Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Astoria Skilled Nursing And Rehabilitation during CMS and state inspections, most recent first.
The facility failed to ensure its smoking policy addressed safe smoking areas for independent smokers. Two residents with COPD and other diagnoses were told they could go off property and smoke across the street outside designated smoking times, even though the written policy only allowed smoking in designated areas outside the building and did not mention LOA or off-property smoking. Surveyors observed the area across the road had no sidewalk or crosswalk and was a narrow roadway with nearby buildings and vehicles.
Improper food storage was observed in a unit kitchenette when surveyors found opened and undated applesauce cups, bread, chow mein noodles, and resident food items in dirty CoolCheck containers. Biohazard-labeled containers were also stored with food items, and staff confirmed the items were not stored appropriately and that the refrigerator and CoolCheck container needed cleaning.
A resident with CVA, OA of the left hip, and BPH had an incident in which he slid out of his wheelchair, but the responsible party was not notified until several days later. The medical record did not document the fall/incident, and the DON confirmed the event and the delayed notification.
Failure to provide adequate nail care for a dependent resident. A cognitively intact resident with multiple medical diagnoses was dependent on staff for ADLs, yet his fingernails were observed to be long with visible debris under them. The resident stated no one had offered to cut them, and he had been biting or trying to rip them off. The ADON confirmed the nails were long and dirty and said nail care was done by CNAs on an as-needed basis, despite facility policy calling for daily cleaning and regular trimming.
Failure to provide appropriate pressure ulcer care occurred for a resident with CVA, metabolic encephalopathy, polyneuropathy, dementia, and multiple skin wounds. The resident had a stage 2 pressure ulcer that had declined, with wound notes citing poor offloading compliance. Staff were not observed assisting with turning/repositioning, and the resident remained on her right side for prolonged periods; the resident said she did not know turning would help healing, and a CNA said she sometimes let the resident stay in the same position when she complained of pain and was comfortable.
Missed Heparin Doses: A resident with CVA, HTN, and CKD missed multiple ordered doses of Heparin after the MAR showed holds, blanks, and notes indicating the medication was awaiting pharmacy delivery and unavailable in the Pyxis. The RQAN confirmed the missed doses, and the facility policy required meds to be given per prescriber orders and required time frames.
Incomplete and inaccurate medical records were found for three residents. One resident’s fall from a wheelchair was confirmed by the DON and family representative but was not documented in the chart, another resident’s PEG tube bolus feeding orders were not clearly reflected on the MAR to show whether the feeding was given or held based on meal intake, and a third resident’s wound was inconsistently documented as both Stage II and Stage III in the skin records, despite wound care notes and the care plan identifying it as Stage III.
Infection Control Lapses During Wound Care: During wound care for a resident with CVA, dementia, and multiple pressure wounds, an RN and CNA brought the wound cart into the room, handled supplies with gloved hands without hand hygiene, changed gloves without washing hands, and touched environmental surfaces with soiled gloves. The DON stated the cart should not enter the room and staff were expected to perform hand hygiene and avoid contaminating surfaces; the wound care policy required handwashing before, during, and after treatment.
Failure to Provide Transfer and Bed Hold Notices: The facility did not provide written transfer/discharge or bed-hold notices for three residents, including one resident sent out for a stroke workup and two residents transferred for inpatient psych care. Records showed one resident was cognitively intact, another had severe cognitive impairment, and the facility also lacked evidence that the LTC Ombudsman was notified of two hospital transfers.
Failure to include residents in care plan meetings: Two cognitively intact residents were not given the opportunity to participate in their care conferences. One resident with DM, ESRD, respiratory failure, and CHF had a care conference held with family by teleconference, but there was no evidence he was invited or attended. Another resident with CVA-related hemiplegia had a phone conference with family and staff about an insurance cut and LTC plan, but she did not participate.
A resident admitted with spinal and diabetic diagnoses did not have the admission nursing assessment completed until the day after admission, and the chart lacked a note showing the arrival time. Another resident with CVA, left hip OA, and BPH had a physician order for a lateral trunk support in the wheelchair, but staff observed the resident poorly positioned in the chair and the ordered support was not in place; the DON verified the missing device.
Unsafe Smoking Practices and Lack of Supervision: Two residents were observed smoking unsupervised in a courtyard that was not a designated smoking area, with no ashtrays or metal can available nearby. One resident had documented cognitive loss and visual deficits and required direct supervision while smoking, while the other resident was not identified as a smoker. Staff also observed cigarette butts and combustible trash in non-smoking courtyards, and an RN confirmed the residents were smoking without supervision.
A resident with ESRD, DM2, HTN, and a right arm fistula had orders for hemodialysis, pre- and post-dialysis VS, fistula bruit/thrill checks, and dialysis communication forms, but the facility had no evidence of the required monitoring on multiple treatment days and no completed communication forms were sent with the resident. Staff confirmed the EMR lacked pre/post dialysis assessments, the resident went to dialysis without a communication form, and the dialysis binder contained only blank forms and basic documents.
Failure to obtain informed consent and a comprehensive assessment for side rail use. A resident with CVA, metabolic encephalopathy, polyneuropathy, and dementia had bilateral half side rails in use while in bed and was observed using them for repositioning and bed mobility. The record lacked documentation of informed consent or a comprehensive assessment, and the DON confirmed the facility could not provide either document.
A resident with GERD, DM, and CKD was prescribed both Famotidine and Pantoprazole for GERD, with no documented rationale in the record for concurrent use of the two medications. The DON verified that no rationale was indicated for the duplicate GERD therapy.
Survey Results Not Prominently Accessible to Residents: Residents in the Resident Council stated they did not know where past survey results were kept or whether they could review them without asking. Observation showed only small notices stating the results were available upon request, including one in a display case above a wheelchair user’s eye level. Staff confirmed the survey binder was kept behind the reception desk and had to be requested, with no other resident-accessible location for review.
Advocacy group contact information was not easily accessible to residents using wheelchairs. Residents in the council interview said they did not know where the list was located, and observation showed the full list was posted above wheelchair eye level near the main entrance while the Ombudsman notice on the receptionist’s desk was also difficult to view. The AD confirmed no other accessible lists were posted.
A resident who required two staff for mechanical lift transfers was moved by a single CNA, resulting in the lift tipping and the resident sustaining a right hip fracture. The CNA did not request assistance, and the transfer was not performed according to facility policy or manufacturer guidelines. The incident led to the resident being hospitalized.
A cognitively impaired resident with a known history of wandering eloped from the facility after staff failed to reapply a required wander guard device following a hospital visit. Despite ongoing exit-seeking behaviors and multiple door alarms, staff did not verify the device's presence or function, and family members were allowed to use the door code to enter and exit without staff assistance. The resident was later found by law enforcement walking in the road, highlighting a lapse in supervision and safety protocols.
A resident with a PICC line and multiple infections did not receive routine dressing changes as required, with no documentation of dressing care until the line was replaced. Facility policy required dressing changes every five to seven days, but the resident reported only two changes since admission, and staff could not locate records of earlier dressing changes.
A resident with a tracheostomy, history of respiratory failure, and recent COVID-19 diagnosis exhibited labored breathing and minimal secretions, but the LPN on duty did not notify the physician or escalate care, relying instead on remote advice from an RT. The resident was later found unresponsive, CPR was initiated, and the resident was transferred to the hospital, where she died. The facility failed to recognize and respond to a significant change in condition, as required by policy.
Surveyors identified multiple sanitary issues in the kitchen, including dirty trash cans, soiled equipment, improper food storage, and undated perishable items. These deficiencies were confirmed by the Dietary Manager and affected all but three residents who did not receive food from the kitchen.
A resident with a history of respiratory failure, tracheostomy, and recent pneumonia experienced labored breathing and fluctuating oxygen levels, but the physician was not notified of these changes. Nursing staff relied on input from the RT, who indicated the condition was baseline, and did not escalate care or inform the family of the respiratory distress. The resident was later found unresponsive, transported to the hospital, and subsequently passed away. This failure to notify the physician of a significant change in condition was confirmed through record review and staff interviews.
A resident with multiple chronic conditions reported that facility-provided washcloths and towels were stained, dingy, and uncomfortable to use. Observations confirmed that linens throughout the facility were discolored, stained, and worn, with staff attributing the issue to the discontinuation of incontinence wipes and repeated use of the same linens. The deficiency had the potential to impact all residents relying on facility linens.
A resident with multiple medical conditions missed a scheduled postoperative surgical appointment because the facility did not arrange transportation as ordered. When the appointment was rescheduled, the resident arrived late and was not taken for required X-rays prior to seeing the surgeon, contrary to the physician's order. Communication gaps between staff and the medical office contributed to the deficiency.
A resident with multiple risk factors and existing pressure ulcers did not receive timely and consistent pressure ulcer interventions, including delayed provision of a low air loss mattress and inconsistent use of heel offloading devices. The resident and a family member reported that necessary equipment and repositioning assistance were only provided after complaints to external authorities, and documentation showed that wounds worsened before improvement. Staff interviews and observations confirmed lapses in following the care plan and facility policy.
A resident with multiple chronic conditions and a history of dental issues reported a lost tooth, prompting a physician order for antibiotics and a prompt dental appointment. The facility did not schedule the dental appointment as ordered, and the resident later required hospital care for dental pain before the appointment was finally arranged.
A CNA failed to maintain proper infection control during incontinence care for a resident with multiple medical conditions by repeatedly using a feces-soiled washcloth and contaminating clean linens, contrary to facility policy requiring cleanliness to prevent infection.
A resident using a BiPAP machine complained about the taste of distilled water, which was not replaced daily as required by facility policy and manufacturer's guidance. The RT replaced the water weekly, unaware of the policy, and informed the Administrator and DON, who initially supported the weekly change. The facility's policy required daily changes to prevent infection.
The facility failed to maintain a medication error rate below five percent, resulting in an eight percent error rate. An LPN inaccurately measured polyethylene glycol for a resident, and an RN forgot to administer a nasal spray to another resident. The facility's policy requires medications to be administered safely and as prescribed, with errors documented and reviewed.
A facility failed to ensure proper infection control during medication administration for two residents. A nurse did not perform hand hygiene before and after glove use and failed to disinfect the glucometer before and after obtaining blood sugar levels. The residents had conditions like heart disease and diabetes. Facility policies and CDC guidance on infection control were not followed.
A resident in an LTC facility was mistakenly administered a discontinued medication, Percocet, by an RN who failed to verify the current medication orders in the computer system. The RN administered the medication after finding it in the narcotic drawer, realizing the error only after attempting to document the administration.
A male resident with severe cognitive impairment was involved in multiple incidents of sexual abuse with two female residents in an LTC facility. The facility failed to implement effective interventions or update care plans to address the male resident's sexual behaviors, resulting in repeated incidents. The facility's policies lacked definitions of sexual abuse and consent, contributing to inadequate responses and failure to report the incidents as abuse.
A resident with complex medical needs, including diabetes and Huntington's disease, was found unresponsive in his wheelchair after being left unattended overnight. Despite an elevated blood glucose level of 400 mg/dl recorded at 10:00 P.M., no follow-up care or monitoring was provided. The resident required CPR and was transported to the hospital with a blood glucose level of 607 mg/dl, where he later passed away. The facility failed to adhere to care plans for monitoring and incontinence checks, contributing to the resident's death.
A resident with complex medical needs was neglected due to inadequate staffing, resulting in the resident being left unattended in a wheelchair and later found unresponsive. The facility was understaffed, with only one STNA on duty, leading to insufficient care and delayed response to the resident's needs.
The facility failed to maintain a clean and sanitary kitchen, affecting 58 residents. Observations revealed gnats, water damage, mold, and food residue in the kitchen and storage areas. The facility's sanitation and pest control policies were not followed.
The facility failed to investigate and report resident-to-resident abuse involving two residents with severe cognitive impairments. Despite multiple incidents where residents were found in compromising situations, the facility did not document or report them as abuse. Additionally, a resident was reported to have been inappropriately touched by another, but the facility did not conduct a thorough investigation. The facility's policy lacked definitions of sexual abuse and consent, contributing to the inadequate response.
A facility failed to report alleged sexual abuse incidents involving two residents to the State Agency. One resident with dementia was found in a bathroom with another resident, both with pants down, and later allegedly grabbed another resident's breast. Despite staff witnessing the incidents, they were not documented or reported as abuse. The facility's policies lacked definitions of sexual abuse and guidelines on consent, contributing to the oversight.
A facility failed to investigate and report allegations of sexual abuse involving two residents with severe cognitive impairments. Despite multiple incidents, including inappropriate behavior in a spa room and unwanted physical contact, the facility did not document or report these as abuse. The facility's policies lacked definitions and guidelines on handling such incidents, contributing to non-compliance.
A resident was discharged without ensuring an adequate supply of narcotic medications until her post-discharge appointment. Despite having multiple health conditions, the facility's policy did not allow for medications to be sent home without physician authorization, which was not obtained. Interviews revealed that medications were called into the pharmacy, but the resident's lack of a primary care physician and the facility's discharge policy contributed to the deficiency.
Smoking Policy Did Not Address Off-Property Smoking for Independent Smokers
Penalty
Summary
The facility failed to ensure its smoking policy included information about safe smoking areas for independent smokers. The smoking policy stated that smoking was only permitted in designated resident smoking areas outside the building, but it did not address the facility practice of allowing independent smokers to go off the property to smoke outside designated smoking times. The Administrator confirmed that residents deemed safe to smoke independently were told to smoke off the property if they wanted to smoke outside the designated times, and that this practice was not included in the written policy. Resident #8 had diagnoses including above the knee amputation of the right leg, COPD, and mantle cell lymphoma, and the admission MDS showed moderately impaired cognition and use of tobacco. Resident #53 had diagnoses including COPD, depression, and right-sided sciatica, and the quarterly MDS showed intact cognition and independence with eating. The facility identified seven residents as independent smokers, including these two residents. Surveyors observed the area across the road from the facility and noted there was no sidewalk, no crosswalk, and a narrow road with buildings and vehicles nearby. Both residents stated they had been told to go across the street to smoke outside designated smoking times, and Resident #53 stated this was not safe. The Administrator, DON, and RQAN confirmed that residents could go off property to smoke via LOA and that this practice had always been in place, but it was not written in the smoking policy.
Improper Food Storage in Unit Kitchenette
Penalty
Summary
Foods were not properly stored in the [NAME] Unit kitchenette. During observation, the refrigerator contained two opened and undated individual applesauce cups and two CoolCheck insulated food pan containers with undated resident food items, including one container that was dirty. In the upper cabinet, surveyors observed an opened and undated half loaf of bread and an opened and undated container of chow mein noodles on the first shelf. The same cabinet also contained a CoolCheck container and four empty red containers labeled as biohazard containers. Nursing Scheduler #878 confirmed the food items, the dirty CoolCheck container, and the biohazard-labeled containers were stored in the kitchenette, and stated the biohazard containers should not have been stored with food items. Housekeeping Supervisor #860 confirmed the biohazard containers were not to be stored in the kitchenette, the refrigerator needed cleaning, and the CoolCheck container was dirty. Facility policy required food storage areas to be kept clean, food items to be dated, and toxic substances not to be stored in food areas.
Delayed Notification After Resident Fall Incident
Penalty
Summary
The facility failed to ensure timely notification was provided to a resident representative following an accident involving Resident #67. Resident #67 was admitted on 03/21/23 with diagnoses including cerebrovascular accident, osteoarthritis of the left hip, and benign prostate hypertrophy. Medical record review found no documentation of any fall, accident, or incident on 03/10/26, although a progress note dated 03/16/26 stated the resident's responsible party was updated on a prior incident and new fall-prevention interventions. The resident's responsible party reported that the resident had a fall in the facility on 03/10/26 and was not notified until several days later. The DON confirmed that Resident #67 had an incident on 03/10/26 in which he slid out of his wheelchair and verified that the incident was not documented in the medical record and that the responsible party was not notified until 03/16/26.
Failure to Provide Adequate Nail Care
Penalty
Summary
The facility failed to ensure a dependent resident received adequate assistance with nail care. Resident #62 was admitted with diagnoses including acute respiratory failure with hypoxia, moderate protein calorie malnutrition, anxiety disorder, contracture of bilateral knees, muscle wasting and atrophy, and stage three chronic kidney disease. The annual MDS indicated the resident was cognitively intact and dependent on staff for bathing, dressing, personal hygiene, transfers, and mobility. During observation, the resident's fingernails were long and had visible debris under them, and the resident stated no one had offered to cut them, so he had been biting them or trying to rip them off. The ADON later confirmed the nails were long and dirty and stated nail care was completed by CNAs on an as-needed basis. The facility policy for fingernails/toenails stated nail care included daily cleaning and regular trimming.
Failure to Reposition Resident With Pressure Ulcer
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met for one resident with a right gluteal stage two pressure ulcer and other skin integrity issues. The resident was admitted with diagnoses including CVA, metabolic encephalopathy, polyneuropathy, and dementia, and the quarterly MDS showed moderate cognitive impairment, maximum assistance needs for ADLs and mobility, frequent bladder incontinence, occasional bowel incontinence, and occasional pain. The care plan identified a left inner buttock pressure wound, right gluteal fold pressure wound, and sacral MASD, and directed staff to encourage and assist with turning and repositioning, use a pressure-relieving mattress, and follow up with the wound care team. Consultant wound care notes documented that the right gluteal stage two pressure ulcer had declined and identified poor compliance with offloading as a contributing factor. The notes included education to staff and the resident about the importance of offloading to promote wound healing and recommended pressure reduction interventions and repositioning per facility protocol. During observation, the resident remained on her right side in bed for an extended period, including during and after wound care, and staff were not observed assisting with turning or repositioning. The resident stated she was unaware that turning and relieving pressure from her wounds would help healing and said she would turn if she knew it would help. A CNA stated she sometimes allowed the resident to remain in the same position when the resident complained of pain and said she was comfortable.
Missed Heparin Doses
Penalty
Summary
Resident #43 was found to have missed multiple doses of Heparin Sodium, an injectable anticoagulant ordered for prophylaxis and later for hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side. The resident was admitted with diagnoses including cerebral infarction, essential hypertension, and chronic kidney disease. A physician’s order dated 04/22/26 directed Heparin 5000 unit/mL, 1 mg subcutaneously twice daily, and the order was discontinued on 04/24/26. A new order dated 04/24/26 directed Heparin 5000 units subcutaneously twice daily. The MAR showed the evening dose was marked on hold on 04/23/26, 04/27/26, and 04/28/26, the morning dose was blank on 04/24/26, and the morning dose on 04/25/26 was marked as see nurses note. Progress notes documented that the facility was awaiting delivery of the resident’s Heparin from pharmacy on 04/23/26 and again on 04/25/26, with no doses left in the automated medication dispensing cabinet (Pyxis). Additional notes on 04/28/26 stated the Heparin was on order. During interview, the Regional QA Nurse confirmed the resident missed Heparin doses on 04/23/26, 04/24/26, 04/25/26, 04/27/26, and 04/28/26, and stated the facility kept two doses of Heparin in the e-kit. Facility policy stated medications were to be administered in accordance with prescriber orders, including required time frames.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents reviewed during the annual survey. For Resident #67, the responsible party reported a fall incident in the facility, and the DON confirmed the resident had slid out of his wheelchair on 03/10/26, but the medical record contained no documentation of that incident. The record did include a progress note dated 03/16/26 stating the responsible party was updated on a prior incident and new fall-prevention interventions, yet the actual accident event itself was not documented in the chart. For Resident #2, the physician’s order directed that if the resident ate less than 50% of a meal, a 240 mL bolus of Nepro Carb Steady was to be given via PEG tube, but the MAR only documented meal percentages and nurse initials, without showing whether the tube feeding was administered or held. For Resident #57, the skin documentation was inconsistent: the care plan and wound care notes identified a left inner buttock wound as a Stage III pressure ulcer, but a Skin Grid Pressure Assessment dated 05/27/26 documented the same wound as Stage II even though the wound location and measurements remained consistent. The ADON stated the Stage II entry was made in error and should have been documented as Stage III.
Infection Control Lapses During Wound Care
Penalty
Summary
The facility failed to maintain effective infection control standards during wound care for Resident #57, who was admitted with diagnoses including CVA, metabolic encephalopathy, polyneuropathy, and dementia. The resident’s quarterly MDS showed moderate cognitive impairment, maximum assistance needs for activities of daily living and mobility, frequent bladder incontinence, occasional bowel incontinence, and occasional pain. The care plan identified the resident as at risk for impaired skin integrity with new wounds and increased nutritional needs related to wound healing, and physician orders included treatment for right gluteal, sacral, and left inner buttock wounds with cleansing, collagen powder, and Triad cream, along with a low air loss mattress for wound management. During observation of wound care, RN #870 and CNA #872 provided treatment in the resident’s room while the wound treatment cart was brought into the room. RN #870 wore gloves and opened a drawer to obtain additional wound cleanser without removing gloves or performing hand hygiene. CNA #872 removed dirty gloves and put on clean gloves without hand hygiene between glove changes. Staff also continued touching environmental surfaces while still wearing soiled gloves. The DON/Infection Preventionist stated wound treatment carts were not to be brought into resident rooms because of contamination and cross transmission concerns, and that staff were expected to perform hand hygiene after glove removal and before donning clean gloves and should not touch environmental surfaces with contaminated gloves. The facility’s wound care policy required handwashing before wound care, after removal of dressings, and after completion of wound treatment, and directed staff to take only disposable supplies needed for treatment into the resident room.
Failure to Provide Transfer and Bed Hold Notices
Penalty
Summary
The facility failed to ensure residents or their representatives were notified in writing of the facility's transfer and bed hold policy for Residents #13, #75, and #76. For Resident #13, the record showed the resident had diagnoses including CVA with left-sided hemiparesis, diabetes mellitus, chronic respiratory failure with hypoxia, schizoaffective disorder, hypertension, anemia, PTSD, polyneuropathy, PVD, atrial fibrillation, insomnia, and aphasia, and required moderate assistance with transfers and varying levels of assistance with ADLs. A nursing note documented the resident was sent to the hospital for a stroke workup and the resident representative was left a voicemail, but the record did not show written transfer/discharge notice or written bed-hold information was provided to the resident or representative. For Resident #75, the record showed diagnoses including chronic respiratory failure with hypoxia, morbid obesity, type II diabetes mellitus, depressive type schizoaffective disorder, personality disorder, and paranoid personality disorder, and the resident was cognitively intact. The resident called EMS due to suicidal thoughts, was on one-on-one supervision, and was transferred for an inpatient psych stay for suicidal ideations, but there was no evidence of a transfer notice or bed hold notice being provided. For Resident #76, who had diagnoses including anxiety disorder, hypertension, type II diabetes mellitus, cognitive communication disorder, cirrhosis of the liver, and morbid obesity, and had a severe cognitive impairment on BIMS, the resident was transferred for an inpatient psych stay for medication review and adjustment, but the record also lacked evidence of written transfer notice or bed hold notice. The facility additionally had no evidence that the Office of the State Long-Term Care Ombudsman was notified of Residents #75 and #76's transfers to the hospital.
Failure to Include Residents in Care Plan Meetings
Penalty
Summary
The facility failed to ensure residents were given the opportunity to participate in their care plan meetings. For Resident #3, the record showed an admission date of 04/18/26 and diagnoses including type II diabetes mellitus, end stage renal disease, acute and chronic respiratory failure with hypoxia, and chronic systolic congestive heart failure. The MDS admission assessment identified the resident as cognitively intact. The Care Conference Sheet and Care Plan Review dated 05/15/26 showed a care conference was held with the interdisciplinary team and the resident's family participated by teleconference, but there was no evidence that Resident #3 was invited to or participated in the meeting. The resident stated he had not attended or participated in a care plan meeting and would like to participate. For Resident #43, the record showed an admission date of 04/22/26 and diagnoses including cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting the non-dominant left side, and symptoms and signs involving cognitive functions following cerebral infarction. The MDS admission assessment identified the resident as cognitively intact. The Plan of Stay Conference sheet dated 05/21/26 showed a phone conference with the resident's daughter, Rehab Director #842, and Social Service Director #843 to discuss an insurance cut and the plan for long term care, but there was no evidence the resident participated. The resident stated she had not participated in a care plan meeting since admission, and the Administrator confirmed there were no additional care plan meetings with evidence of the resident's participation.
Admission Assessment Delay and Missing Wheelchair Positioning Support
Penalty
Summary
The facility failed to ensure an admission nursing assessment was completed timely for one resident admitted with diagnoses including status post spinal surgery, intervertebral disc disease, spinal stenosis, and diabetes mellitus. The resident’s admission MDS showed an admission date matching the facility admission date, but the admission nursing assessment was not completed until the following day at 5:50 P.M. The resident’s progress notes did not include any notation by medical staff identifying the time the resident arrived at the facility. The DON verified that the assessment was completed the day after admission and that no progress note was entered to show when the resident arrived. The facility also failed to ensure a physician-ordered positioning aid was in place for another resident. The resident had diagnoses including CVA, osteoarthritis of the left hip, and benign prostate hypertrophy, and the physician ordered a lateral support for trunk positioning in the wheelchair. During observation, the resident was seen asleep and leaning over the left armrest of the high-back wheelchair in the dining room, then later again leaning over the left armrest. Later observation of the wheelchair in the resident’s room showed no left lateral support in place. The DON observed and verified that the left lateral support was not in place as ordered.
Unsafe Smoking Practices and Lack of Supervision
Penalty
Summary
The facility failed to maintain safe and responsible smoking practices for two residents. Resident #13 was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, type II diabetes mellitus, and bipolar type schizoaffective disorder. A smoking assessment documented cognitive loss and visual deficits and indicated the resident required supervision while smoking, with the facility to store the resident’s lighter and cigarettes. Resident #24 was admitted with diagnoses including COPD, dementia with behavioral disturbance, and essential hypertension, and the medical record did not identify this resident as a smoker. During observation, cigarette butts and combustible trash were found in courtyards by the 400 hallway and 100 hallway, which were not identified as smoking areas and did not have ashtrays or a metal can readily available. Later, Resident #13 and Resident #24 were observed sitting in the courtyard by the 400 hallway with lit cigarettes and no staff supervising them. RN #799 confirmed the two residents were smoking unsupervised and stated she was unsure of their smoking safety needs. The facility’s smoking policy stated smoking was only permitted in designated resident smoking areas, ashtrays would be available in smoking areas, residents requiring monitoring would have direct supervision while smoking, and residents were not permitted to give smoking materials to other residents.
Failure to Monitor Dialysis Resident and Document Communication
Penalty
Summary
The facility failed to ensure routine monitoring was completed before and after dialysis treatments for a resident with end stage renal disease, type II diabetes mellitus, and essential hypertension. The resident was admitted with a right arm fistula with bruit and thrill present and had physician orders for hemodialysis on Mondays, Wednesdays, and Fridays, along with orders to obtain pre- and post-dialysis vital signs, monitor the fistula for bruit and thrill, and send dialysis communication forms with the resident on treatment days. Review of the TAR for April, May, and June 2026 showed no evidence that the facility monitored the dialysis site for bruit and thrill, and no evidence of post-dialysis vital signs on multiple treatment dates. The record also showed no evidence that dialysis communication forms were completed or sent with the resident to dialysis. During observation, the resident was transported to dialysis without a communication form. Staff interviews confirmed the facility did not have the resident’s pre- or post-dialysis assessments in the EMR and could not provide evidence of completed communication forms. The dialysis communication binder contained only blank forms, a face sheet, code status, and current orders, while the facility’s dialysis agreement stated both parties were to ensure documented evidence of collaboration and communication.
Failure to Obtain Consent and Assessment for Side Rail Use
Penalty
Summary
The facility failed to ensure a comprehensive assessment and informed consent were completed before implementing bilateral half side rails for Resident #57. The resident was admitted with diagnoses including CVA, metabolic encephalopathy, polyneuropathy, and dementia, and the quarterly MDS showed moderate cognitive impairment, maximum assistance needs for ADLs and mobility, frequent bladder incontinence, occasional bowel incontinence, and occasional pain. The Restraint Enabler Decision Tree dated 05/09/26 identified side rails as an enabler device, but the record did not contain documentation of informed consent or a comprehensive assessment for the resident's side rail use. During the survey period, Resident #57 was observed in bed with bilateral half side rails in place and using them for repositioning and bed mobility. The DON confirmed the facility could not provide documentation of informed consent or a comprehensive assessment for the side rail use.
Duplicate GERD Medication Therapy Without Documented Rationale
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs by allowing duplicate medication treatment for GERD. Resident #11 was admitted with diagnoses including GERD, diabetes mellitus, and chronic kidney disease. Review of the medical record showed that the resident was prescribed Famotidine 20 mg twice daily and later was also prescribed Pantoprazole 40 mg twice daily, both oral medications used to treat GERD. Review of progress notes and physician and nurse practitioner examination notes found no documented rationale for the concurrent use of both GERD medications. During interview, the DON verified that no rationale was indicated for treating the resident with duplicate medication therapy with Famotidine and Pantoprazole.
Survey Results Not Prominently Accessible to Residents
Penalty
Summary
The facility failed to ensure that past survey results were available in a prominent area accessible to residents. During the Resident Council interview, twelve residents stated they did not know where the facility’s past survey results were kept and did not know whether they could review them without making a request. The facility census was 67, and the issue had the potential to affect all residents. Observation of the main entryway and reception area showed a notice on the reception desk stating, "Past survey results available upon request," and a small note in a display case near the entrance stating, "Past survey results are available upon request." The display case was above the eye level of a resident using a wheelchair, and the resident confirmed it was too high to view. The receptionist stated the survey results were kept in a binder behind the reception desk and residents needed to ask for it, and the Activity Director confirmed the survey results were not accessible to residents in any other area.
Advocacy Group Contact Information Not Easily Accessible to Residents in Wheelchairs
Penalty
Summary
The facility failed to ensure that a list of advocacy groups, including contact information, was easily accessible to residents in wheelchairs. During the Resident Council interview, residents stated they did not know where the list of advocacy groups with contact information was located within the facility. Nine of the twelve residents interviewed who attended the council and used wheelchairs for mobility were affected, and the facility identified 47 residents who used wheelchairs for mobility out of a census of 67. Observation showed the display case containing the full list of advocacy groups was mounted on the wall to the left of the main entrance and was above the eye level of a resident in a wheelchair. A separate notice with the local Ombudsman’s contact information was located on the receptionist’s desk approximately four to five feet high. Resident #8, who entered the facility in a wheelchair, stated the display case was too high to view and that the Ombudsman information on the receptionist’s desk had not been noticed. The receptionist stated there had been requests for the Ombudsman’s contact information, and the Activity Director confirmed the only full list of advocacy groups was in the display case near the main entrance with no other accessible lists posted in the facility.
Resident Injury Due to Improper Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a resident, who was dependent on two staff members and a mechanical (Hoyer) sling lift for all transfers, was transferred by only one Certified Nursing Assistant (CNA) using the lift. During this unsupervised transfer, the lift tipped over, causing the resident to fall to the floor and sustain a right hip fracture. The resident was subsequently transferred to the hospital for treatment and did not return to the facility after discharge. The resident had a history of multiple rib fractures, syncope, and anxiety disorder, and was assessed as having an activity of daily living (ADL) deficit, requiring a mechanical lift for transfers. The care plan and facility policy both specified that at least two staff members were required for safe use of the mechanical lift. The manufacturer's guidelines also recommended two assistants for all lifting and transferring procedures. Despite these requirements, the CNA performed the transfer alone, without requesting assistance from other available staff. Interviews with staff confirmed that the CNA did not ask for help before attempting the transfer. Other CNAs and the nurse on duty were only called to assist after the resident had already fallen. The facility's investigation verified that the transfer was not conducted according to policy or manufacturer instructions, directly resulting in the resident's injury.
Failure to Prevent Elopement of Cognitively Impaired Resident Due to Lapses in Supervision and Wander Guard Use
Penalty
Summary
A severely cognitively impaired resident, with diagnoses including senile degeneration of the brain, anxiety disorder, encephalopathy, and type 2 diabetes mellitus, was identified as high risk for wandering and elopement upon admission. The resident's assessments indicated severe cognitive impairment, disorientation, and a history of wandering, with interventions including the use of a wander guard device. On the night of the incident, the resident had experienced a seizure and was transported to the hospital by paramedics, during which the wander guard was removed. Upon the resident's return from the hospital, there was no verifiable evidence that the wander guard was reapplied, and the nurse responsible for re-admission was unaware of the need for the device. Throughout the night, staff observed the resident wandering the building, attempting to redirect him with snacks, television, and conversation, but were unsuccessful in keeping him in his room. Multiple staff members noted the resident's persistent wandering and attempts to exit, with door alarms sounding at various times. Despite these behaviors and the resident's known risk, staff did not verify the presence or function of the wander guard, and there was no documentation indicating it was reapplied after the hospital visit. Additionally, staff allowed family members of other residents to enter and exit the facility using the door code without staff assistance, which created an opportunity for the resident to follow someone out of the building. The resident ultimately exited the facility unnoticed during the early morning hours and was found by a concerned citizen walking in the middle of the road, approximately 0.55 miles away from the facility, dressed in a t-shirt, pajama pants, and without shoes, in 46-degree weather. Facility staff were unaware of the resident's absence until notified by local law enforcement. The facility's failure to ensure the wander guard was in place and to provide adequate supervision and control of exit doors directly led to the resident's elopement.
Removal Plan
- Local law enforcement called facility and spoke with Licensed Practical Nurse (LPN) #107 to notify about Resident #12 being found and taken to the hospital.
- LPN #107 and Registered Nurse (RN) #108 completed a head count of all residents to ensure all were present and accounted for.
- LPN #107 attempted to notify Resident #12's Responsible Party and left a message.
- LPN #107 notified RN Manager #109 of Resident #12 leaving the facility and being taken to the hospital; RN Manager #109 notified the Administrator.
- RN Manager #109 attempted to contact Resident #12's Responsible Party and left a message.
- RN Manager #109 called and spoke with the hospital nurse for an update on Resident #12.
- RN #111 spoke with Resident #12's Responsible Party and notified them of the incident.
- Resident #12 returned to the facility accompanied by paramedics; RN #111 obtained vital signs and assessed Resident #12.
- Resident #12's wander guard was placed back on by RN #111 and Resident #12 was placed on one-on-one (1:1) supervision.
- Facility staff were educated on the Wandering/unsafe resident policy, Behavioral Assessment, Intervention, and Monitoring policy, ensuring interventions were in place for residents with exit seeking behaviors, ensuring interventions were put back in place when residents returned from the hospital, and not giving residents or families the door code.
- RN #101 audited resident orders and care plans for wander guards; any variances were corrected immediately.
- Receptionist #114 and Maintenance Director #115 audited all residents with wander guards for functioning, placement, and expiration; all were placed properly, functioning appropriately, and not expired.
- Maintenance Director #115 audited all exit doors and the wander guard system at all doors to ensure proper function.
- RN #101 audited current resident progress notes to ensure if behaviors consistent with exit seeking were noted, then residents had appropriate interventions in place.
- Resident #12's Nurse Practitioner (NP) #116 was notified of Resident #12 leaving the facility and being taken to hospital by law enforcement with return to facility.
- Administrator audited the facility records of exit door function checks.
- ADON #103 completed elopement and wandering risk assessments on all in-house residents.
- An elopement drill was completed by Maintenance Director #115.
- An ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was held to review the facility correction plan including ongoing compliance.
- ADON #103 educated all current resident responsible parties via phone that they were to ensure staff let them in and out the doors when the front door was locked and should not enter the code themselves or let anyone else out without staff assistance.
- SecureCare was called and the front door code was changed by Maintenance Staff #117.
- The Care Conference form was updated by the Administrator to include education for new families and a reminder for others to request staff assistance with doors when locked, not put in code themselves or assist anyone else out of facility.
- Resident #12's care plan was updated by RN #101 to include wandering and elopement risk with interventions including 1:1 as needed, monitor and report changes in behaviors, orient to new surroundings, provide diversional activities of interest as needed, redirect as needed, and wander guard with placement and function checks as ordered.
- Nursing staff would monitor the effectiveness of interventions for Resident #12 by reviewing point of care (POC) documentation and conducting a review for weekend POC.
- CNAs would report behaviors to the charge nurse if behaviors were not resolved with interventions.
- 1:1 (staff) supervision would continue for Resident #12 until discharge.
- If a call off occurred for a person doing 1:1 supervision, the Administrator would be immediately notified and re-assign floor staff, management staff, or other department staff to cover 1:1 as appropriate. The Administrator would oversee 1:1 coverage scheduling.
- All new hires and agency staff would be educated regarding the facility's Wandering/unsafe resident policy, Behavioral Assessment, Intervention, and Monitoring policy, ensuring interventions are in place for residents with exit seeking behaviors, ensuring interventions are put back in place when residents return from the hospital, and not giving residents or families the door code.
- The Administrator or designee would review all door checks to ensure all doors were checked and functioning appropriately. All variances would be corrected upon discovery and education/follow-up would be provided as deemed necessary.
- Maintenance Director #115 or designee would conduct elopement drills to ensure staff respond accordingly. All variances would be corrected upon discovery and additional education/follow-up would be provided as deemed necessary.
- The DON or designee would assess all residents with wander guards to ensure proper placement, function and expiration. All variances would be corrected upon discovery and additional education/follow-up would be provided as deemed necessary.
- The Administrator or designee would audit the wander guard system and resident accessible exit doors to ensure they were functioning properly to ensure all doors were intact and functioning properly, including alarm. All variances would be corrected upon discovery and additional education/follow-up would be provided as deemed necessary.
- The DON or designee would complete elopement and wandering risk assessments for facility residents to ensure no changes in behavior patterns or acute changes in condition affecting mental status were present placing residents at risk for elopement and ensuring that appropriate and effective interventions were in place. All variances would be corrected upon discovery and additional education/follow-up would be provided as deemed necessary.
- The DON or designee would audit progress notes to ensure any residents with behaviors that increase risk for elopement or exit seeking have appropriate interventions in place.
- The Administrator or Designee would interview visitors to ensure visitors were aware they were not to enter door codes when the door was locked and should wait for staff assistance to exit facility, as well as not let anyone else out without staff assistance.
- The facility Quality Assurance (QA) committee would review audits to ensure compliance. Variances would be corrected immediately upon discovery and education provided.
- Results of these audits would be reported to the facility quality assurance committee. Ongoing compliance would be maintained by recommendations of the facility quality assurance committee.
Failure to Perform Routine PICC Line Dressing Changes
Penalty
Summary
The facility failed to ensure that dressing changes for a resident's peripherally inserted central catheter (PICC) line were performed on a routine, ongoing basis as required. Upon admission, the resident had a double lumen PICC line and an order for intravenous antibiotics, but there were no documented orders regarding PICC line care at that time. Medical record review and staff interviews confirmed that there was no documentation of PICC dressing changes until the PICC line was replaced, despite the facility's policy requiring dressing changes at least every five to seven days and as necessary. The resident reported that the dressing had been changed no more than twice since admission, and the dressing in place was dated several days after the initial placement. The resident's diagnoses included methicillin-resistant staphylococcus aureus infection, bacteremia, and a post-surgical site infection, all of which require careful management of central lines to prevent further complications. A nursing note indicated the PICC line became clogged, leading to its replacement. Orders for routine dressing changes and site monitoring were only written after the replacement, and staff were unable to locate documentation of prior dressing changes. The facility's policy emphasized the importance of keeping dressings clean, dry, and intact to prevent catheter-related infections, but this standard was not met for the resident in question.
Failure to Timely Identify and Treat Change in Respiratory Condition
Penalty
Summary
A deficiency occurred when the facility failed to timely identify and respond to a significant change in a resident's respiratory condition, resulting in actual harm. The resident, who was a full code, non-verbal, and had a tracheostomy, exhibited labored breathing, tested positive for COVID-19, and was being treated for pneumonia. Despite these risk factors and a history of respiratory complications, the LPN on duty did not notify the physician about the resident's labored breathing or the absence of secretions during suctioning. The LPN, unfamiliar with the resident, relied on information from a respiratory therapist (RT) via Facetime, who indicated the resident's breathing was at her baseline, and did not escalate care or seek further assistance until the resident was found unresponsive. The resident's medical record showed multiple complex diagnoses, including respiratory failure, pneumonia, encephalopathy, and tracheostomy status. Documentation revealed that the resident had previously required frequent suctioning for thick secretions and had a history of mucous plugs, which could cause acute respiratory distress. On the night of the incident, the LPN noted labored breathing and minimal secretions during suctioning but did not recognize these as signs of a potential mucous plug or acute deterioration. The RT, who was off-site, advised that the resident's condition was normal based on prior experience, but had not personally assessed the resident that day. There was no evidence in the records that labored breathing was normal for this resident, and the physician later confirmed she was not contacted about the change in condition. The facility's policy required prompt notification of the physician and responsible party for significant changes in a resident's condition. However, the LPN did not notify the physician or seek additional help until the resident was found without vital signs, at which point CPR was initiated and the resident was transferred to the hospital. Hospital records indicated the resident was admitted for acute on chronic respiratory failure with hypoxia, with findings suggestive of a possible mucous plug and severe sepsis. The resident ultimately passed away at the hospital. Interviews with staff and review of documentation confirmed that the failure to recognize and act upon the resident's change in respiratory status, and the lack of timely physician notification, directly contributed to the deficiency.
Sanitary Deficiencies Observed in Kitchen
Penalty
Summary
Surveyors observed multiple sanitary concerns in the facility's kitchen during a tour with the Dietary Manager. Three trash cans were found dirty with a dark substance on their sides, and the bottom shelf of a steel table was soiled with an orange substance, which a staff member confirmed was present at the start of her shift. A flour container was found with a measuring cup left inside, and two black three-tiered carts were visibly dirty with a buildup of various spilled substances. The refrigerator contained two packages of American cheese wrapped in aluminum foil without any dates indicating when they were opened or their expiration, and the cheese was hard and discolored at the edges. Additionally, an opened package of deli ham slices was found with no date of opening. These issues were all verified by the Dietary Manager during the inspection. The facility's policy requires the food service area to be maintained in a clean and sanitary manner, but these observations indicated non-compliance. All residents except three who did not receive food from the kitchen were affected.
Failure to Notify Physician of Change in Condition for Resident with Respiratory Distress
Penalty
Summary
A deficiency occurred when the facility failed to notify the physician of a significant change in condition for a resident with complex medical needs, including respiratory failure, pneumonia, tracheostomy, and recent COVID-19 diagnosis. The resident, who was a full code and dependent on staff for all activities of daily living, returned from a hospital stay with new orders for antibiotics and continued to require oxygen and suctioning. Documentation showed that the resident experienced labored breathing and fluctuating oxygen saturations, but there was no evidence that the physician was notified of these changes during the night prior to the resident's death. Nursing and respiratory therapy staff noted increased secretions, labored breathing, and the need for frequent suctioning. Despite these observations, the nurse on duty relied on input from the respiratory therapist, who was contacted via Facetime and indicated that the resident's condition appeared to be her baseline. The nurse did not escalate the situation or seek further assistance, and there was no documentation of physician notification regarding the resident's respiratory distress. The resident's family was not informed of the labored breathing, and the physician later confirmed she was not contacted during the critical period. Interviews with staff revealed uncertainty and lack of familiarity with the resident's baseline condition, as well as a lack of clear communication and documentation regarding the resident's respiratory status. The facility's policy required prompt notification of the physician and responsible party for significant changes in condition, but this was not followed. The resident ultimately experienced respiratory failure and was transported to the hospital, where she passed away. The deficiency was substantiated by review of medical records, staff interviews, and facility policy.
Failure to Provide Clean, Stain-Free Linens for Resident Care
Penalty
Summary
The facility failed to ensure that linens provided to residents were free from stains and maintained in a clean, comfortable, and homelike condition. During interviews and observations, it was found that a resident reported the washcloths and towels were stained, dingy, and not white, expressing discomfort with using them for personal hygiene. Direct observation of the linen closets confirmed that the available washcloths, hand towels, and bath towels were light brown in color, had several large brown stains, and appeared worn and thin. Staff confirmed that all linens were in similar condition and attributed the staining to the use of washcloths and towels for cleaning up bowel movements after the facility stopped purchasing incontinence wipes. The laundry manager stated that the same linens had been in use for an extended period, and new supplies ordered had not yet arrived. She also noted that the facility had been experiencing shortages of washcloths and towels since discontinuing incontinence wipes, leading to repeated use and further deterioration of the linens. The affected resident had multiple chronic medical conditions, including chronic respiratory failure, diabetes, kidney disease, and cognitive impairment, and was dependent on the facility for daily living supports. The deficiency had the potential to affect all residents utilizing facility linens.
Failure to Arrange Transportation and Pre-Appointment X-rays for Postoperative Follow-Up
Penalty
Summary
The facility failed to ensure that transportation was arranged for a resident's postoperative appointment as ordered by the physician. The resident, who had multiple complex diagnoses including cervical disc disorder, spinal stenosis, diabetes, and recent spinal surgery, was admitted with orders for a follow-up surgical appointment. The medical record and staff interviews confirmed that the resident missed the initial postoperative appointment because transportation was not set up by the facility. The appointment had to be rescheduled, and there was a lack of communication between the facility and the neurosurgery office regarding the resident's follow-up care. When the appointment was rescheduled, the resident arrived late and was not taken to radiology for X-rays prior to seeing the surgeon, as specified in the physician's order. The resident ultimately had the X-rays completed after the appointment instead. Interviews with staff revealed uncertainty about the transportation arrangements and the requirements for pre-appointment X-rays. The resident also confirmed that he was not informed about the need for radiology prior to the appointment and that transportation arrangements were not properly communicated or executed.
Failure to Timely Implement Individualized Pressure Ulcer Interventions
Penalty
Summary
The facility failed to implement timely, individualized, and effective interventions for pressure ulcer care for one resident with significant risk factors and existing pressure ulcers. The resident was admitted with multiple diagnoses, including hemiplegia, contractures, incontinence, and existing pressure ulcers on both heels. Upon admission, assessments identified the resident as high risk for pressure injuries, and documentation showed the presence of unstageable and Stage III pressure ulcers with heavy drainage and necrotic tissue. The care plan included interventions such as pressure-relieving devices, nutritional supplements, moisture barriers, and assistance with mobility and hygiene. Despite these documented interventions, there were delays and inconsistencies in their implementation. The resident did not receive a low air loss mattress until eight days after admission, despite requesting it on the first day and being at high risk for further skin breakdown. The resident also reported that staff did not consistently assist with turning, repositioning, or offloading the heels unless specifically requested. Observations confirmed that the resident's heels were directly on the bed without protective boots, and interviews with staff verified that the boots were not in use at the time of observation. The resident and a family member both indicated that necessary equipment and interventions were only provided after complaints were made to external authorities. Further review of wound care notes showed that the pressure ulcers increased in size before eventually showing some improvement, and that debridement was delayed due to the resident's pain and refusal, with some interventions only initiated after repeated documentation of wound status. The facility's policy required assessment and documentation of risk factors and timely intervention, but the evidence indicated that these were not consistently or promptly followed, resulting in a failure to provide adequate pressure ulcer care and prevention.
Failure to Timely Arrange Dental Appointment Following Physician Order
Penalty
Summary
The facility failed to arrange a dental appointment as ordered for a resident who experienced a dental issue. The resident, who had multiple diagnoses including chronic respiratory failure, diabetes, schizoaffective disorder, and a history of dental problems, reported to nursing staff that a tooth had fallen out. Although the resident did not initially report pain, the physician was notified and ordered Clindamycin and a dental appointment to be scheduled as soon as possible. Documentation review showed that the dental appointment was not scheduled or completed following the initial order. Subsequently, the resident called 911 for toothache pain and dizziness and was transported to the hospital. Upon return, new orders for antibiotics were given for dental caries and a periapical abscess. It was only after this hospital visit that a dental appointment was scheduled, several weeks after the original physician order. Interviews with facility staff confirmed that the dental appointment was not set up until after the resident's hospital visit, despite the earlier order to do so.
Inappropriate Infection Control During Incontinence Care
Penalty
Summary
During an observation of incontinence care, a Certified Nursing Assistant (CNA) provided care to a resident with multiple diagnoses, including malignant neoplasm of the colon, duodenal ulcer, dementia, urinary retention, depression, chronic pain syndrome, gastritis, and moderate protein-calorie malnutrition. The CNA used two washcloths and a bath towel to perform perineal and rectal care. After washing the resident's perineal and rectal area, the CNA continued to use a visibly soiled washcloth, using a different part of the same cloth, and placed the soiled washcloth on a clean towel. The CNA then dried the resident with the towel that had come into contact with the contaminated washcloth. The CNA proceeded to wipe the resident from the perineal area to the rectum with the same soiled washcloth, and upon noticing additional feces, used tissues from the bedside stand to clean the area. The CNA then continued to use the feces-soiled washcloth to wipe the resident two more times before being stopped by the surveyor, who instructed her to obtain a clean washcloth. The CNA confirmed in an interview that she had used a feces-soiled washcloth during the care. Facility policy on perineal care requires cleanliness to prevent infection and skin irritation, which was not followed in this instance.
Failure to Replace Distilled Water for BiPAP Machine
Penalty
Summary
The facility failed to ensure the proper replacement of distilled water used in respiratory therapy, specifically for a resident using a BiPAP machine. The resident, who had multiple health conditions including chronic obstructive pulmonary disease and obstructive sleep apnea, complained about the taste of the distilled water, which he claimed made him feel nauseous and affected his breathing. Despite the resident's complaints, the respiratory therapist (RT) and staff did not replace the distilled water daily as requested by the resident. Instead, the RT replaced the water once a week, contrary to the facility's policy and the manufacturer's guidance, which required the water to be changed every 24 hours or when it had an unusual taste. The RT was unaware of the facility's policy regarding the use of distilled water for respiratory equipment and believed that changing the water weekly was sufficient. The RT had informed the Administrator and the Director of Nursing (DON) about the resident's request, but they initially supported the RT's practice of weekly changes. However, the DON later stated that the distilled water should be changed every 24 hours, as per the facility's policy. The facility's policy and the manufacturer's guidance both emphasized the importance of changing the distilled water to prevent infection and ensure the safety of the resident using the BiPAP machine.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in an eight percent error rate during the observation period. This deficiency affected two residents during medication administration. For Resident #50, the error involved the incorrect measurement of polyethylene glycol powder by an LPN, who filled the cap below the required white line, leading to an inaccurate dosage. The LPN confirmed the mistake upon review of the medication instructions, which specified filling the cap to the white line to achieve the correct 17 grams dosage. For Resident #3, the error occurred when an RN failed to administer the Azelastine Hydrochloride nasal spray as prescribed. The RN acknowledged forgetting to give the nasal spray during the medication pass. The facility's policy on administering medications, revised in April 2019, mandates that medications be administered safely, timely, and as prescribed, with errors documented and reviewed by the QAPI committee. This deficiency was investigated under two complaint numbers, indicating non-compliance with the facility's medication administration policy.
Infection Control Lapses During Medication Administration
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during medication administration for two residents. During an observation, a registered nurse did not perform hand hygiene before and after glove use while administering medications to a resident. The nurse also failed to disinfect the glucometer before and after obtaining blood sugar levels for two residents. This lack of adherence to infection control protocols was confirmed during an interview with the nurse. The residents involved had multiple medical conditions, including heart disease, diabetes, and neurological conditions. The facility's policies on medication administration and blood sampling required adherence to infection control procedures, such as hand hygiene and disinfection of reusable medical devices. The Centers for Disease Control guidance also emphasized the importance of hand hygiene in healthcare settings, which was not followed in this instance.
Medication Administration Error in LTC Facility
Penalty
Summary
The facility failed to ensure that a resident's medications were administered as ordered, affecting one resident out of four reviewed for medications. The resident, who was readmitted with diagnoses including pneumonia, depression, and acute respiratory failure with hypoxia, had an order for hydrocodone/Tylenol (Percocet) to be given every six hours as needed for up to five days. This order was discontinued on 10/01/24. However, a review of the Controlled Drug Record form showed that a Percocet tablet was administered on 12/08/24 at 11:45 P.M. by a registered nurse, despite the medication being discontinued. The registered nurse confirmed in an interview that she accidentally administered the Percocet without checking the computer records first. She admitted to looking in the narcotic drawer and noticing the Percocet, which led her to administer it. It was only after attempting to sign off the medication in the resident's medical record that she realized the medication had been discontinued. This incident was a violation of the facility's policy, which requires medications to be administered safely, timely, and as prescribed.
Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to protect residents from incidents of sexual abuse, specifically involving a male resident with severe cognitive impairment and two female residents. On two occasions, the male resident was found in compromising situations with a female resident who was also severely cognitively impaired. The first incident occurred when the female resident was found naked in the spa room with the male resident, who was dressed. Later the same day, the male resident was observed with his pants down, engaging in inappropriate sexual behavior with the same female resident. There was no evidence that the female resident had consented or was capable of consenting to the interaction. The facility did not implement effective interventions to prevent these incidents from occurring or to protect the female resident and others from the male resident. Despite the male resident's care plan not being updated to address his sexual behaviors until after the incidents, the facility failed to ensure adequate supervision and safety measures were in place. This lack of action resulted in another incident where the male resident was observed grabbing the breast of a different female resident without her consent. The facility's policies on abuse prevention and reporting did not include definitions of sexual abuse or consent, contributing to the inadequate response to the incidents. The facility did not complete a self-reported incident for the events involving the male and female residents, as they did not believe it constituted abuse. This oversight and failure to recognize the severity of the incidents led to a deficiency in ensuring resident safety and protection from abuse.
Removal Plan
- Resident #4 and Resident #61 were immediately separated. Resident #4 and Resident #61 were placed on 1:1 supervision.
- Resident #4 and Resident #51 were immediately separated, and Resident #4 was placed back on 1:1 supervision with staff.
- Regional Quality Assurance Registered Nurse (RQARN) #800 reviewed the progress notes of Resident #4 since his admission to the facility to ensure there were no other documented occurrences of like behaviors.
- Facility Assistant Administrator (FAA) #801 completed interviews with 28 of 28 alert and oriented residents with Brief Interview of Mental Status (BIMS) scores of 12 and higher. All 28 residents denied any like concerns and denied abuse and mistreatment by staff and/or other residents.
- Unit Manager Licensed Practical Nurses (UMLPN) #802 and #803 performed skin sweeps on 33 of 33 residents with BIMS scores less than 12. No new or unidentified skin impairments, psychosocial distress or signs of abuse or mistreatment were noted for these 33 residents.
- Regional Director of Operations (RDO) #501 educated 18 of 18 administrative staff on the facility Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy, the Abuse, Neglect, Exploitation and Misappropriation Prevention Program Policy and re-educated on 1:1 supervision requirements.
- The Administrator and other staff re-educated 98 of 99 facility staff on the facility Abuse, Neglect, Exploitation or Misappropriation -Reporting and Investigating policy, the Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy and re-educated on 1:1 supervision requirements.
- RDO #510 visually confirmed Resident #4 to be on 1:1 supervision.
- RDO #510 educated the Administrator, Assistant Administrator #801, the DON, the ADON, and UMLPNs #802 and #803 on federal regulation F609: Reporting of Alleged Violations and F610: Response to Alleged Violations.
- The care plan of Resident #4 was updated to include the 1:1 supervision.
- RDO #510 notified the Medical Director via phone of the Immediate Jeopardy and abatement plan.
- SSD #809 performed a psychosocial assessment on Resident #51 who showed no signs of psychosocial distress.
- RQARN #800 reviewed progress notes for the last 90 days for all current facility residents for any related sexually inappropriate behaviors.
- STNA #817, who was assigned to Resident #4's 1:1 supervision, was terminated from employment at the facility for not maintaining 1:1 supervision.
- An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held to review the facility Immediate Jeopardy and removal plan.
- The DON or designee would verify 1:1 was in place for Resident #4 and the staff person assigned to the 1:1 had full understanding of the requirement for providing 1:1, each shift seven days a week for a period of one week and each shift five times a week for a period of three weeks thereafter.
- The DON or designee would interview eight staff members five times weekly for a period of four weeks to ensure understanding of the 1:1 education provided.
- The DON or designee would review progress notes of current residents five times a week for a period of four weeks to ensure any notable changes in sexual behavior had an appropriate and timely intervention.
- The Administrator or designee would interview 10 residents weekly, for a period of four weeks regarding abuse and mistreatment.
- The DON or designee would assess 10 non-interviewable residents weekly for a period of four weeks to ensure residents remain free of signs of unknown skin impairment and abuse and/or mistreatment.
- RDO #510 or designee would review all allegations of abuse three times a week, for a period of four weeks to ensure timely follow-up, completion of full investigation, documentation of allegation, reporting, and appropriate intervention implementation.
- The Administrator would audit 100% of new hires five times a week for four weeks for education on the facility Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating Policy.
- RDO #510 would review all audits weekly for a period of four weeks to ensure completion and compliance.
Failure to Monitor and Provide Care Leads to Resident's Death
Penalty
Summary
The facility failed to provide adequate and timely care to Resident #42, who was dependent on staff for various needs, including transfers, incontinence care, and diabetes management. The resident, who had a complex medical history including Huntington's disease, diabetes, and was at risk for falls, was found unresponsive in his room, slumped over in his wheelchair with blood on his face and clothing. The last documented interaction with the resident was at 10:00 P.M. when an LPN checked his blood glucose level, which was elevated at 400 mg/dl, and administered 40 units of Glargine insulin. However, there was no follow-up or monitoring of the resident's condition throughout the night. The resident was not checked again until 4:30 A.M. when a nursing assistant found him unresponsive. Despite the elevated blood glucose level earlier, no further assessments or interventions were documented. The resident required CPR and was transported to the hospital, where his blood glucose was recorded at 607 mg/dl. He was admitted to the intensive care unit and subsequently passed away. The facility's failure to monitor the resident's condition and provide necessary care contributed to the resident's deterioration and eventual death. Interviews and record reviews revealed that the resident was supposed to be checked every two hours for incontinence care and was care planned to be in a common area when in his wheelchair due to fall risk. However, these interventions were not followed, and the resident remained in his room unattended. Staff statements indicated a lack of communication and follow-through on the resident's care needs, leading to a significant lapse in care that resulted in immediate jeopardy and actual harm.
Removal Plan
- Regional Quality Assurance Registered Nurse (RQARN) #800 audited residents with physician orders for blood sugar checks to ensure parameters for notifying the physician were included.
- Assistant Director of Nursing (ADON) #403 audited residents with physician orders for blood sugar checks to ensure compliance with physician's orders and appropriate follow-up.
- Regional Director of Operations (RDO) #510 educated facility leadership on following individualized care plans related to incontinence checks and resident monitoring.
- RQARN #800 educated nursing leadership on the facility policy Nursing Care of the Resident with Diabetes Mellitus, including obtaining follow-up blood sugar checks if indicated.
- Facility Medical Director was notified of the Immediate Jeopardy related to quality of care and treatment.
- Facility leadership educated all nursing staff on following individualized care plans related to incontinence checks and resident monitoring.
- RQARN #800, the DON, ADON #403, and UMLPNs educated all licensed nursing staff on the facility policy Nursing Care of the Resident with Diabetes Mellitus.
- Clinical Resource Specialist LPN #816 audited all current resident care plans to ensure fall interventions reflect resident preferences and refusals are addressed.
- Clinical Resource Specialist LPN #816 audited all current resident care plans to ensure incontinence care plans include resident preferences and refusals.
- RDO #510 added facility education for following individualized care plans and the facility policy Nursing Care of the Resident with Diabetes Mellitus to the facility General Orientation manual.
- Clinical Operations Specialist RN #992 completed an audit of progress notes for active residents with physician's orders for blood sugar checks.
- Ad hoc Quality Assurance Performance Improvement (QAPI) meeting held to discuss the plan of action.
- Regional Quality Assurance RN/Designee to review all residents with physician's orders for blood sugar checks.
- DON/designee to interview staff members to ensure understanding of individualized care plans.
- DON/Designee to review progress notes of current residents with physician orders for blood sugar checks.
- DON or Designee to audit new hires to ensure education on facility policy for care plans and diabetes management.
- DON or designee to audit all residents with physician orders for blood sugar checks to ensure parameters for physician notification are included.
- DON or designee to audit all residents with fall care plans to ensure interventions are in place and followed.
- DON or designee to audit all residents with incontinence care plans to ensure standard of care is followed.
- RDO #510 to review all audits to ensure completion and compliance.
- QA Committee to monitor the results of all audits and follow-up as needed.
Inadequate Staffing Leads to Resident Neglect
Penalty
Summary
The facility failed to maintain sufficient staffing levels to meet the care needs of all residents, specifically affecting Resident #42. This resident had a complex medical history, including respiratory failure, diabetes, and severe protein-calorie malnutrition, among other conditions. The care plan for Resident #42 included interventions for fall risk, incontinence, and diabetes management, requiring regular monitoring and assistance from staff. However, the facility's staffing shortages led to inadequate care, as evidenced by the resident being left unattended in a wheelchair for an extended period. On the night of the incident, staffing was insufficient, with only one State Tested Nursing Assistant (STNA) working on the unit where Resident #42 resided. The STNA was overwhelmed with responsibilities and unable to provide timely assistance to all residents. Despite being informed that Resident #42 needed to be laid down, the STNA was unable to attend to this task due to the high workload and lack of support. This situation was exacerbated by another STNA calling off, leaving the unit understaffed and unable to meet the residents' needs effectively. The deficiency was further highlighted when Resident #42 was found unresponsive in his wheelchair, having not been laid down as required. The nursing staff attempted resuscitation, but the delay in care due to staffing issues may have contributed to the severity of the situation. Interviews with staff revealed that working alone was a common occurrence, indicating a systemic issue with staffing levels at the facility. This deficiency was identified during the investigation of specific complaint numbers, underscoring the potential risk to all residents due to inadequate staffing.
Sanitation and Pest Control Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, which had the potential to affect 58 residents receiving meals. During an observation, it was noted that extra dish racks were stored on old milk crates under the sink, and when moved, gnats were seen flying out from under the sink. There was significant water damage with missing tiles and a large hole in the wall, from which the gnats were emerging. The Dietary Manager confirmed the presence of the hole and gnats, although he was unsure of how long the damage had been present. A dietary aide confirmed that the wall had been in disrepair for some time, with water occasionally leaking into an adjacent dining room. A follow-up visit revealed that while the tile had been replaced, the wall behind it had food splatter, and a pipe above had chunks of food, with gnats still present around the dish machine. The walk-in refrigerator had mold on three shelves, food residue, paper pieces, and a broken egg on the floor. Additionally, a box of thickener in the dry storage area was improperly wrapped, labeled, and dated. The walk-in freezer had water on the floor outside it, which had been leaking for a week. The facility's policies on sanitation and pest control, dated 2008, were not adhered to, as the kitchen areas were not kept clean or free from pests, and the pest control program was ineffective.
Failure to Investigate and Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to implement its abuse policy to thoroughly investigate and report all allegations of resident-to-resident abuse, affecting two residents. Resident #61, who had severe cognitive impairments and a history of mood and behavioral issues, was involved in an incident with Resident #4, who also had severe cognitive impairments and a history of behavioral disturbances. On multiple occasions, both residents were found in compromising situations in the spa room, with their pants down. Despite these incidents, the facility did not document or report them as abuse, nor did they conduct a thorough investigation. Resident #4 was involved in another incident with Resident #51, who had moderately impaired cognition and a history of mental health issues. Resident #4 was reported to have grabbed Resident #51's breast, but the facility did not document this incident in the progress notes or conduct a thorough investigation. The facility's policy on abuse, neglect, and exploitation did not include a definition of sexual abuse or information on consent to sexual activity, which may have contributed to the lack of appropriate response. Interviews with staff and family members revealed inconsistencies in the facility's handling of these incidents. Staff reported that Resident #4 was supposed to have 1:1 supervision, but this was not consistently provided. The facility also failed to complete a Self-Reported Incident (SRI) for the incidents involving Resident #4, as they did not believe the situations constituted abuse. The lack of documentation, investigation, and reporting of these incidents highlights a significant deficiency in the facility's implementation of its abuse policy.
Failure to Report Alleged Sexual Abuse Incidents
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving two residents to the State Agency, affecting two out of five residents reviewed for abuse. Resident #61, who had a history of dementia and other cognitive impairments, was found in the bathroom with Resident #4, both with their pants down. Despite being placed on one-on-one supervision, the facility did not document the incident properly or report it as a potential case of abuse. The facility's investigation noted no skin-to-skin contact or distress, but conflicting accounts from staff and family members suggested inappropriate behavior by Resident #4. Resident #4, who also had dementia and other cognitive impairments, was involved in another incident with Resident #51, where he allegedly grabbed her breast. Despite staff witnessing the incident, it was not documented in the progress notes, and the facility did not report it to the State Agency. The facility's policies on abuse prevention and reporting did not include definitions of sexual abuse or guidelines on consent, contributing to the oversight in reporting these incidents. Interviews with staff and family members revealed discrepancies in the facility's handling of the incidents. Staff reported missing witness statements, and there was a lack of consistent one-on-one supervision for Resident #4. The facility's failure to report these incidents as potential abuse cases and the lack of thorough documentation and investigation highlight significant deficiencies in their abuse prevention and reporting protocols.
Failure to Investigate and Report Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to thoroughly investigate allegations of resident-to-resident sexual abuse involving two residents. Resident #61, who had severe cognitive impairment and a history of mood and behavioral issues, was found in the spa room with Resident #4, both with their pants down. Despite being placed on one-on-one supervision, there was no documentation of an earlier incident on the same day. The facility's investigation lacked a written statement from a key witness, and the facility did not report the incident as abuse, believing it was a misunderstanding. Resident #4, who also had severe cognitive impairment and a history of behavioral disturbances, was involved in multiple incidents of inappropriate sexual behavior. On one occasion, he was found with Resident #61 in the spa room, and on another, he allegedly grabbed the breast of Resident #51. Despite these incidents, there was no thorough investigation or documentation, and the facility did not report the incidents as abuse. The facility's policy on abuse reporting and investigation did not include a definition of sexual abuse or guidelines on consent. The facility's failure to investigate and report these incidents as abuse represents a deficiency in their handling of resident safety and compliance with regulatory requirements. The lack of documentation, missing witness statements, and inadequate supervision contributed to the facility's non-compliance. The facility's policies were insufficient in guiding staff on handling and reporting sexual abuse, leading to a lack of appropriate action in response to the incidents.
Inadequate Medication Supply for Safe Discharge
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #63, had an adequate supply of narcotic medications for a safe discharge until her post-discharge physician appointment. Resident #63, who had multiple diagnoses including ADHD, anxiety, arthritis, and fibromyalgia, was discharged to her home without confirmation of having enough medication to last until her scheduled follow-up appointment. The facility's policy required that medications be called into the resident's pharmacy of choice, but did not allow for medications to be sent home unless specifically ordered by a physician. In this case, the physician did not authorize the release of narcotics, and there was no documentation confirming whether the resident had sufficient medication at home. Interviews with facility staff revealed that the discharge process involved calling in a 10-day to two-week supply of medications to the resident's pharmacy, but did not include sending medications home with skilled Medicare residents. The Social Services Director and the Director of Nursing confirmed that medications were not sent home unless ordered by a physician. Additionally, it was noted that Resident #63 had difficulty maintaining a primary care physician due to her boyfriend's actions, which contributed to the lack of a PCP at the time of discharge. The facility's policy on discharge medications required physician authorization for releasing controlled substances, which was not obtained in this case, leading to the deficiency.
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.
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What surveyors actually found near you
We read the 878 citations issued within 25 miles in the last 12 months — including the 3 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 Canton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Pines Healthcare Center | 0.6 mi | ★★★★★ | 14 | 0 |
| Hall Of Fame Rehabilitation And Nursing Center | 0.7 mi | ★★★★★ | 26 | 0 |
| Canton Christian Home | 1.9 mi | ★★★★★ | 14 | 0 |
| Mckinley Nursing | 2.1 mi | ★★★★★ | 59 | 0 |
| The Pavilion At Edgefield For Nursing And Rehabili | 2.5 mi | ★★★★★ | 38 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.