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 Susquehanna Nursing & Rehabilitation Center, L L C during CMS and state inspections, most recent first.
The facility failed to maintain consistently adequate hot water temperatures for resident use, despite policies requiring water between 90°F and 110°F and procedures for reporting and managing hot water loss. Over several weeks, multiple work orders documented no hot water in various areas, and maintenance staff repeatedly reset an electronic mixing valve and boiler without consistently documenting these actions or rechecking temperatures. A resident room sink was measured at 85.6°F, and residents reported lukewarm or cold showers, with some stating they had gone weeks without a proper shower. CNAs and an RN described intermittent hot water that would turn cold shortly after resets, leading staff at one point to bring hot water from the kitchen for a bed bath without documented temperature checks. Leadership interviews showed inconsistent awareness and communication about the extent and duration of the problem, the loss-of-hot-water policy was not formally activated, and there was no documented staff training or systematic verification of water temperatures during the deficiency period.
The facility failed to provide adequate care for two residents, one with a feeding tube and another requiring lorazepam for anxiety. The feeding tube placement and residuals were not checked for months, leading to the resident's death. The other resident did not receive their medication for seven days due to reordering issues and lack of communication with the provider. Staff interviews revealed gaps in training and adherence to protocols.
A facility failed to conduct a thorough investigation following an abuse allegation involving a resident. The administration did not ensure accurate documentation, and staff statements were falsified. Key staff members were unaware of the falsification, and the incident was not reported to the Department of Health. The accused staff member was not suspended during the investigation, compromising resident safety.
Two residents in an LTC facility experienced inadequate pressure ulcer care, with one developing a Stage 4 ulcer leading to sepsis and hospitalization. The facility failed to consistently document wound care and assessments, contributing to the deficiencies. Staff interviews revealed lapses in following protocols for treatment documentation and reporting.
The facility failed to properly label and store medications, with multiple instances of medications lacking opened or expired/discard dates and resident identifiers on medication carts. Staff admitted to administering these medications without verifying expiration, contrary to facility policies.
The facility failed to maintain professional standards in food preparation and sanitation, with observations of uncleanliness and improper food handling in the main kitchen and Third floor kitchenette. Issues included debris on floors, leaking sinks, and improper food cooling. Staff interviews revealed a lack of clarity and training regarding cleaning responsibilities and food cooling procedures.
The facility failed to maintain a clean and homelike environment, with issues such as peeling wallpaper, unclean floors, and a broken wheelchair brake for a resident with Alzheimer's. Staff interviews revealed confusion over cleaning responsibilities and delayed maintenance communication, highlighting systemic issues in policy adherence.
Three residents in the facility developed pressure ulcers due to inadequate reassessment of their nutritional needs. One resident with a hip fracture and chronic kidney disease developed multiple wounds that progressed to a Stage 4 ulcer without timely nutritional intervention. Another resident with Alzheimer's and depression had a worsening Stage 3 ulcer on the foot, with no follow-up on nutritional consult recommendations. A third resident with diabetes and obesity developed a Stage 3 ulcer on the sacrum, and their protein needs were not reassessed, contributing to the deficiency.
The facility failed to serve meals at appropriate temperatures, affecting four residents who reported cold and unpalatable food. Observations confirmed that food items were not within safe temperature ranges, and staff interviews revealed inconsistencies in temperature standards and practices.
Two residents experienced a lack of dignity in care practices. One resident, with osteoarthritis and an amputation, was denied a requested shower before a family event, affecting their experience. Another resident, with an enlarged prostate, was observed with an uncovered urine collection bag visible, contrary to facility protocols. Staff interviews highlighted inconsistencies in adhering to resident preferences and dignity protocols.
Three residents were found with medications at their bedsides without proper assessments or physician orders for self-administration. One resident self-administered a discontinued nasal spray, another had multiple unlabeled inhalers, and a third was left with cough syrup without supervision. The facility failed to adhere to its policy requiring assessments for self-administration.
A resident with bipolar disorder and depression was not provided with meaningful activities that matched their interests, such as reading and one-on-one visits, despite these being documented in their care plan. Observations showed the resident often in bed without books, and interviews with staff revealed inconsistencies in providing one-on-one visits, leading to a deficiency finding.
An LPN failed to perform appropriate hand hygiene during wound care for a resident with a sacral ulcer, despite facility policy requiring glove changes and hand washing after removing soiled dressings. The resident, with Parkinson's disease and a local skin infection, was on antibiotics for a wound infection. Interviews confirmed the importance of hand hygiene to prevent contamination and infection.
A resident with dementia and cerebral infarction was unable to use their call bell to contact caregivers due to a malfunction. Despite staff awareness, the issue persisted due to unfamiliarity with the work order system and communication breakdowns. The facility's policy required operational call systems, but the resident's call bell remained non-functional, highlighting procedural failures.
The facility failed to assist residents with activities of daily living, particularly in nutrition and hygiene. A resident with Alzheimer's and feeding difficulties did not receive the required meal assistance, leading to inadequate food intake. Additionally, two residents had long, unclean nails due to a lack of proper nail care, with staff unclear on responsibilities, especially for diabetic residents requiring licensed nurse intervention.
A facility failed to obtain a timely urinalysis for a resident with dementia and other conditions, despite a physician's order. The resident's care plan included interventions for bladder function, but the urinalysis was not collected or documented. Interviews with staff revealed lapses in entering the order and collecting the sample, leading to a deficiency finding.
Failure to Maintain Consistent Hot Water Temperatures for Resident Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain safe, adequate, and consistently warm domestic hot water for resident use, resulting in an environment that was not safe, clean, comfortable, or homelike on at least one resident unit. Facility policies required that hot water temperatures for resident use be maintained between 90°F and 110°F, that cooler-than-normal water be reported up the chain of command, and that a loss-of-hot-water policy be implemented when hot water was outside the allowable range. Despite these policies, work orders and interviews showed repeated reports of no hot water or inadequate hot water throughout the building over multiple days, including documented work orders for no hot water on various floors and in the building as a whole. A temperature check of a resident room sink showed water at 85.6°F, which the Regional Director of Facilities acknowledged was below the facility’s acceptable range. Maintenance documentation and staff interviews revealed that the hot water system was malfunctioning intermittently, with maintenance staff repeatedly resetting an electronic mixing valve and boiler controls without consistently documenting these actions or verifying water temperatures afterward. The work order log showed multiple entries for no hot water on different dates and locations, but there were gaps in documentation, including missing work orders for repeated resets of the electronic mixing valve between certain dates. The Regional Director of Facilities stated that water temperatures were not taken on weekends because maintenance staff were only onsite Monday through Friday, and there was no documentation that shower water temperatures had been checked during the period in question. Maintenance staff confirmed that they had not always checked or recorded water temperatures before closing work orders and that they were not informed that the facility’s loss-of-hot-water policy had been activated. Resident and staff interviews corroborated that residents experienced lukewarm or cold water for showers and that this persisted for weeks. One resident reported that their last shower had been lukewarm and uncomfortable and that they were later told they could not shower due to cold water. Another resident stated they had not had a shower for five weeks because the water was cold and that the water system was frequently being repaired. CNAs and an RN reported that hot water would be available only briefly after the boiler or mixing valve was reset, then turn cold again, sometimes remaining cold until the next day. One CNA reported that hot water had been brought from the kitchen to a unit for a bed bath when shower water was cold, and acknowledged that some residents had not received showers for ten or eleven days. Facility leadership, including the Administrator and Assistant Administrator, gave differing accounts of when they became aware of the hot water issues and confirmed that the loss-of-hot-water policy was not formally activated, that staff training on emergency procedures and work orders was not documented, and that there was no verification of the temperature of water brought from the kitchen for resident care. Leadership interviews further showed inconsistent communication and oversight regarding the hot water problem. The Assistant Administrator stated they were aware of a hot water issue on one date and believed it had been resolved after a valve reset, and they were not aware that boiler parts were on order or that staff had transported hot water from the kitchen. The Administrator stated they first heard of hot water loss on a specific date, believed the issue had been addressed before going on vacation, and did not consider the intermittent hot water to be a significant impact at that time. The Director of Facilities and Maintenance described a two-boiler system problem that caused the hot water zone valve to shut off, but also indicated they assumed hot water was functioning after a reset and did not know the exact cause until informed by a vendor. Throughout this period, the facility did not provide documentation of staff training on the loss-of-hot-water policy, and there was no consistent process to ensure that water temperatures were within the required range for resident bathing and hygiene.
Deficiencies in Resident Care and Medication Management
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' choices. Resident #1, who had a feeding tube, did not have the placement and residuals checked for four months, despite physician orders to do so. The resident developed diarrhea and nausea, but there was no documented assessment to determine if the tube feeding should have been held. The resident was later found deceased with vomit on their face, and the death certificate listed acute cardiopulmonary arrest due to multiorgan failure as the cause of death. Resident #7, who had a diagnosis of malignant neoplasm of the prostate and secondary malignant neoplasm of the bone, did not receive their prescribed lorazepam for anxiety for seven consecutive days. The facility's medication administration record showed that the medication was unavailable, and there was no evidence that the pharmacy access code was obtained when the medication was removed from the Automated Drug Dispensing System. The resident reported not receiving the medication and was told by nurses that a refill was needed, but the medical provider was not informed about the unavailability of the medication. The facility's policies on medication administration and tube feeding were not followed, leading to significant lapses in care for both residents. The failure to check the feeding tube placement and residuals for Resident #1 and the lack of timely medication administration for Resident #7 highlight deficiencies in the facility's adherence to care protocols. Interviews with staff revealed a lack of awareness and training regarding the procedures for medication reordering and the use of the Automated Drug Dispensing System.
Incomplete Investigation and Falsified Documents in Abuse Allegation
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, as evidenced by an incomplete and inaccurate investigation following an allegation of abuse involving a resident. The administration, including the Director of Nursing, did not ensure a thorough investigation was conducted after a resident reported that a night shift nurse was rough with them. The investigation lacked essential details, such as the identity of the accused nurse and the actions taken against them. Furthermore, the investigation summary was unsigned and undated, and it did not include statements from all relevant staff members, such as certified nurse aides. The report revealed that staff statements provided to the Department of Health were falsified. Several staff members, including a Licensed Practical Nurse Supervisor and a Registered Nurse, stated that they did not author or sign the statements attributed to them, and the signatures on the documents were not theirs. This falsification of documents undermined the integrity of the investigation and raised concerns about the facility's ability to rule out abuse and neglect accurately. Interviews with staff members indicated that the facility's procedures for handling allegations of abuse were not followed. The accused staff member was not suspended pending the investigation, and the incident was not reported to the New York State Department of Health as required. The Administrator and former Director of Nursing were unaware of the falsified statements and did not ensure that a comprehensive investigation was conducted. This failure to adhere to established protocols and accurately document the investigation process compromised the facility's ability to protect residents and maintain their well-being.
Inadequate Pressure Ulcer Care Leads to Harm
Penalty
Summary
The facility failed to provide necessary treatment and services for residents with pressure ulcers, leading to significant harm in one case. Resident #195, who had a history of hip fracture and chronic kidney disease, developed a Stage 4 pressure ulcer on the sacrum that was not properly assessed or treated. The facility's records showed inconsistent documentation of wound care, and there was no evidence that the wound was assessed by a qualified professional. The resident's condition worsened, resulting in sepsis and hospitalization. Resident #88, diagnosed with Alzheimer's disease and depression, also experienced inadequate wound care. The resident had a Stage 3 pressure ulcer on the left plantar foot, and the facility failed to consistently document the completion of prescribed treatments. The Treatment Administration Record showed missing entries for several shifts, indicating that the treatments may not have been completed as ordered. Interviews with facility staff revealed a lack of adherence to protocols for wound assessment and treatment documentation. The Director of Nursing and other staff members acknowledged that treatments should be signed off when completed and that any issues preventing treatment should be documented and reported. The facility's failure to follow these procedures contributed to the deficiencies observed during the survey.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional principles, as observed during a recertification survey. On the Second floor short hall medication cart, there were 49 loose, unidentified pills, and several medications, including eye drops and inhalers for specific residents, lacked opened or expired/discard dates. Additionally, an inhaler was found without any resident identifiers. A registered nurse acknowledged that multi-dose medications should be dated when opened and that expired medications might not be effective. On the Third floor long hall medication cart, a similar issue was observed. There was a loose pill, opened medicated pain patches, and a vial of nitroglycerin tablets without resident identifiers. Several medications, including an insulin pen and eye drops for specific residents, lacked opened or expired/discard dates. A licensed practical nurse stated that without an opened date, it would be unclear if the medication was expired, and all medications should have resident identifiers to ensure correct administration. Interviews with staff, including the Assistant Director of Nursing, revealed that medications should be dated when opened to determine expiration. Staff admitted to administering medications without checking for opened or expired dates, which could lead to ineffective treatment. The facility's policies on medication labeling and storage were not adhered to, resulting in the potential for residents to receive expired or improperly identified medications.
Deficiencies in Food Preparation and Sanitation
Penalty
Summary
The facility failed to ensure that food was prepared, distributed, and served in accordance with professional standards, as observed during a recertification survey. In the main kitchen, there were multiple instances of uncleanliness and improper food handling. Debris was found on the floors and under shelving in the dry storage area, and food debris was present under and around the cookline equipment. The 2-bay sink was leaking, and there was grime buildup on the plumbing, with a bus pan full of moldy stagnant liquid beneath it. The cooler was labeled out of order for two years, yet it contained food spills and debris. The walk-in freezer had food debris on the floors and ice piling up beside the door, and a yellow dried puddle was observed under shelving in the walk-in cooler. Additionally, there was a significant amount of food debris and drain backup around the ice machine and back door. In the Third floor kitchenette, similar issues were noted. Sugar packets were scattered on the floor, and the right side of the warmer was not clean. A dirty black plastic bin under the sink was full of water with a white/grey film on the surface. The faucet of the large sink basin was leaking, and the stainless-steel shelving had dried food debris. The walk-in freezer had food debris on the floor and ice buildup on the door, and there was food debris behind the ice machine. The eye wash station was unclean, and the paper towel dispenser had a dried white/gray substance covering it. These observations indicate a lack of adherence to the facility's policies on kitchen sanitation and food cooling. Interviews with staff revealed a lack of clarity and training regarding cleaning responsibilities and food cooling procedures. The Food Service Director was unsure who was responsible for cleaning the kitchenettes and acknowledged issues such as a leaking faucet and grease in a bus pan. The cooling process for a pureed grilled cheese was not properly documented or executed, as it did not meet the required temperature standards. Housekeeping staff were not trained to clean certain areas, such as the refrigerator, contributing to the overall lack of cleanliness and proper food handling in the facility.
Deficiencies in Facility Cleanliness and Equipment Maintenance
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment in several areas, including the Main Lobby, resident rooms, nursing stations, and oxygen storage rooms. Observations revealed peeling wallpaper, unclean floors with dust and food debris, and stained floors. Interviews with staff indicated confusion over cleaning responsibilities, particularly regarding the oxygen storage rooms, which were not cleaned due to limited access to keys. Housekeeping staff were behind schedule on floor maintenance, contributing to the unclean conditions. Additionally, the facility did not address a safety issue concerning a resident's wheelchair. The resident, who had Alzheimer's disease and required a wheelchair for mobility, had a broken right wheelchair brake that had not been repaired for several weeks. Despite the resident notifying staff multiple times, the issue was not communicated to maintenance until a work order was placed days after the survey began. Interviews with staff revealed a lack of awareness and communication regarding the broken wheelchair brake, which was essential for the resident's safety and mobility. The facility's policies on daily cleaning, maintenance requests, and medical equipment management were not effectively implemented. Staff interviews highlighted a lack of clarity and communication regarding responsibilities for cleaning and maintenance tasks. The failure to maintain a clean environment and promptly repair essential equipment like the resident's wheelchair brake indicates systemic issues in the facility's operations and adherence to its policies.
Failure to Reassess Nutritional Needs for Wound Healing
Penalty
Summary
The facility failed to ensure the maintenance of acceptable nutritional parameters for three residents, leading to the development and worsening of pressure ulcers. Resident #195, with a history of hip fracture and chronic kidney disease, developed multiple wounds on the buttocks. Despite the presence of these wounds, there was no timely reassessment of the resident's nutritional needs to accommodate increased requirements for wound healing. The registered dietitian was not notified promptly, and the resident's protein and calorie needs were not adjusted accordingly, resulting in the progression of the wounds to a Stage 4 pressure ulcer. Resident #88, diagnosed with Alzheimer's disease and depression, had a Stage 3 pressure ulcer on the left foot that worsened over time. The resident's nutritional needs were not reassessed despite recommendations for a nutritional consult due to poor oral intake and the worsening condition of the wound. The registered dietitian did not follow up on the wound care physician's recommendations, and the resident's nutritional intake was not adequately adjusted to support wound healing. Resident #2, with diabetes and obesity, developed a Stage 3 pressure ulcer on the sacrum. The resident's protein needs were not reassessed after the wound was identified, and the registered dietitian did not follow up on the wound care physician's recommendations. The oversight in reassessing the resident's nutritional needs contributed to the deficiency in providing adequate nutrition to support wound healing.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to ensure that residents received food and drink that were palatable, flavorful, and at an appetizing temperature during the dinner meal on 9/10/2024. This deficiency was observed for four residents, who reported that their meals were served cold. Specifically, Resident #93 mentioned that meals were usually cold when served in their room, Resident #15 noted the absence of a microwave to reheat food, Resident #36 found the food unappealing and cold, and Resident #112 stated that meals were often late and cold. During an observation, Resident #71's meal tray was found to have food items at inappropriate temperatures, with hot foods below 135 degrees Fahrenheit and cold foods above 41 degrees Fahrenheit. Interviews with facility staff revealed inconsistencies in food temperature standards and practices. Certified Nurse Aide #30 acknowledged that food items on Resident #71's tray were not at appropriate temperatures, which could lead to bacterial growth and potential illness. The Food Service Director and Registered Dietitian conducted test trays to monitor food quality, but discrepancies in temperature expectations were noted. The Food Service Director aimed for hot foods over 135 degrees Fahrenheit and cold foods under 55 degrees Fahrenheit, while the Registered Dietitian was unsure of specific temperature ranges. The deficiency highlights a failure in maintaining food safety and quality standards, impacting resident satisfaction and safety.
Failure to Ensure Resident Dignity in Care Practices
Penalty
Summary
The facility failed to honor the resident's right to a dignified existence for two residents during a recertification survey. Resident #37, who had a diagnosis of osteoarthritis, muscle weakness, and right above the knee amputation, was not provided with a requested shower before attending their child's wedding. Despite being cognitively intact and expressing the importance of choosing their bathing method, the resident was denied a shower on the day of the event, receiving only a bed bath in the morning. This left the resident feeling unclean and affected their experience at the wedding, leading to feelings of sadness and a reluctance to request such accommodations in the future. Resident #137, diagnosed with benign prostatic hypertrophy and using a urinary drainage device, was observed multiple times with their urine collection bag visible in plain sight. The resident, who had intact cognition, was seen carrying the uncovered bag in their room and standing in the doorway with the bag visible from the hallway. Despite facility policies requiring the use of dignity bags to cover such devices, the resident's collection bag was not concealed, potentially leading to feelings of embarrassment or self-consciousness. Interviews with facility staff revealed inconsistencies in adhering to resident preferences and dignity protocols. Certified Nurse Aide #34 and Licensed Practical Nurse Unit Manager #1 acknowledged the importance of accommodating resident preferences and using dignity bags but noted lapses in practice. The failure to provide a shower for Resident #37 and the visible urinary collection bag for Resident #137 were identified as dignity issues that could negatively impact the residents' psychosocial well-being.
Failure to Assess Residents for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents were assessed for their ability to safely self-administer medications, as required by their policies. Three residents were found with medications at their bedsides without physician orders or assessments to determine their capability to self-administer these medications. This oversight was observed during a recertification survey, highlighting a lack of adherence to the facility's self-administration policy. Resident #95, who had a history of chronic embolism and thrombosis, was found with a bottle of fluticasone nasal spray at their bedside, which they self-administered daily for allergies. However, there was no documented physician order or assessment for self-administration, and the medication had been discontinued without proper documentation. The LPN Unit Manager confirmed the absence of a current order and acknowledged the importance of removing discontinued medications to prevent potential harm. Resident #41, diagnosed with chronic obstructive pulmonary disease, was observed with multiple unlabeled Combivent inhalers in their possession, including in their shirt pocket and nightstand. Despite the resident's claim of self-administering the inhaler due to the unpredictability of nurse visits, there was no documented order or assessment for self-administration. The Director of Nursing noted that the resident's family had previously brought medications from home, and the resident had a history of overusing the inhaler, leading to a physician's decision against allowing bedside medications. Similarly, Resident #38, with a history of asthma and diabetes, was left with cough syrup at their bedside without a self-administration order, and the nurse did not verify its ingestion, contrary to the facility's policy.
Failure to Provide Meaningful Activities for Resident
Penalty
Summary
The facility failed to provide ongoing programs to support the interests and well-being of Resident #5, who was cognitively intact and had diagnoses of bipolar disorder, depression, and spinal stenosis. The resident expressed a strong preference for activities such as reading, listening to music, and going outside, as well as one-on-one visits, which were documented in their care plan. However, the facility did not offer meaningful activities that aligned with these interests, and there was no evidence of one-on-one visits since November 2023. Observations during the survey revealed that Resident #5 was often found lying in bed, wearing a hospital gown, and without access to books or other reading materials. The resident expressed dissatisfaction with the lack of one-on-one visits, stating they only occurred one to three times per year, despite their preference for weekly visits to help with their mood. The activity calendar and attendance records from June to September 2024 showed no participation or provision of activities for the resident, indicating a lack of engagement with their documented interests. Interviews with facility staff, including Activities Aide #22 and Activity Director #20, confirmed that one-on-one visits were supposed to be provided to residents who did not attend group activities. However, there was a discrepancy in the documentation and actual provision of these visits for Resident #5. The Activity Director acknowledged the importance of these visits for social interaction but was unsure of the last time such a visit occurred for the resident. This lack of adherence to the resident's care plan and preferences contributed to the deficiency identified during the survey.
Inadequate Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of an LPN during a wound care treatment for a resident. The LPN did not perform appropriate hand hygiene after removing a soiled dressing and before applying a clean dressing to the resident's sacral wound. This lapse in protocol occurred despite the facility's policy, which requires changing gloves and washing hands after removing a soiled dressing. The resident, who had diagnoses including Parkinson's disease and a local skin infection, was being treated for a sacral ulcer wound and was on antibiotics for a wound infection. Interviews with the LPN, the LPN Unit Manager, and the Director of Nursing confirmed that proper hand hygiene should be performed before and after entering a room, between glove changes, and during wound care procedures. The LPN acknowledged that failing to change gloves and perform hand hygiene could contaminate clean dressing supplies and potentially worsen the resident's wound infection. The resident had a history of wound infections and was currently being treated for an infection in a Stage 4 pressure ulcer on the sacrum.
Deficiency in Resident Call System Functionality
Penalty
Summary
The facility failed to ensure that a working call system was available for Resident #90, who had diagnoses including dementia and cerebral infarction, and was dependent on staff for mobility and personal hygiene. During the recertification survey, it was observed that the resident's call bell was not functioning, preventing them from directly contacting caregivers. Despite the facility's policy requiring operational call systems and immediate reporting of defects, the resident's call bell remained non-functional, and there was no documentation to ensure the call bell was within reach. Multiple staff members, including Certified Nurse Aides and Licensed Practical Nurses, were aware of the malfunctioning call bell but did not effectively communicate or resolve the issue. Staff members were unfamiliar with the work order system, leading to delays in addressing the problem. The Plant Operation Director was notified of the issue but could not address it immediately due to the lack of a formal work order. This deficiency highlights a breakdown in communication and procedure adherence, resulting in the resident's inability to call for assistance.
Failure to Assist Residents with ADLs and Maintain Hygiene
Penalty
Summary
The facility failed to provide necessary assistance to residents who were unable to perform activities of daily living, specifically in the areas of nutrition and personal hygiene. Resident #2, diagnosed with Alzheimer's disease and feeding difficulties, required moderate assistance with eating as per their care plan. However, during observations, staff did not provide the required assistance during meals, resulting in the resident consuming minimal portions of their meals independently, often using their fingers or struggling with utensils. Interviews with staff revealed a misunderstanding of the resident's care plan, with some staff believing the resident was independent with eating, contrary to the documented need for moderate assistance. Additionally, the facility did not maintain proper nail care for Residents #35, #37, and #64, who were observed with long, unclean fingernails. Resident #37, who was dependent on personal hygiene assistance, had long and jagged nails with debris, despite the care plan indicating nail care should be performed on bath days. Interviews with staff confirmed that nail care was overlooked, and there was a lack of communication regarding the resident's preferences and needs. Resident #35, a diabetic, also had long, unkempt nails with debris, and staff interviews indicated a lack of clarity on who was responsible for nail care. Certified nurse aides were aware of the resident's need for nail care but were unable to perform it due to the resident's diabetic status, which required a licensed nurse's intervention. The oversight in nail care was attributed to the absence of reminders in the treatment administration record, leading to assumptions that aides would handle it, despite the resident's specific needs.
Failure to Obtain Timely Urinalysis for Resident
Penalty
Summary
The facility failed to ensure that a resident received timely treatment and care in accordance with professional standards and the resident's care plan. Specifically, a physician-ordered urinalysis for a resident with diagnoses of unspecified dementia, cerebral infarction, and hypothyroidism was not obtained in a timely manner. The resident's care plan included interventions for bladder function alteration, and a physician had ordered a urinalysis with microscopy and reflex for culture. However, there were no nursing notes or laboratory results documenting that the urinalysis was collected or processed. Interviews with facility staff revealed that the urinalysis order was not entered into the computer system, and the urine sample was not collected. The Assistant Director of Nursing and the Director of Nursing acknowledged the importance of following physician orders and obtaining the urinalysis to ensure appropriate treatment. The physician who ordered the urinalysis noted the importance of timely collection to start treatment if a urinary tract infection was present. The failure to obtain the urinalysis was identified as a deficiency during the recertification survey.
What surveyors are citing around you — mapped
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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 20 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Johnson City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willow Point Rehabilitation And Nursing Center | 0.7 mi | ★★★★★ | 0 | 0 |
| Elizabeth Church Manor Nursing Home | 2.6 mi | ★★★★★ | 0 | 0 |
| James G Johnston Memorial Nursing Home | 3 mi | — | 0 | 0 |
| Good Shepherd-fairview Home Inc | 4.3 mi | ★★★★★ | 0 | 0 |
| Good Shepherd Village At Endwell | 4.6 mi | ★★★★★ | 6 | 0 |
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