Below average — CMS composite of the measures below.
The next survey window likely opens around April 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 Aventura At Assumption Village during CMS and state inspections, most recent first.
A CNA was allowed to keep working after the facility learned she had an arrest warrant for resident abuse. The incident involved a resident with severe cognitive impairment and dementia who became combative during care, and an LPN reported the CNA struck the resident’s legs. Police later confirmed a warrant for assault, but the CNA still worked on the secured memory care unit and returned for multiple shifts before being sent home during the survey.
A resident with severe cognitive impairment and vascular dementia was involved in an abuse allegation during incontinence care when a CNA said the resident became combative. The CNA claimed she only blocked the resident’s hands, but an agency LPN reported hearing the resident yell out and seeing the CNA swat the resident’s exposed lower extremity twice with an open hand. The police report documented the eyewitness account, and the facility’s investigation was inconclusive despite the allegation of physical abuse.
Failure to Complete Ordered Pressure Wound Care: A resident with quadriplegia, COPD, diabetes, and multiple pressure injuries did not receive ordered daily wound care as documented in the MAR/TAR. The TAR was blank on one day, another day lacked clear wound documentation, and the resident reported that sacrum and mid-back wound care was missed for two days. Observation found undated dressings with dried drainage, and later wound assessment showed a Stage IV sacral ulcer, an unstageable buttock injury, and a Stage III lower back ulcer.
Failure to respond to acute change in condition and wound deterioration: One resident with COPD, chronic respiratory failure, and diabetes developed respiratory distress, abdominal pain, and severe hypoxia, but reassessment and EMS transfer were delayed after the LPN documented low O2 sat and labored breathing. Another resident with recent abdominal surgery had an ordered stool specimen not completed after one attempt, and staff did not notify the MD when the abdominal wound became odorous and largely necrotic; the resident was later hospitalized with sepsis and an abdominal wall abscess.
Failure to provide ordered pressure ulcer care led to a resident’s coccyx wound worsening from Stage II to Stage III and remaining inconsistently treated. The resident had multiple chronic conditions, required extensive ADL assistance, and had repeated gaps in wound assessments and TAR documentation. Staff also missed ordered treatments, used the wrong wound products, and an RN altered the wound order without consulting the physician or WCNP; during dressing care, the RN also broke sterile technique and directed an LPN to backdate a dressing.
Resident council concerns were not thoroughly documented, effectively addressed, or resolved. Repeated complaints involved dietary issues, housekeeping, laundry, CNA cell phone use, poor room cleaning, wrong or wrinkled clothing, lack of notification about a spouse’s ambulance transfer, and frequent dining room closures. Residents and an LPN reported that the same problems kept recurring, the kitchen often ran out of items, menus were wrong, and food quality remained poor, while the DON and Administrator said the issues were addressed to the best of their ability.
Failure to provide nutritious and palatable meals: During a meal observation, the menu listed fruit but none was served until a CNA provided fruit cups after a resident asked for them. The DNM reported no substitution log was maintained, residents complained in council about the dining room being closed, menus being incorrect, food items running out, and poor food quality, and a dietary aide said staffing cuts and shortages led to frequent missing items such as milk and cereal.
Repeated dietary staffing shortages resulted in frequent dining room closures, missed meal service in the dining room, and resident complaints about food quality, incorrect menus, and the kitchen running out of items. Staff reported that cooks and dietary aides repeatedly called off or were not scheduled, several dietary workers were not replaced, and the Administrator said staffing decisions were made by a third-party vendor.
Failure to Recognize and Respond to Acute Changes in Condition and Follow Physician Orders: A resident with multiple chronic conditions and a DNR-CC developed respiratory distress, severe hypoxia, lethargy, abdominal discomfort, and critically low blood glucose, but staff delayed monitoring, physician notification, and EMS transfer until hours later; the resident died the same day. Another resident with recent digestive surgery had a worsening necrotic abdominal wound and an ordered C. diff stool specimen was not obtained or reported, and the resident was later hospitalized with sepsis and an abdominal abscess.
Expired Food Service License: Surveyors found that the facility did not have a current food operating license displayed in the kitchen, and staff reported learning from local news that the license had expired. The Local Health Department confirmed the license had lapsed and was not renewed for more than two months. The DON and Administrator stated the kitchen had been a QAPI concern and that food services were outsourced, while the Administrator confirmed the kitchen operated without a valid license during that period.
Failure to Employ Required Full-Time LSW: The facility did not have a full-time LSW even though its census exceeded 120 residents. The SSD was not a licensed social worker and confirmed the facility had been without a full-time LSW for some time. The Administrator stated two part-time social workers from other facilities were covering duties, but they did not meet the 40-hour requirement, and the SSD job description did not specify that a social work license was required.
Facility staff failed to keep resident information private and confidential by using WhatsApp on personal phones to send resident-specific information to physicians, NPs, the pharmacy, unit managers, the Administrator, and the DON. An RN Manager and an LPN were observed using the unsecured app, while the Administrator stated providers were supposed to be called and that WhatsApp was not permitted. In addition, resident-identifiable STNA reports with names, room numbers, care needs, and fall-risk information were found on the floor and in the hallway, accessible outside the intended area.
Nighttime Snacks Not Available to Residents: Residents reported that requested nighttime snacks were not provided, and the Administrator confirmed the snack basket was not being filled and no snacks were available. Survey observations found no snacks available at night or delivered to residents, and staff including an LPN, CNA, and Dietary Assistant confirmed that snacks were usually not available.
Food was not stored, prepared, distributed, and served under sanitary conditions. A leaking 3-compartment sink had containers placed under the pipes, an undated package of ground beef was found in a cooler, and debris with spilled milk and juice was observed in two coolers. A dietary manager said the sink had been leaking for months and confirmed the unsanitary conditions, while a dietary aide later said the coolers still had not been cleaned.
The facility failed to explain its arbitration agreement to residents during admission and did not provide guidance on how to contact local, state, or federal officials before signing. The Admission Director stated she was instructed not to explain the agreement and instead told residents to read it themselves, while the Administrator confirmed staff were not required to explain or answer questions if the information was written in the document. The arbitration agreement stated signing was voluntary and that all terms had been explained, but interviews did not support that residents or their representatives were actually given those explanations.
Incomplete records, missing anticoagulation monitoring, and inaccurate documentation were identified for several residents. An LPN and RN confirmed PT/INR orders were not entered into the EMR for residents on warfarin, and there was no documented follow-up for lab results or physician notification. Staff also described an instance where a dressing was dated after the fact, and interviews confirmed inaccurate admission weights and a missed weekly weight for a resident with a tube feed and severe cognitive impairment.
Ineffective Pest Control Program: The facility failed to maintain an effective pest control program, with confirmed mice and ants found in multiple areas including resident rooms, dry storage, windowsills, the soiled linen area, and the special care unit. A resident reported carpenter ants crossing the floor and entering the bathroom, another resident reported ants entering through the window, and the Maintenance Director confirmed ongoing pest issues and dead mice in traps throughout the facility.
A facility failed to consistently provide ordered supplements, selected menu items, and basic food supplies. Surveyors observed a resident with a Magic Cup order not receive the supplement, another resident not receive coffee that was marked on the meal ticket, and other residents not receive selected alternatives such as cottage cheese and fruit, an egg salad sandwich, or a tuna fish sandwich because items were unavailable. Staff also reported recurring food shortages, late deliveries, and running out of utensils and menu items, while residents reported frequent dining room closures, incorrect menus, and poor food quality.
Infection control practices were not followed during linen handling, incontinence care, enteral feeding, and wound care. Dirty linens were moved through the facility in a way that crossed into the clean linen area, two CNAs handled clean briefs and linens after soiled brief care without changing gloves or performing hand hygiene, an LPN left an enteral feeding tube end uncapped and exposed, and an RN touched the sterile center of a dressing with bare hands before using it on a resident with a coccyx wound.
Inaccurate and backdated documentation was identified for two residents. An LPN said an RN asked her to date an existing coccyx dressing even though it had originally been undated, and the RN confirmed she gave that instruction. For another resident, an RN reported the DON asked her to backdate a GDR form because the physician took too long to sign it; the RN refused, and the record also showed an MRR entry with an indecipherable date. The facility policy required documentation to be accurate, complete, factual, timely, and properly authenticated.
Failure to provide bathing and grooming assistance: A resident with multiple chronic conditions and extensive ADL needs was care planned for twice-weekly showers with two-staff assistance, but was observed in soiled clothing and not well groomed. He stated he had not received any shower since admission and preferred staff help with shaving. Documentation showed no showers or bed baths were provided during the first several days of the stay, and the RN/UM confirmed this.
A resident with ESRD and dependence on hemodialysis had major gaps in required pre- and post-dialysis assessments. The resident’s care plan included dialysis management, AV shunt monitoring, and symptom assessment, but records showed missing, incomplete, and inconsistent documentation over multiple months. The Dialysis Manager reported communication issues and missed dialysis appointments due to transportation, and the DON, Administrator, and VPCS acknowledged staff were responsible for the assessments and that they were not completed.
Missed Physician-Prescribed Medications for Multiple Residents: The facility failed to provide ordered meds to three residents, with MARs showing multiple missed doses of cardiac, anticoagulant, psychiatric, endocrine, and other medications. One resident was cognitively intact and independent with ADLs, another had mild cognitive impairment and needed assistance with ADLs, and a third was cognitively intact and independent with ADLs. Staff reported several residents went without meds when the medical director changed, orders had to be manually entered into the EMR for pharmacy supply, and the physician was unaware residents had missed medications.
Pharmacy MRR recommendations were not addressed timely or completely for multiple residents. One resident with dementia and major depressive disorder had a GDR recommendation for Buspirone that was declined without the required clinical rationale, while another resident with acute transverse myelitis and Parkinson’s disease had Benadryl remain active after the MRR flagged it for increased fall risk. A third resident with anxiety, depression, and other diagnoses had repeated GDR recommendations for psychotropic meds that were delayed, incomplete, or lacked rationale, and the care plan did not include nonpharmacological interventions.
Opened insulin pens were found without documented open dates in medication carts for three residents receiving insulin. The RN Unit Manager confirmed the pens were opened without dates, and the DON confirmed facility policy requires insulin pens to be dated when opened. The residents had diagnoses including Type II DM, neuropathy, angiopathy, hyperglycemia, CKD, and dementia, and the review identified additional residents receiving insulin.
Unclean Tube Feeding Equipment: A resident with respiratory failure, asthma, malnutrition, heart disease, osteoporosis, sleep apnea, and epilepsy had a nocturnal tube feeding order. During observation, the tube feeding pump and pole were found with dried, crusted beige-to-light-brown debris on the pole, wheels, and display screen. A CNA confirmed nursing staff were responsible for cleaning the equipment each night and stated it had not been cleaned as expected.
A resident who was cognitively intact and receiving Citalopram, Xanax, and Buspirone was not fully informed of the risks and benefits of his psychotropic medications. The psych NP documented education on side effects and drug interactions, but there was no documentation that risks and benefits were reviewed, and the resident stated this discussion had not occurred. The DON also verified there was no order or care plan for non-pharmacological interventions.
Failure to Notify Physician About Unobtained Stool Sample: An LPN documented that a stool sample was ordered to rule out C. diff for a resident with recent digestive surgery and chronic diarrhea, but the sample was not obtained and there was no documentation that the physician was notified. Nursing notes showed the issue was passed to the next shift, and the resident later developed increased confusion and was sent to the ER, where she was admitted with sepsis and an abdominal wall abscess.
A resident with urinary incontinence and multiple chronic conditions had spotting, dysuria, and abnormal UA findings, but the UA result was delayed, monitoring and provider follow-up were inconsistent, and a later specimen was contaminated without documented notification or prompt repeat testing. The resident continued to have pain and burning with urination, then developed altered speech, vomiting, and abnormal vital signs before being sent to the ED, where hospital paperwork showed admission for UTI and stroke-like symptoms.
Delayed response to nutritional decline. A resident with osteoarthritis, depression, and hypertension had >5% weight loss and was cognitively intact. The RD recommended stopping Marinol and starting Remeron to improve intake, but the medication change was not activated for 17 days. The DON confirmed dietary and clinical recommendations should be addressed the same day and acknowledged the change should not have been left unaddressed for weeks.
Oxygen Not Administered as Ordered: Two residents receiving continuous O2 did not receive it as ordered. One resident with respiratory failure, asthma, and other conditions was observed without her O2, and the LPN said she often refused, but there was no EMR documentation of refusals. Another resident with COPD and severe cognitive impairment had O2 set at 3 LPM instead of the ordered 4 LPM, and the tubing was undated. Facility policy required verification of the physician order and documentation of refusals.
A resident with multiple chronic conditions and moderate cognitive impairment did not have the administration of PRN Percocet accurately documented. On several occasions, the controlled drug record showed the medication was removed, but there was no corresponding entry on the MAR. This discrepancy was identified after the resident alleged an LPN gave the wrong medication and took her Percocet. Investigation confirmed that required documentation procedures were not followed, leading to incomplete records for controlled substances.
Staff did not follow proper hand hygiene and glove-changing protocols during incontinence care for two residents who were dependent on staff for all ADLs and always incontinent. In both cases, CNAs failed to change gloves or perform hand hygiene after providing peri care and before applying clean briefs or touching the environment, contrary to facility policy and CDC guidelines.
A resident with chronic pain and multiple health conditions did not receive six scheduled doses of Lyrica due to a delay in prescription renewal and miscommunication among staff, resulting in increased pain and headaches. The facility failed to ensure pain management medication was administered as ordered.
A nurse failed to prime an insulin pen before administering a prescribed dose to a resident with diabetes, despite manufacturer instructions requiring priming to ensure accurate dosing. The nurse was unsure of the correct priming procedure, and the facility's policy to follow physician orders and manufacturer instructions was not adhered to during the observed medication administration.
A resident with hypertension and other conditions was prescribed Carvedilol with instructions to hold the dose if systolic BP was below a certain threshold. Nursing staff administered the medication without documenting BP readings prior to each dose, and the MAR did not prompt for this documentation. Interviews confirmed BPs were checked but not recorded in the EMR, and any written records were discarded, resulting in incomplete and inaccurate medical records.
The facility did not provide substantial evening snacks to residents when the time between dinner and breakfast exceeded 14 hours, affecting 92 residents. Observations showed meal delivery intervals exceeded 14 hours, and residents reported not being offered snacks. The Dietary Manager confirmed the issue, and the facility policy required snacks or resident agreement for such meal plans, which was not followed.
The facility failed to maintain sanitary conditions in food storage, preparation, and serving, affecting 92 residents. Observations revealed undated and exposed food items, expired foods, and unsanitary practices during tray line processes. The facility's policies on food safety and sanitation were not followed, leading to potential risks for residents.
The facility failed to follow its weekly and always available menus, affecting several residents. Budget constraints and delivery issues led to frequent menu substitutions, such as chicken tenders for meatballs and toast for donuts. Residents expressed dissatisfaction with the inconsistency between the menu and meals served, and the Ombudsman noted systemic concerns with food quality and choices.
The facility failed to provide palatable and appropriately heated meals to residents, affecting eight individuals and potentially impacting nearly all residents receiving meals. Residents expressed dissatisfaction with food quality, noting it was often cold and lacked flavor. An observation confirmed that peas served were at an inadequate temperature and flavor, which was corroborated by a dietitian. The facility's policy to ensure palatable food was not followed.
A resident experienced a significant unplanned weight loss of 9.3%, but the facility failed to notify the physician and resident representative as required by policy. The dietitian did not contact the resident's representatives due to their work schedules and only thought she informed the nurse practitioner, who confirmed there was no written notification in the chart.
A resident with multiple health conditions, including hemiplegia and dementia, did not receive the necessary meal setup assistance as outlined in her care plan. Staff consistently left meal trays with lids intact and did not assist in cutting food or opening packages, despite the resident's need for such help. This was confirmed through observations, interviews, and documentation review.
The facility failed to monitor a resident's weekly weights as ordered, impacting her nutritional care, and did not adhere to another resident's fluid restriction, risking his health. Despite orders and care plans, weights were missed, and fluid intake exceeded limits, with no accurate tracking system in place.
A facility failed to maintain proper communication with a dialysis center for a resident with end-stage renal disease. The resident, who required dialysis thrice weekly, did not receive communication forms from the facility to take to the dialysis center. Although the resident brought back forms from the center, there were significant gaps in documentation. Staff interviews confirmed the lack of communication, and the LPN Manager acknowledged the missing forms, stating that the facility should have contacted the dialysis center when forms were not received.
Two residents were found with unattended medications at their bedsides, contrary to the facility's policy requiring nurse supervision during medication administration. One resident, with moderate cognitive impairment, had medications left out of reach, while another, requiring a mechanically altered diet, was unable to swallow potassium tablets without assistance. The facility's policy mandates that medications be administered safely and with supervision.
A resident with quadriplegia and dysphagia, on a mechanical soft diet, received coleslaw instead of green beans, contrary to their dietary requirements. The facility's policy mandates adherence to prescribed diets, but the meal provided did not meet the necessary consistency, as confirmed by staff. This incident suggests a broader issue with meal preparation for residents on specialized diets.
The facility failed to maintain proper infection control procedures, affecting three residents on isolation precautions. A resident with an antibiotic-resistant infection and another with a urinary catheter were not provided care with the required PPE by CNAs who were unaware of the enhanced barrier precautions. Additionally, a CNA failed to doff PPE after exiting a COVID-19 positive resident's room, contrary to facility policy.
A facility failed to implement a comprehensive care plan for a resident's leave of absence (LOA), resulting in the resident being stranded twice at a bus station due to a dead wheelchair battery. The resident, who had multiple medical conditions, left the facility without signing out or notifying staff, and the care plan did not address their LOA preferences or needs. Despite being aware of the resident's tendencies, the facility did not update the care plan to ensure safety during LOA.
A facility failed to refund an overpayment to a resident's family within the required 30 days after the resident's discharge. The resident, who had severe cognitive impairment and was admitted as a private pay, expired in the facility. Despite the spouse's inquiry, the refund was not processed, as confirmed by the Business Office Manager and Administrator.
Failure to Remove CNA After Abuse Warrant Was Known
Penalty
Summary
The facility failed to protect residents from potential abuse when a CNA was not immediately removed from duty after the facility learned of an arrest warrant for resident abuse. Resident #6 was admitted with chronic obstructive pulmonary disease and vascular dementia with agitation, and the quarterly MDS showed severe cognitive impairment with maximum staff assistance to dependence for activities of daily living. During incontinence care, Resident #6 became combative, and the CNA reported the resident hit her; the CNA then made contact with the resident’s hands while saying not to hit. An LPN came to the doorway and reported that the CNA struck the resident’s legs with an open hand. The resident was assessed afterward with no abnormal findings. The police incident report documented that an officer was dispatched to the facility for an assault between a staff member and a resident, and the prior DON stated the CNA had been escorted off the property after striking Resident #6. A warrant for assault was issued for the CNA, and the officer informed the Administrator of the warrant. Despite this, the CNA worked a brief shift the next morning, later returned to work on the secured memory care unit after the investigation, and continued working multiple shifts on that unit. The facility identified 34 additional residents on the secured dementia unit who were also present during the period the CNA was allowed to work. The Administrator later stated she became aware of the arrest warrant and that the CNA was permitted to begin a scheduled shift before being sent home during the survey. The addendum to the incident record stated the Administrator and HR attempted to contact the CNA after learning of the warrant, but the CNA still reported to work as scheduled. The facility policy stated that when abuse is identified, the facility would take all appropriate steps to remediate the noncompliance and protect residents from additional abuse immediately, including steps to prevent further potential abuse. The deficiency was investigated under complaint numbers 3073795 and 3067841.
Failure to Protect Resident from Physical Abuse During Care
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment from physical abuse during incontinence care. Resident #6 was admitted with diagnoses including chronic obstructive pulmonary disease and vascular dementia with agitation, and the Quarterly MDS showed severe cognitive impairment with maximum staff assistance to dependence for activities of daily living. During care, the resident became combative, and a CNA reported that the resident hit her while she was providing incontinence care. According to the facility’s self-reported incident, the CNA said she reflexively held her hands up in a defensive position and came in contact with the resident’s hands while telling the resident not to hit. However, an agency LPN stated she heard a woman yell out, opened the door, and saw the CNA swat the resident’s left lower extremity twice with an open hand while standing over the resident, whose bed was elevated and whose lower body was exposed. The police report also documented the LPN’s statement that she observed the CNA swat the resident twice, and a warrant for assault was later issued based on an eyewitness account. The resident could not be interviewed because of severe cognitive impairment, and the facility’s investigation was described as inconclusive. The CNA denied hitting the resident’s legs and stated she only moved the resident’s hands away. The Administrator stated the resident had no marks and did not personally feel abuse occurred, and the CNA later returned to work in the memory care unit caring for residents including Resident #6. The facility policy stated residents must be free from physical abuse and that associates must not use physical abuse against any resident.
Failure to Complete Ordered Pressure Wound Care
Penalty
Summary
The facility failed to ensure Resident #77’s ordered pressure wound care was completed. Resident #77 was admitted with diagnoses including quadriplegia, chronic obstructive pulmonary disease, and diabetes, and the record showed a Stage IV pressure ulcer on the admission MDS. The physician ordered daily dressing changes to the bilateral buttocks and lower back on 07/06/26, including cleansing with normal saline, application of Santyl, slightly moistened opticell, and coverage with dry and abdominal dressings. Review of the MARS and TARS showed the resident refused wound care on 07/11/25, the TAR was blank on 07/12/26, and an LPN documented “see nursing note” for wound care on 07/13/26, but the progress notes did not explain why the wound care was not completed on 07/12/26. During interview, Resident #77 stated that sacrum and mid back wound care had not been completed as ordered and said he was upset that it was not done for two days. Observation of wound care showed the dressings on the mid lower back and sacrum were not dated and had a large amount of red dried drainage on the old dressings. A later wound assessment documented an unstageable left buttock pressure injury, a Stage IV sacral pressure injury with undermining, and a Stage III lower medial back pressure ulcer. The Administrator stated one LPN was terminated for not doing the wound care on 07/12/26 and another LPN was placed on the do not return list for not completing the wound care on 07/13/26.
Failure to Respond to Acute Change in Condition and Wound Deterioration
Penalty
Summary
The facility failed to recognize and respond timely and appropriately to an acute significant change in condition for one resident with pneumonia, type 2 diabetes mellitus, COPD, and chronic respiratory failure with hypoxia. The resident had an order for oxygen at 4 to 6 liters per minute via nasal cannula to maintain pulse oximetry above 90% and had a DNR-CC directive. On 03/09/26 at 1:38 A.M., an LPN documented increased shortness of breath, poor appetite, abdominal pain, use of accessory abdominal muscles, deep and labored respirations, and an oxygen saturation of 84% while on 6 liters of oxygen. The note stated the physician was notified and the resident would be closely monitored, but there was no written evidence that the responsible party was notified. After that note, there was no documented monitoring or reassessment until 6:55 A.M., when the resident was again found to have an oxygen saturation of 84% on 6 liters of oxygen. There was no evidence the physician was contacted at that time. At 7:14 A.M., the physician called and ordered transfer to the emergency room, but EMS was not contacted until 7:58 A.M. When EMS arrived, the resident remained in respiratory distress, was confused, had a blood glucose of 33 mg/dL, and had an oxygen saturation of 85% on 6 liters of oxygen. The resident was treated in the ER and later died at the hospital. The facility also failed to ensure care and services were provided consistent with professional standards for another resident with recent digestive system surgery, diabetes, congestive heart failure, thyroid disease, and kidney disease. The resident had orders for antidiarrheal medication, a wound vac to an abdominal surgical wound, and a stool specimen to rule out C. diff. After one unsuccessful attempt to obtain the stool specimen, staff made no further attempts and did not notify the physician that the specimen had not been collected. In addition, a nurse observed the abdominal wound dressing was odorous and the wound bed was more than 60 percent necrotic, but did not notify the physician or wound nurse practitioner. There was no documented monitoring or assessment of the wound after that observation until the resident was transferred to the hospital with sepsis and an abdominal wall abscess.
Failure to Provide Ordered Pressure Ulcer Care
Penalty
Summary
Facility failed to provide appropriate pressure ulcer care and prevent a facility-acquired coccyx pressure ulcer from worsening for Resident #14, who was admitted with pneumonia, MRSA, COPD, CHF, atrial fibrillation, anxiety, dialysis dependence, and Stage IV hypertensive chronic kidney disease. The quarterly MDS documented the resident was cognitively intact and required extensive assistance with all ADLs, including bed mobility and transfers. On 10/07/25, a wound assessment identified a Stage II pressure ulcer to the coccyx measuring 1.5 cm by 1 cm by 0.1 cm, with treatment orders for zinc oxide to the bilateral buttocks and for the coccyx wound to be cleansed with an antiseptic solution, covered with silver alginate, and dressed with bordered foam. Between 10/07/25 and 10/21/25, there were no documented wound assessments, and the 10/21/25 wound note stated the resident was not seen due to dialysis. Review of the TARs for October, November, and December 2025 showed multiple dates with no documentation that ordered treatments were completed. No further wound documentation was found until 12/23/25, when the wound was documented as having progressed to Stage III, measuring 1.4 cm by 1 cm by 0.4 cm with 20 percent granulation, 80 percent slough, serosanguineous drainage, and odor. Weekly wound assessments were then completed, although some were missed due to dialysis. On 01/02/26, the treatment order changed to cleansing with normal saline, applying wound gel, and covering with a dry dressing. Review of the TAR for January and February 2026 again showed multiple missed treatment entries. On 02/20/26, the order changed to normal saline, collagen, and a dry dressing every three days. The care plan dated 03/05/26 directed staff to administer treatments as ordered, monitor wound healing, report changes, follow pressure ulcer protocols, apply a Roho cushion, monitor pain and nutrition, assess for infection, and consult wound care as necessary. On 04/15/26, the wound measured 1.3 cm by 0.5 cm by 0.5 cm with 100 percent granulation and no signs of infection. During observation on 05/13/26, RN #586 touched the sterile center pad of an occlusive dressing with ungloved hands and applied collagen instead of the ordered collagen with silver. RN #586 stated she changed the order because collagen with silver was unavailable and acknowledged she did so without consulting the physician or WCNP #695. WCNP #695 stated staff were either using the wrong products or not completing the treatment, and LPN #556 reported RN #586 instructed her to date an old dressing as 05/09/26 even though it originally had no date.
Resident Council Concerns Were Not Consistently Documented or Resolved
Penalty
Summary
The facility failed to honor residents’ right to organize and participate in resident/family groups by not thoroughly documenting, effectively addressing, and resolving concerns raised in resident council meetings. Review of resident council minutes from 05/02/25 through 04/03/26 showed repeated complaints about dietary services, housekeeping, laundry, nursing communication, CNA cell phone use, room cleanliness, clothing being returned wrinkled or delivered to the wrong room, and residents not being notified about a spouse’s ambulance transfer. Several meetings also documented ongoing concerns that the dining room was closed, the kitchen ran out of items, menus were wrong, and food quality was poor. The facility’s Resident Council Follow-Up Summary showed multiple concerns marked closed or satisfied even though similar complaints continued in later council meetings. Some follow-up entries documented staff re-education, monitoring, or review of processes, but the same issues persisted across multiple months. There was no follow-up documentation provided for July 2025, August 2025, or January 2026, and the Administrator verified this on 05/07/26. At that time, education and monitoring that were stated to have been completed or started were requested but not provided to the survey team. During the resident council meeting on 05/06/26, multiple residents stated that the dining room was closed, the kitchen frequently ran out of items, menus were always wrong, medications were not available, and food quality remained poor. Residents stated they continued to report the same problems and that they were never fixed. The Administrator and DON stated they felt the issues were addressed to the best of their ability. Additional interviews on 05/07/26 confirmed ongoing unresolved concerns, including repeated dining room closures due to staffing, residents not being informed until mealtime, and dietary staff reporting frequent shortages of food items and unavailable menu items.
Failure to Provide Nutritious and Palatable Meals
Penalty
Summary
The facility failed to provide food that was nutritious and palatable. During an observation at lunch, the menu indicated fruit, but no residents were served fruit. One resident requested fruit, and a CNA provided oranges and applesauce in individual cups; the CNA then obtained three additional fruit cups and offered them to other residents. The Dietary Manager stated the facility did not maintain a substitution log for meal changes and presented a binder containing only blank substitution log forms. At the Resident Council meeting with the Administrator present, multiple residents reported frequent closure of the dining room, the kitchen running out of food items, incorrect menus, and poor food quality, stating these concerns had been repeatedly reported without resolution. A Dietary Aide reported the dining room was closed most days at lunch and dinner, five dietary workers left in March 2026 and were not replaced, staffing cuts were ordered, and the kitchen often ran out of items such as milk and cereal without buying replacements. Food Committee minutes from February 2025 through January 2026 documented ongoing complaints about palatability, including food being too spicy, tough meat, overly salty food, poor presentation, and soup that was too salty.
Dietary staffing shortages led to repeated dining room closures and service issues
Penalty
Summary
The facility failed to provide sufficient support personnel to safely and effectively carry out the food and nutrition service. Review of dietary staff schedules and staff interviews showed repeated kitchen staffing shortages and call-offs, including days with no morning cook scheduled and multiple morning and afternoon dietary aide call-offs between 04/26/26 and 05/21/26. The facility census was 107, and three residents were identified as receiving nothing by mouth. During the Resident Council meeting, multiple residents reported frequent closure of the dining room, the kitchen running out of food items, incorrect menus, and poor food quality, stating these concerns had been repeatedly reported without resolution. Staff interviews confirmed the dining room was closed a couple of times a week or most days at lunch and dinner because of dietary staffing shortages, that five dietary workers left in March 2026 and were not replaced, and that staffing cuts had been ordered by the regional team. The Administrator stated she did not determine dietary staffing hours because the department was contracted to a third-party vendor that made staffing decisions before notifying her.
Failure to Recognize and Respond to Acute Changes in Condition and Follow Physician Orders
Penalty
Summary
The facility failed to recognize and respond to an acute change in condition for a resident with multiple chronic conditions and a DNR-CC directive. During the night of the event, the resident developed respiratory distress, severe hypoxia with oxygen saturations documented at 84%, lethargy, poor appetite, abdominal discomfort, and critically low blood glucose. The record shows that no monitoring occurred for several hours after the change in condition, EMS was not contacted until later in the morning, and the resident was ultimately transferred to the hospital and died the same day. The resident’s hospital course reflected severe clinical deterioration, including acidosis, hypoglycemia, and suspected mesenteric ischemia. The report states that staff did not promptly reassess the resident, notify the physician appropriately, or contact the family in a timely manner after the acute change was identified. Interviews confirmed that facility staff did not follow the facility policy for timely communication and escalation when a significant change in condition occurred. The deficiency also included failure to follow physician orders and report significant changes for another resident with multiple chronic conditions and recent digestive surgery. Staff did not obtain a physician-ordered C. diff stool specimen, did not notify the physician when the specimen could not be collected, and did not report worsening abdominal wound findings. The wound became odorous with more than 60% necrotic tissue, documentation showed foul-smelling drainage and acute confusion, and the resident was later hospitalized with sepsis and an abdominal wall abscess.
Expired Food Service License
Penalty
Summary
The facility failed to comply with applicable State and local licensure laws by allowing its food service license to lapse for more than two months. During a kitchen tour on 05/04/26, surveyors observed that no current food operating license was displayed. Dietary Aide #672 and [NAME] #672 stated during interview that they learned from local news that the facility's food operating license had expired in March 2026. The Local Health Department later confirmed that the food service license expired on 02/28/26 and was not renewed until 05/04/26. The DON and Administrator stated that the kitchen had been identified as a QAPI concern in late 2025 and that food services were outsourced to a third-party company in February 2026. The Administrator confirmed the kitchen operated without a valid food service license from 02/26/26 through 05/04/26 and described the kitchen as a work in progress.
Failure to Employ Required Full-Time LSW
Penalty
Summary
The facility failed to employ a full-time Licensed Social Worker (LSW) in a building with more than 120 beds, as required by the facility assessment and the Social Services Director job description. Review of the personnel file for the Social Services Director showed she was hired on 03/16/26 and her application and resume indicated she did not have a degree in social services. During interview, the Social Services Director confirmed she was not a Licensed Social Worker and stated the facility had been without a full-time LSW for some time; she had been working at the facility since 03/16/26, and the prior full-time LSW’s last day was 02/13/26. The Administrator confirmed the facility did not currently have a full-time LSW and stated that two part-time employees from other facilities had been covering social services duties but did not meet the 40-hour requirement. The job description signed by the Social Services Director and Administrator did not state that a social work license was required when the census exceeded 120 residents.
Failure to Maintain Privacy and Confidentiality of Resident Information
Penalty
Summary
The facility failed to keep resident personal and medical records private and confidential by allowing staff to transmit protected resident information through an unsecured text-messaging application, WhatsApp, when communicating with physicians, nurse practitioners, and other providers. During observation and interview, an RN Manager used WhatsApp on an unsecured text-messaging application to contact a physician with protected patient information for a resident, and the RN Manager confirmed the facility used WhatsApp to communicate resident information to the physician. The Administrator stated staff were expected to call providers to relay resident-specific information and confirmed she had no knowledge that staff were using WhatsApp and that it was not permitted. On another observation, an LPN retrieved a personal phone and used WhatsApp to contact the physician with resident-specific information, and later confirmed staff used WhatsApp to communicate resident information to the physician and nurse practitioner. In addition, four STNA Report, Intermediate Unit documents containing identifiable resident information were observed lying on the floor and in the hallway of the 1500 unit with information for residents on the 1400 and 1500 units. A CNA confirmed the documents had fallen from the desk and should not have been accessible to anyone other than facility staff. The reports included resident names, room numbers, transfer status, assistance needs, shower schedules, feeding needs, and fall-risk information. An LPN later reported that all staff used WhatsApp to send resident information to the physician, pharmacy, unit managers, the Administrator, and the DON.
Nighttime Snacks Not Available to Residents
Penalty
Summary
The facility failed to ensure snacks were available to residents during nighttime hours. During the Resident Council meeting, multiple residents reported that the facility did not provide nighttime snacks even when requested, with the Administrator present. The Administrator stated that kitchen staff did not fill the snack basket kept in the dining room and confirmed there were no snacks available for residents. Multiple observations during the survey found no snacks available at night, and no snacks were observed being delivered to residents at any time during the survey. Staff interviews also confirmed that nighttime snacks were not available: an LPN stated the kitchen does not provide them, a CNA confirmed the kitchen does not provide snacks, and a Dietary Assistant stated they had been instructed to put snacks out because state was in the building and acknowledged that snacks were usually not available for residents.
Unsanitary Kitchen Storage and Food Handling
Penalty
Summary
Food was not stored, prepared, distributed, and served under sanitary conditions. During observation, the kitchen three-compartment sink was leaking and had two containers placed underneath to catch dripping water. In cooler #2, an undated package of ground beef was observed. Debris, spilled milk, and spilled juice were also observed on the floors of cooler #1 and cooler #2. A dietary manager stated they did not know when the ground beef had been pulled because they had not worked over the weekend, and confirmed the sink had been leaking for months as well as the presence of debris and spills in both coolers. The dietary aide later confirmed the coolers still had not been cleaned and said they planned to clean them after dinner preparation. The report also noted that three residents were consuming nothing by mouth, and the facility census was 107.
Failure to Explain Arbitration Agreement and Resident Rights
Penalty
Summary
The facility failed to explain its arbitration agreement to residents during the admission process and did not provide guidance on how residents could contact local, state, or federal officials with questions before signing. During an interview, the Admission Director and Administrator stated that the Admission Director had been instructed not to explain the arbitration agreement and instead to tell residents to read it themselves. The Admission Director reported that she does not explain admission documents to residents and tells them to reread the form if they have questions, and the Administrator confirmed that if information is written in the document, the Admission Director should not be required to explain or answer questions about it. The Admission Director also confirmed that the arbitration agreement did not inform residents that they may contact state, federal, or local officials for guidance before signing. Review of the facility’s undated arbitration agreement showed that signing was described as voluntary and solely the resident’s decision, and that all terms had been explained to the resident and/or authorized representative, although interviews did not support that such explanations were being provided.
Incomplete Records, Missing Anticoagulation Monitoring, and Inaccurate Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for multiple residents, including failure to enter physician and laboratory orders into the EMR, failure to document physician communication and follow-up actions, and failure to maintain accurate treatment documentation and weights. The report states this affected Residents #77, #20, #14, #111, and #9, and that the deficiency had the potential to affect all residents in the facility. Resident #77 had diagnoses including atrial fibrillation, a left wrist fracture, protein-calorie malnutrition, hypertension, and mitral valve stenosis, and was receiving warfarin for blood thinning. Resident #20 had congestive heart failure, Parkinson's disease, hemiplegia following cerebral infarction, and atrial fibrillation, and was also identified as being at risk for bleeding and bruising related to anticoagulation. For both residents, the record showed warfarin therapy, but there were no current PT/INR orders in the EMR. An LPN confirmed that PT/INR lab orders were not being entered into the EMR for these residents and stated the unit managers had been placing them in the lab portal without writing a physician order. An RN unit manager confirmed there were no PT/INR orders in the EMR and acknowledged there should be one for each lab drawn, and also stated there was no follow-up documentation in progress notes related to dose changes or physician notification of results. Resident #14 had pneumonia, COPD, anxiety, kidney disease, and heart failure. During staff interview, an LPN stated she was asked by the RN unit manager to date a coccyx dressing with a specific date even though the dressing had not originally been dated, and she complied but felt uncomfortable with the request. For Resident #111, who had hypertension, heart failure, atrial fibrillation, and gastrointestinal hemorrhage, the record showed warfarin orders but no physician order for PT/INR monitoring. The resident also had a nosebleed documented during the stay, and the DON confirmed there was no PT/INR order and acknowledged the nosebleed occurred while the resident was in the facility. Resident #9 was admitted with aphasia following cerebral infarction, type II diabetes mellitus with diabetic polyneuropathy, and COPD, and was severely cognitively impaired with a tube feed. The record showed weekly admission weights were not completed as expected, including a missing weight around the third week after admission. Staff interviews confirmed new admissions were to be weighed weekly for 30 days, and multiple staff later acknowledged that the first two recorded weights were inaccurate. The RD also stated the 197-pound weights were inaccurate, and maintenance documentation showed a scale had been removed from service for malfunctioning.
Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program designed to provide a safe, sanitary, and comfortable environment for residents. Based on staff interview, resident interview, review of the pest control log, and review of the facility policy, mice and ants were confirmed in multiple areas throughout the facility, including resident rooms, dry storage areas, windowsills, the soiled linen area, and the special care unit. The facility policy titled Resident Environmental Quality stated the facility was to be maintained in a safe, functional, sanitary, and comfortable condition, but the facility did not implement or sustain an effective pest control system. Maintenance Director #659 confirmed ongoing pest issues and stated that dead mice were found in traps placed in multiple locations throughout the facility. He also stated that the pest control company sprayed monthly and that maintenance sprayed independently when pests were sighted. Resident #58 reported carpenter ants in his room crossing the floor and entering the bathroom, and Resident #3 reported ants entering her room through the window and moving across the floor. Pest control logs documented a mouse in dry storage, ants on windowsills in resident rooms, mice in the special care unit, ants in the soiled linen area, and ants crawling on the floor into a bathroom in a resident room.
Failure to Provide Ordered and Selected Food Items
Penalty
Summary
The facility failed to ensure residents received food and drink as requested, selected, and ordered. Surveyors found that residents did not consistently receive ordered supplements, selected menu alternatives, or basic food items, and that the kitchen repeatedly ran out of food and supplies. Interviews with dietary staff confirmed recurring food shortages and late deliveries, and residents at the Resident Council meeting reported frequent dining room closures, incorrect menus, poor food quality, and repeated unresolved complaints to staff. Resident #12, who had diagnoses including respiratory failure, asthma, malnutrition, heart disease, osteoporosis, sleep apnea, and epilepsy, had an order for Magic Cup twice daily beginning 04/01/26, but on 05/07/26 at lunch she was not served the supplement. Dietary staff confirmed her tray ticket did not indicate the supplement and stated they had no knowledge of her ever receiving it. Resident #81, who had dementia, malnutrition, arthritis, anxiety, high cholesterol, and depression, had coffee circled on the meal ticket, but her breakfast tray did not include coffee, and a CNA stated coffee was available but not served unless requested. Resident #102, who had COPD, obesity, asthma, diabetes, sleep apnea, prostate cancer, and high cholesterol, selected cottage cheese and fruit on the tray ticket, but his breakfast tray did not include those items, and staff stated residents often did not receive alternatives because items were not available. Resident #41, with Parkinson's disease, dementia, hypertension, and bipolar disorder, selected an egg salad sandwich, but no eggs were available to prepare it. Resident #83, with vascular dementia, hypertension, and bipolar disorder, selected a tuna fish sandwich, but no tuna fish was available. Surveyors also observed the facility run out of silverware and use plastic utensils for eight residents, and fruit listed on the lunch menu was not served to residents until a CNA retrieved oranges and applesauce cups after a request.
Infection Control Lapses During Linen Handling, Incontinence Care, Enteral Feeding, and Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program to prevent the development and transmission of infections. During observation and interview, dirty linens were brought into the building through one door and transported to the laundry room with washers and dryers, while clean linens were returned to the nursing units after washing; the housekeeping aide confirmed that dirty linen barrels routinely crossed into the clean linen area. The facility policy titled Laundry Guidelines stated soiled linen must be kept separate from clean linen at all times and processed per CDC guidance. Resident #71, who had mild cognitive impairment, was dependent for ADLs, and was always incontinent of bowel and bladder, was observed during incontinence care with two CNAs who removed soiled linen and the resident's brief while wearing gloves, then handled clean briefs and linens without changing gloves or performing hand hygiene. Resident #65, who had severe cognitive impairment, was dependent for ADLs, and was enteral feed dependent, was observed with the feeding tube line draped over the pump and the male end uncapped, and the LPN confirmed the uncapped end was exposed. Resident #14, who was cognitively intact and had an in-house acquired coccyx wound, was observed during wound care when the RN removed her gloves, washed her hands, set up the treatment items, and then touched the sterile center pad of the new occlusive dressing with no gloves on before using it on the resident.
Inaccurate and Backdated Nursing Documentation
Penalty
Summary
The facility failed to ensure nursing staff documented resident care in an accurate, complete, and truthful manner. For Resident #14, who was cognitively intact and admitted with diagnoses including pneumonia, COPD, anxiety, kidney disease, and heart failure, LPN #556 stated that RN #586 asked her to date an existing coccyx dressing as 05/09/26 even though the dressing originally had no date. LPN #556 said she complied but did not feel right about it, and RN #586 later verified that she told the LPN to put a date on the dressing. For Resident #4, who was admitted with diagnoses including Parkinson's disease, asthma, quadriplegia, and obesity, RN #522 reported that the DON asked her to backdate a GDR form because it took the physician too long to sign it. RN #522 refused to alter the date and stated the date currently on the form was not the date she originally documented. Review of the MRR for Resident #4 showed the pharmacist completed a medication review and requested physician input, with changes noted by RN #522 and dated with an indecipherable date. The facility policy required documentation to be complete, accurate, factual, timely, and reflective of the resident's condition and services provided, with entries dated, timed, authenticated, and corrected only through approved amendment procedures.
Failure to Provide Ordered Bathing and Grooming Assistance
Penalty
Summary
The facility failed to ensure bathing and grooming were provided in accordance with Resident #119’s assessed needs and stated preferences. Resident #119 was admitted with diagnoses including type II diabetes mellitus, hypertensive heart disease with heart failure, neuromuscular dysfunction of bladder, hypothyroidism, anxiety disorder, GERD, urinary retention, depression, dysphagia, and cognitive communication deficit. The care plan identified the resident as at risk for decline in ADL functioning due to impaired mobility and directed that he receive showers twice weekly with two-staff assistance. Observation on 05/05/26 found Resident #119 wearing soiled clothing and not well groomed or clean-shaven. During interview, the resident stated he had not received a shower at any point since admission and said he preferred staff assistance with shaving despite owning his own shaver. The MDS assessment identified the resident as cognitively intact and requiring extensive assistance for all ADL. Review of shower documentation from 04/30/26 through 05/06/26 showed no showers or bed baths were provided, and the RN/UM confirmed the resident did not receive any showers or bed baths during the first five days of his stay.
Missing Dialysis Assessments and Documentation
Penalty
Summary
The facility failed to ensure required pre-dialysis and post-dialysis assessments were completed for a resident who required hemodialysis services. Resident #14 was admitted with diagnoses including pneumonia, MRSA infection, end-stage renal disease, hypertension, and dependence on hemodialysis. The resident’s care plan identified ongoing dialysis management needs, including monitoring labs, infection-prevention measures, monitoring the AV shunt, and assessing for symptoms related to fluid balance, toxicity, or complications. Physician orders directed staff to monitor the hemodialysis shunt every shift, including assessment for bruit and thrill. Review of dialysis assessment records from 01/01/26 through 05/12/26 showed significant gaps and inconsistencies in documentation. No pre-dialysis assessments were completed for the entire month of January, and later records included incomplete assessments, errors, entries marked as in progress, or missing documentation. Post-dialysis assessments were absent from 01/01/26 through 02/28/26, with additional missing entries throughout March, April, and May. The Dialysis Manager reported that the facility did not send communication back and did not send the resident’s binder to dialysis appointments, and also stated the resident missed three dialysis appointments due to transportation issues. The Administrator, DON, and VPCS confirmed that facility staff were responsible for completing both pre- and post-dialysis assessments and acknowledged that these assessments had not been completed; they also confirmed there was no order for these assessments in the EMAR.
Missed Physician-Prescribed Medications for Multiple Residents
Penalty
Summary
The facility failed to provide physician-prescribed medications to three residents, resulting in missed doses across multiple dates for each resident. Resident #46 was admitted with diagnoses including myasthenia gravis with acute exacerbation, dementia with behavioral disturbance, type II diabetes mellitus, COPD, Alzheimer's disease, bipolar disorder, major depressive disorder, anxiety disorder, and mixed obsessional thoughts and acts. The quarterly MDS dated 03/02/26 showed the resident was cognitively intact and independent with ADLs, with medication administration care planned. April 2026 MAR review showed missed doses of carvedilol, Depakote, donepezil, vitamin D3, apixaban, buspirone, oxybutynin, pyridostigmine, and Vistaril on 04/16/26, with additional carvedilol doses missed on 04/20/26 and 04/21/26. Resident #52 was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, type II diabetes mellitus with hyperglycemia, vascular dementia, hypertension, peripheral vascular disease, hyperlipidemia, and major depressive disorder. The quarterly MDS dated 04/15/26 showed mild cognitive impairment and a need for set-up and partial to moderate assistance with ADLs, with medication administration care planned. MAR review showed missed doses of Remeron and latanoprost eye drops. Resident #110 had diagnoses including hypokalemia, type II diabetes mellitus with diabetic neuropathy, COPD, atrial fibrillation, hypertension, hyperlipidemia, major depressive disorder, anxiety disorder, GERD, arthritis, chronic kidney disease stage III, and osteoporosis; the discharge MDS dated 03/12/26 showed intact cognition and independence with ADLs. MAR review showed missed doses of atorvastatin, furosemide, Prevacid, Tylenol PM, Synthroid, apixaban, buspirone, potassium chloride, doxazosin, and metoprolol. Staff interviews stated several residents went without medications when the medical director changed, that all medication orders had to be manually entered into the EMR for pharmacy supply, and that the facility had been without medications for several residents for several consecutive days. The physician stated he was unaware residents had missed medications and that the previous prescriber wrote prescriptions only through 04/01/26.
Pharmacy MRR Recommendations Not Addressed Timely or Completely
Penalty
Summary
The facility failed to ensure that pharmacy medication regimen review (MRR) recommendations were addressed timely and completely for residents reviewed for unnecessary medications, including gradual dose reductions (GDRs), safety-related medication changes, and required clinical rationales. For Resident #57, who had dementia and major depressive disorder and was receiving Buspirone 10 mg twice daily, an MRR recommended a GDR, but the NP marked disagreement without providing the required clinical rationale or dating the form. Although a psychiatric follow-up note stated that a GDR would worsen the resident’s symptoms, that information was not incorporated into the pharmacy MRR response, and the care plan still referenced evaluating GDRs as indicated. The DON confirmed the psychiatric note supported not reducing the medication but acknowledged it had not been included on the MRR form. For Resident #4, who had acute transverse myelitis and Parkinson’s disease, Benadryl 25 mg remained an active order with no discontinue date even after the MRR recommended addressing it due to increased fall risk. The RN Manager reported receiving the recommendation but did not obtain a discontinue order until several days later, and the physician’s orders still showed Benadryl active at the time of review. For Resident #31, who had anxiety disorder, major depressive disorder, atrial fibrillation, hypertension, muscle weakness, pain, and a BIMS score of 15, the record showed repeated pharmacy recommendations for GDRs involving Citalopram, Xanax, and Buspirone that were delayed, not completed, or completed without required clinical rationale. The care plan addressed psychotropic risk generally, but it did not include nonpharmacological interventions or related orders, and the DON confirmed there were no orders, care plan interventions, or documentation showing nonpharmacological approaches had been attempted.
Opened insulin pens were not dated
Penalty
Summary
Drugs and biologicals were not labeled in accordance with accepted professional principles because opened insulin pens were not dated when opened. During the medication storage review, three opened insulin pens were observed without documented open dates: an insulin pen for Resident #42 in the 1500-unit medication cart, an insulin pen for Resident #21 in the 1200-unit cart, and an insulin pen for Resident #99 in the 1300-unit cart. The RN Unit Manager confirmed that all three insulin pens were opened without documented open dates, and the DON confirmed that facility policy requires insulin pens to be dated when opened. Resident #21 was admitted with Type II diabetes with neuropathy and angiopathy and had orders for Lantus SoloStar and Humalog KwikPen. Resident #42 was admitted with metabolic encephalopathy and Type II diabetes with hyperglycemia and had an order for Lispro 100 units/mL per sliding scale. Resident #99 was admitted with Type II diabetes with neuropathy, chronic kidney disease, and dementia and had an order for Humulin 70/30 KwikPen at bedtime. The facility review also identified 11 additional residents receiving insulin, and manufacturer instructions reviewed for Humalog KwikPen and Lantus SoloStar stated opened pens must be discarded 28 days after first use.
Unclean Tube Feeding Equipment
Penalty
Summary
The facility failed to ensure that Resident #12's tube feeding pump and pole were maintained in a clean and sanitary condition. Resident #12 was admitted on 01/08/21 and had diagnoses including respiratory failure, asthma, malnutrition, heart disease, osteoporosis, sleep apnea, and epilepsy. Her MDS assessment showed she was cognitively intact and required supervision for eating and toileting, set-up assistance for oral and personal hygiene, and partial to moderate assistance for showering. Physician orders for May 2026 showed an active order for nocturnal tube feeding from 7:00 p.m. to 7:00 a.m. During an observation and interview on 05/07/26 at 8:08 A.M., the tube feeding pump and pole were observed with dried, crusted beige-to-light-brown debris on the pole, wheels, and display screen. A CNA confirmed that nursing staff were responsible for cleaning the pole and display each night when the tube feeding was connected and stated that, based on the condition observed, the equipment had not been cleaned as expected.
Failure to Fully Inform Resident About Psychotropic Medications
Penalty
Summary
Resident #31 was admitted with diagnoses including traumatic ischemia of muscle, anxiety, major depressive disorder, hypothyroidism, atrial fibrillation, and hypertension. The MDS assessment dated [DATE] indicated the resident was cognitively intact and independent with all activities of daily living. The resident’s current psychotropic medication orders included Citalopram 20 mg daily, Xanax 0.25 mg twice daily, and Buspirone 15 mg twice daily, with each medication requiring monitoring for adverse reactions every shift. Review of psychiatric NP documentation dated 10/14/25 showed the resident was educated on drug side effects and drug interactions, but there was no documentation that the risks and benefits of the medications were reviewed with the resident. During interview on 05/11/26 at 10:30 A.M., Resident #31 stated that the risks and benefits of his medications had not been reviewed with him. During interview on 05/11/26 at 11:35 A.M., the DON verified there was no order for non-pharmacological interventions and no care plan for non-pharmacological interventions, and also verified that while there was documentation of education on side effects and drug interactions, there was no documentation that the risks and benefits of the medications were reviewed with the resident.
Failure to Notify Physician When Ordered Stool Sample Could Not Be Obtained
Penalty
Summary
The facility failed to notify the physician when an ordered stool sample could not be obtained for a resident who was cognitively intact and had diagnoses including digestive system surgery, diabetes, congestive heart failure, thyroid disease, and kidney disease. The resident’s care plan identified her as being at risk for bowel elimination alteration due to recent digestive system surgery, with interventions to monitor for abdominal distension, notify the physician of unrelieved constipation, and observe for signs and symptoms of constipation or abdominal obstruction. Physician orders included antidiarrheal medications for chronic diarrhea, and on 04/23/26 a nurse documented that a stool sample was ordered to rule out C. diff. The next day, nursing documented that the resident had no bowel movement and staff would pass the request to day shift to collect the sample. However, the medical record from 04/24/26 through 04/26/26 contained no documentation that the physician was notified that the ordered stool sample could not be obtained. During this period, the resident later developed increased confusion, was pulling off dressings and clothing, and was sent to the ER after the physician was updated; she was admitted to the hospital for sepsis and an abdominal wall abscess.
Delayed UTI Evaluation and Follow-Up
Penalty
Summary
The facility failed to ensure timely laboratory testing, monitoring, and follow-up to diagnose and treat a urinary tract infection for a resident with diagnoses including acute kidney failure, protein calorie malnutrition, diabetes, and overactive bladder. The resident’s care plan identified a potential for urinary incontinence and included monitoring for mental status changes, medication efficacy, ordered labs, and incontinence care as needed. The resident was frequently incontinent of bowel and bladder and required substantial to maximum assistance with personal hygiene and total assistance with toileting and showering. After the resident was noted to have spotting in her brief for two days, an LPN contacted the NP, who ordered a urinalysis and stated she would see the resident the next day. The urinalysis collected shortly after was not resulted for 16 days, and the record showed no follow-up to obtain the results during that time. The chart also showed no documentation of clinical assessment or monitoring for several days after collection despite the resident’s recent symptoms and the pending UA. Later, the resident continued to report pain and burning with urination, and another UA was ordered along with Macrobid. The record included documentation that the earlier UA was abnormal, although it had not yet resulted, and there was no evidence the NP evaluated the resident despite worsening symptoms. A subsequent UA showed dark brown, extra turbid urine with elevated RBCs and WBCs and bacterial presence, with culture reported as probable contamination, but there was no documentation that the provider was notified or that a repeat specimen was promptly obtained. The resident later developed altered speech, vomiting, and abnormal vital signs, and was sent to the ED; hospital paperwork showed admission for UTI and stroke-like symptoms.
Delayed Response to Nutritional Decline
Penalty
Summary
The facility failed to ensure that Resident #27 received adequate nutrition care and services by not ensuring timely physician notification and timely implementation of a recommended medication change intended to address nutritional decline. Resident #27 was admitted on 05/15/25 with diagnoses including bilateral primary osteoarthritis of the knee, major depressive disorder, recurrent, unspecified, and essential hypertension. A Nutrition/Dietary note dated 03/17/26 documented the Registered Dietitian’s recommendation to discontinue Marinol and start Remeron because of observed nutritional decline, but the order for Remeron was not activated until 04/03/26, 17 days later. The MDS assessment documented that Resident #27 had lost more than 5% of body weight and was cognitively intact. RN Manager #522 confirmed the resident had recently been switched to Remeron to improve oral intake and stated the resident was a picky eater. The DON confirmed that the prior physician had periods when orders were not signed and stated that dietary or clinical recommendations should be addressed the same day, acknowledging that the medication change recommendation should not have been left unaddressed for weeks.
Oxygen Not Administered as Ordered
Penalty
Summary
The facility failed to ensure oxygen was administered as ordered for two residents who were receiving continuous oxygen. Resident #12 had diagnoses including respiratory failure, asthma, malnutrition, heart disease, osteoporosis, sleep apnea, and epilepsy, and was cognitively intact. Her care plan directed staff to administer oxygen per orders, and the physician’s order required continuous oxygen at 2 liters per minute. During observation and interview, she was found not wearing her oxygen, and the LPN confirmed she was ordered continuous oxygen but was not wearing it at the time. The LPN stated she believed the resident often refused and only wore oxygen at night, but nursing progress notes for April and May 2026 contained no documentation that she had refused oxygen as ordered. Resident #22 had diagnoses including COPD, malnutrition, emphysema, bone cancer, hypertension, and anemia, and was severely cognitively impaired. Her care plan included administering oxygen as ordered, and the physician’s order required continuous oxygen at 4 liters per minute and changing the tubing every Sunday with date and initials. During observation and interview, the CNA confirmed the resident’s oxygen was set at 3 liters per minute and was unsure if the setting was accurate. The CNA also confirmed the resident’s oxygen tubing was undated. The facility policy required staff to verify the physician’s order before administering oxygen and to document refusals and notify the supervisor of refusals.
Failure to Accurately Document Controlled Drug Administration
Penalty
Summary
The facility failed to accurately document the administration of a controlled medication, specifically Percocet, for a resident with multiple complex medical conditions including neuropathy, diabetes, chronic pain, and moderate cognitive impairment. Review of records showed several instances where Percocet was removed for PRN administration as documented on the controlled drug record (CDR), but there was no corresponding documentation on the medication administration record (MAR) to confirm that the medication was actually administered. This discrepancy occurred on multiple dates and times, indicating a pattern of incomplete or missing documentation for controlled substances. The issue came to light following an allegation by the resident that an LPN gave the wrong medication and stole her Percocet. Investigation revealed that the LPN in question was suspended, tested positive for benzodiazepines without a current prescription, and was later terminated. Interviews with staff and review of facility policy confirmed that nurses are required to document all administered controlled medications on both the MAR and CDR to prevent medication errors. The facility's failure to ensure accurate and complete documentation for controlled drug administration created the potential for significant medication errors and/or misappropriation.
Failure to Follow Hand Hygiene and Glove Use During Incontinence Care
Penalty
Summary
Staff failed to follow appropriate infection control practices during incontinence care for two residents who were dependent on staff for all activities of daily living and were always incontinent of bowel and bladder. In one instance, a CNA provided peri care to a resident, then, without changing gloves or performing hand hygiene, touched a barrier cream container, applied the cream, continued care to the resident's buttocks, and applied a new brief, all with the same soiled gloves. The CNA only removed gloves and washed hands after completing the care and handling soiled materials. The CNA confirmed in an interview that she did not change gloves or wash hands between steps as required. In another instance, a different CNA performed incontinence care for a resident, including removing a soiled brief, washing the resident's peri area and buttocks, and applying a clean brief, all without changing gloves or performing hand hygiene. The CNA then pulled up the covers and lowered the bed while still wearing the soiled gloves. The CNA confirmed in an interview that she did not change gloves or wash hands before applying the clean brief and handling the resident's environment. The facility's policy and CDC guidelines require glove changes and hand hygiene after contact with body fluids and before moving from a soiled to a clean site, which was not followed in these cases.
Failure to Administer Ordered Pain Medication Due to Prescription Renewal Delay
Penalty
Summary
A resident with multiple chronic conditions, including multiple sclerosis, chronic pain, and paraplegia, was admitted to the facility and had a care plan that included both scheduled and as-needed pain medications. The resident was prescribed Lyrica 100 mg twice daily for pain, among other pain management medications. Review of the medication administration record revealed that the resident did not receive six scheduled doses of Lyrica over several days. Documentation showed that some doses were held without a reason, while others were not administered because the medication was on order or awaiting a prescription renewal from the nurse practitioner. Progress notes indicated a delay in obtaining the necessary prescription, resulting in missed doses. Interviews with the resident confirmed that the missed doses led to increased pain and more frequent, severe headaches during the period when Lyrica was not administered. Nursing staff and the Assistant Director of Nursing acknowledged that there was a miscommunication regarding the timely renewal of the prescription, which led to the interruption in pain management. Facility policy required pain to be managed according to the care plan and professional standards, but the failure to ensure timely medication renewal and administration resulted in the resident not receiving ordered pain management as required.
Failure to Prime Insulin Pen Prior to Administration
Penalty
Summary
A deficiency occurred when a registered nurse failed to properly administer insulin to a resident with type 2 diabetes mellitus and multiple other diagnoses, including hypertension and peripheral vascular disease. The resident had a physician's order for Humalog (Insulin Lispro) to be administered subcutaneously before meals according to a sliding scale based on finger-stick blood sugar (FSBS) results. During a medication administration observation, the nurse checked the resident's blood sugar, which was 238, and prepared to administer three units of insulin as ordered. However, the nurse did not prime the insulin pen prior to dialing the dose and administering the medication. Interview with the nurse confirmed that the insulin pen needle was not primed before use, and the nurse was uncertain about the specific priming instructions. Review of the manufacturer's instructions for the Insulin Lispro KwikPen indicated that the pen should be primed with two units before administration to ensure accurate dosing. The facility's policy required medications to be administered according to physician orders and manufacturer instructions, but this was not followed in this instance, resulting in the resident potentially receiving an incorrect dose of insulin.
Failure to Document Blood Pressure Prior to Medication Administration
Penalty
Summary
The facility failed to ensure complete and accurate documentation of specified assessment criteria for a resident receiving medication with blood pressure (BP) parameters. A resident with multiple diagnoses, including hypertension and peripheral vascular disease, had a physician order for Carvedilol to be administered twice daily, with instructions to hold the medication if systolic BP was less than 130. During medication administration observation, the nurse did not document the BP prior to giving the medication, and the last recorded BP in the medical record was several days prior. There was no evidence in the medical record that BP was checked and met the ordered parameters before each dose, as required by the medication order. Further review revealed that the medication administration record (MAR) did not prompt or provide a place for nurses to document BP readings before each Carvedilol dose, only requiring monthly vital signs. Interviews with nursing staff confirmed that BPs were typically checked before administration but not documented in the electronic medical record, and any written notes were discarded. The Assistant Director of Nursing confirmed the lack of documentation and that nursing administration was not informed of the issue prior to the survey. Facility policy required documentation of services and objective observations in the resident's medical record, which was not followed in this case.
Failure to Provide Evening Snacks When Meal Intervals Exceed 14 Hours
Penalty
Summary
The facility failed to ensure that residents were offered a substantial snack in the evening when the time between dinner and breakfast exceeded 14 hours. This deficiency had the potential to affect 92 residents who received meals from the kitchen, excluding two residents who were identified as receiving nothing by mouth (NPO). Observations revealed that the time between dinner and breakfast delivery exceeded 14 hours for all meal delivery carts, with the longest interval being 15 hours and 40 minutes. The facility's policy stated that no more than 14 hours should elapse between a substantial evening meal and breakfast unless a nourishing snack was provided at bedtime, which was not the case. Interviews with residents during a Resident Council meeting indicated that they felt the time between dinner and breakfast was too long and that snacks were not being offered in the evening. Some residents had snacks provided by their families, but others did not have family support or the means to purchase snacks. The Dietary Manager confirmed that meal times had been adjusted, resulting in intervals greater than 14 hours between dinner and breakfast, and acknowledged that a substantial snack was not being offered to all residents. The facility's policy required resident group agreement for meal plans exceeding 14 hours between dinner and breakfast, which had not been obtained.
Sanitation and Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and served under sanitary conditions, potentially affecting all 92 residents who received food from the kitchen. Observations revealed multiple issues in the dry storage area, walk-in cooler, and walk-in freezer, including open and undated packages of food, food items exposed to air, and equipment with visible corrosion and food debris. The facility's policy required items to be dated when opened and discarded after three days, but these practices were not followed. Further observations in the skilled and intermediate unit refrigerators showed a lack of labeling and dating on various food items, including expired foods and items with offensive smells. The facility's policy mandated that all food and beverages be labeled with the resident's name and dated to ensure food safety, but this was not adhered to, leading to the presence of expired and potentially unsafe food items. During the tray line process, dietary aides were observed using soiled towels to dry trays and dome lids, which were placed on a dirty cart. This practice was confirmed by the dietitian as inappropriate, and the facility's policy required kitchen areas and equipment to be kept clean and free of grime. The county health inspection report also noted non-compliance in maintaining food in good condition and ensuring food contact surfaces were cleaned and sanitized.
Menu Inconsistencies and Substitutions Due to Budget and Delivery Issues
Penalty
Summary
The facility failed to ensure that the weekly and always available menus were followed, affecting seven residents and potentially impacting all residents except for two who were NPO. The facility's always available menu included items such as deli sandwiches, chef salads, and baked lemon pepper fish, among others. However, observations and interviews revealed that several items were missing from the menu, and substitutions were frequently made due to budget constraints and delivery issues. For instance, on multiple occasions, items like chicken tenders and toast were substituted for meatballs and donuts, respectively, due to late or incomplete deliveries. Interviews with the Dietary Manager and Dietary Aides confirmed that budget limitations and delivery schedules often resulted in unavailable menu items, leading to substitutions that did not match the planned menu. Residents expressed dissatisfaction with the inconsistency between the menu and the meals served, and the Ombudsman noted systemic concerns with food quality and choices. The facility's policy stated that substitutions should only occur in uncontrollable situations, yet the frequency of substitutions indicated a broader issue with inventory management and budget adherence.
Deficiency in Food Palatability and Temperature
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, attractive, and at a safe and appetizing temperature. This deficiency affected eight residents and had the potential to affect nearly all residents receiving meals from the kitchen. During a review of the monthly Residents' Dietary Meeting minutes, it was noted that residents expressed a desire for food to be seasoned more and served hotter. Interviews with residents revealed dissatisfaction with the food quality, with one resident stating the food was terrible and relying on outside food. An ombudsman also reported systemic concerns regarding food quality, choices, and temperatures. An observation of the dinner tray line and a test tray revealed issues with food temperature. The test tray, which included milk, cranberry juice, cobbler, chicken, and peas, was found to have peas at a temperature of 109.5 degrees Fahrenheit, which was considered cold and lacking flavor. The dietitian confirmed these findings. Further interviews with residents during a council meeting indicated that meals were often cold and lacked good taste. The facility's policy stated that menus would be followed and food would be palatable, yet this was not adhered to, leading to the deficiency.
Failure to Notify of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician/nurse practitioner and resident representative of a significant weight change for a resident. The resident, who was admitted with diagnoses including hemiplegia, dysphagia, vascular dementia, lymphedema, and obesity, experienced a significant unplanned weight loss of 9.3% between October and November. Despite this significant weight change, there was no documented evidence that the physician or resident representative was informed, as required by the facility's policy. Interviews with the dietitian and nurse practitioner confirmed the oversight. The dietitian acknowledged the significant weight loss but admitted she had not contacted the resident's representatives due to their work schedules and only thought she had verbally informed the nurse practitioner. The nurse practitioner stated that if she had been notified, there would have been a written record in the chart. The facility's policy mandates that any weight change of five percent or more should be communicated to the physician and resident representative, which was not adhered to in this case.
Failure to Assist Resident with Meal Setup
Penalty
Summary
The facility failed to provide the necessary assistance to Resident #36 during meal times, as required by her care plan. Resident #36, who has a history of cerebral ischemia, dementia, hemiplegia, and other conditions, was observed to have difficulties with eating due to her physical impairments. Despite her care plan indicating the need for setup assistance with meals, staff consistently left meal trays with lids intact and did not assist in cutting food or opening packages. This lack of assistance was confirmed through interviews with the resident, her family, and staff members, as well as through observations of meal setups that were not completed as required. The deficiency was further highlighted by the documentation in the electronic medical record, which showed multiple instances where no setup or physical help was provided to Resident #36. Interviews with staff, including CNAs and LPNs, confirmed that the resident required setup assistance, which included opening food packages, removing lids, and ensuring accessibility of utensils. The facility's policy on Activities of Daily Living, revised in August 2022, mandates appropriate support for residents unable to perform ADLs independently, including meal assistance, which was not adhered to in this case.
Failure to Monitor Nutritional Needs and Fluid Restrictions
Penalty
Summary
The facility failed to ensure that Resident #70's weekly weights were obtained as ordered, which was crucial for monitoring her nutritional status. Resident #70 had a complex medical history, including hemiplegia, dysphagia, vascular dementia, and significant weight loss, necessitating enteral feeding. Despite a physician's order for weekly weights to monitor trends, several weights were missed in October and November 2024. Interviews with the LPN Manager and Dietitian revealed that the weights were not consistently recorded, and there was uncertainty about the accuracy of the weights that were obtained. Additionally, the facility did not adequately monitor and follow Resident #57's fluid restriction, which was critical due to his end-stage renal disease and other related conditions. The care plan specified a 1000 ml fluid restriction, with dietary and nursing staff responsible for providing specific amounts. However, observations and interviews indicated that the resident received more fluids than allowed, and there was no system in place to accurately track fluid intake. The resident was unaware of the specifics of his fluid restriction, and staff did not consistently adhere to the prescribed limits. The facility's policies on weight assessment and fluid restriction were not effectively implemented, leading to deficiencies in the care of Residents #70 and #57. The lack of adherence to these policies resulted in missed weight measurements for Resident #70 and excessive fluid intake for Resident #57, highlighting a failure in monitoring and documentation processes within the facility.
Failure in Communication with Dialysis Center
Penalty
Summary
The facility failed to ensure ongoing communication and collaboration with the dialysis center for a resident requiring dialysis services. Resident #57, who has end-stage renal disease and is dependent on renal dialysis, was affected by this deficiency. The resident was scheduled for dialysis every Tuesday, Thursday, and Saturday. However, there were significant gaps in the communication between the facility and the dialysis center, as evidenced by missing communication sheets from the dialysis center on multiple occasions. The facility did not send communication forms with the resident to the dialysis center, and there was no documented evidence of communication on dialysis days. Interviews with the resident and facility staff confirmed that the resident did not take any paperwork to the dialysis center, but brought back forms from the center, which were supposed to be placed in the medical chart. The LPN Manager acknowledged the missing communication forms and stated that if there was no communication from the dialysis center, the facility staff should have contacted the center. The renal RN from the dialysis facility confirmed that the facility never sent forms with the resident, but the dialysis center staff consistently sent forms back with the resident.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were not left unattended, affecting two residents and potentially impacting 20 additional residents. Resident #27, who had moderate cognitive impairment and required assistance with personal care, was found with a medicine cup containing five pills on his bedside table, which he could not reach. The nurse confirmed leaving the medication unattended, contrary to the facility's policy that required nurses to remain with residents while they took their medicine. Resident #4, who had intact cognition but required a mechanically altered diet, was also found with a medication cup containing potassium tablets at her bedside. The resident confirmed that the nurse left the medication in her room without supervision, and she was unable to swallow the potassium tablets without assistance. The facility's policy stated that residents could only self-administer medications if deemed safe by the care planning team, which was not the case for Resident #4. Interviews with the Director of Nursing confirmed that the facility's policy required nurses to stay with residents until they finished taking their medication. The facility's policy on administering medications, revised in August 2022, emphasized that medications should be administered as prescribed and in a safe manner, which was not adhered to in these instances.
Inappropriate Meal Consistency for Resident on Mechanical Soft Diet
Penalty
Summary
The facility failed to ensure that residents on mechanical soft diets received meals with the appropriate consistency, affecting one resident specifically. Resident #6, who has diagnoses including quadriplegia, dysphagia, unspecified dementia, and macular degeneration, was identified as being on a mechanically altered diet. The resident's care plan and physician orders specified a regular diet with mechanical soft texture and thin consistency. However, during an observation, it was noted that Resident #6 received coleslaw with shredded cabbage instead of the prescribed green beans, which was not suitable for a mechanical soft diet. This inconsistency was confirmed by a Certified Nursing Assistant who removed the coleslaw from the tray. The facility's policy requires that menus be followed and food be served in a form designed to meet individual needs. Despite this, the meal provided to Resident #6 did not adhere to the dietary requirements outlined in the care plan and physician orders. The Speech Therapy staff confirmed that coleslaw was inappropriate for a mechanical soft diet, highlighting a lapse in the facility's adherence to dietary protocols. This incident was part of a broader issue, as the facility identified 13 residents on mechanical soft diets, indicating a potential systemic problem in meal preparation and delivery.
Infection Control Deficiencies in PPE Usage
Penalty
Summary
The facility failed to maintain proper infection control procedures, affecting three residents who were observed for isolation precautions. Resident #68, who had a stroke with right-sided weakness and dementia, was on enhanced barrier precautions (EBP) due to an antibiotic-resistant infection. Despite a sign indicating the need for personal protective equipment (PPE) during high-contact activities, two certified nursing assistants (CNAs) entered the resident's room without donning PPE and provided incontinence and catheter care. Both CNAs were unaware of the EBP requirement. Similarly, Resident #148, who had a left femur fracture and urinary retention, was also on EBP due to an indwelling urinary catheter. A CNA entered the room without PPE and provided incontinence care, unaware of the EBP requirement. Resident #151, diagnosed with COVID-19 and dementia, was on droplet precautions. A sign on the door indicated the need for an N95 mask, gown, gloves, and face shield. A CNA exited the resident's room wearing PPE and proceeded to the nurse's station to obtain a straw, then returned to the room without doffing the PPE. The registered nurse confirmed that the CNA should have removed the PPE before exiting the room. The facility's policies on EBP and COVID-19 precautions were not followed, leading to these deficiencies.
Failure to Implement Comprehensive Care Plan for Resident's Leave of Absence
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident regarding their leave of absence (LOA) from the facility. The resident, who was cognitively intact and used a wheelchair for mobility, had multiple medical conditions including multiple sclerosis, paraplegia, diabetes, and pressure ulcers. Despite having a physician's order allowing LOA with medications, the care plan did not address the resident's preference for LOA or the necessary preparations for such absences, such as ensuring the resident's power wheelchair was fully charged and that they had a means of communication. On two occasions, the resident left the facility without signing out or notifying staff, resulting in them being stranded at a bus station due to a dead wheelchair battery. The resident was subsequently found by emergency services and taken to a hospital for evaluation. The facility's LOA book did not have records of the resident signing out on these dates, and the care plan lacked any mention of the resident's LOA preferences or needs, such as taking medications with them as per the physician's order. Interviews with staff and the resident revealed that the facility was aware of the resident's tendency to leave on Saturdays and their impulsive nature. However, the care plan was not updated to reflect these preferences or to ensure the resident's safety during LOA. The facility's policy required residents to sign out and receive medications for LOA, but there was no policy to include LOA preferences in the care plan, contributing to the oversight.
Failure to Refund Overpayment to Resident's Family
Penalty
Summary
The facility failed to provide a final accounting of overpayment to the spouse of a resident within thirty days of the resident's discharge, as required by their Resident Admission Agreement. The resident, who had severe cognitive impairment and was admitted with diagnoses including dislocation of an unspecified cervical vertebrae and respiratory failure, expired in the facility. The resident was admitted as a private pay resident, and the admission agreement, signed by the spouse, stipulated that refunds should be made within 30 days of discharge. Upon review, it was found that the facility received a payment of $3825.00 for the resident's stay, while the total cost was only $1020.00, resulting in an overpayment of $2805.00. Despite the spouse's inquiry about the refund in September 2023, the facility had not issued the refund. The Business Office Manager and the Administrator confirmed that all refunds are processed through their corporate office, and no refund check had been issued to the spouse. This deficiency was investigated under Complaint Number OH00154001.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near North Lima
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willow Woods Rehabilitation And Nursing | 0.2 mi | ★★★★★ | 18 | 0 |
| Caprice Health Care Center | 0.6 mi | ★★★★★ | 5 | 0 |
| Shepherd Of The Valley Poland | 0.9 mi | ★★★★★ | 1 | 0 |
| Briarfield Place | 1.3 mi | ★★★★★ | 3 | 0 |
| Hampton Woods Nursing Center, Inc | 2.2 mi | ★★★★★ | 3 | 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.