage, but these expectations were not met, leading to a deficiency in infection control practices.
Failure to Timely Complete Annual MDS Assessment
Penalty
Summary
The facility failed to conduct a comprehensive assessment of a resident at least once every 12 months, as required. Specifically, the Annual Minimum Data Set (MDS) assessment for a resident was completed 369 days after the previous comprehensive assessment, exceeding the 366-day requirement. Additionally, the assessment was not completed until 21 days after the Assessment Reference Date, which was a delay beyond the expected timeline. The resident involved had a history of cellulitis, hypertension, and dysuria, and was noted to have mild cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 10. Interviews with facility staff revealed that the delay in completing the MDS assessment was due to the MDS Director being on vacation at the time the assessment was due. The Director of Nursing Services indicated that the staff have five days to complete their assigned sections of the MDS, and the MDS Coordinator is responsible for ensuring timely completion. The facility's Administrator acknowledged the importance of completing MDS assessments on time and suggested that a backup assessor should be in place to prevent such delays.
Delayed Transmission of MDS Assessment
Penalty
Summary
The facility failed to ensure that all completed Minimum Data Set (MDS) assessments were electronically transmitted to the Center for Medicare and Medicaid Services (CMS) within the required 14-day period following the completion of the resident assessment. This deficiency was identified during a Recertification Survey for one resident, whose Annual MDS assessment was completed on February 10, 2025, but was not transmitted until February 25, 2025, which was 15 days after the completion date. The facility's policy requires timely and accurate completion and transmission of MDS assessments, and the MDS Coordinator is responsible for this process. The delay in transmission was attributed to the MDS Director being on vacation at the time the assessment was due for transmission. The Director stated that any Registered Nurse could have completed and transmitted the MDS assessment in their absence. Interviews with the Director of Nursing Services and the Administrator confirmed that the facility's protocol requires timely transmission of MDS assessments and that a backup assessor should be in place to ensure compliance with this requirement.
Resident Elopement Due to Inadequate Monitoring and Unalarmed Exit
Penalty
Summary
The facility failed to ensure a secure environment free from accident hazards, resulting in a resident with severe cognitive impairment and an assessed risk for elopement exiting the facility undetected. The resident, who had a history of exit-seeking behavior, left through an unalarmed south stairwell emergency exit door. The resident was found by local law enforcement 0.2 miles away from the facility approximately 45 minutes after leaving, but the facility staff did not identify the resident as missing until over two hours later. The facility's policies on elopement prevention and the use of Wander Guards were not effectively implemented. The resident had a Wander Guard placed on their right hand, which was supposed to be checked every shift. However, documentation showed inconsistencies in monitoring, and the Wander Guard was found intact in the dining room after the incident. Surveillance footage revealed that the resident exited the building through a door that was not equipped with an alarm, which was a known issue as the door was used by staff and delivery personnel. Interviews with staff indicated a lack of immediate response and awareness regarding the resident's whereabouts. The CNA assigned to the resident's shift did not document the Wander Guard check, and the LPN on duty did not notice the resident's absence until hours later. The Director of Maintenance confirmed the lack of an alarm on the exit door, and the Director of Nursing acknowledged the failure in monitoring the resident's Wander Guard. These lapses contributed to the resident's undetected elopement and delayed response in locating them.
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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 East Farmingdale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Massapequa Center Rehabilitation & Nursing | 3.3 mi | ★★★★★ | 0 | 0 |
| Central Island Healthcare | 3.6 mi | ★★★★★ | 0 | 0 |
| Parkview Care And Rehabilitation Center, Inc | 4.2 mi | ★★★★★ | 0 | 0 |
| Belair Care Center Inc | 5.5 mi | ★★★★★ | 0 | 0 |
| Berkshire Nursing & Rehabilitation Center | 5.7 mi | ★★★★★ | 5 | 0 |
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