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 Ayden Healthcare Of Fairfield during CMS and state inspections, most recent first.
A resident with dementia, hypothyroidism, and hyperlipidemia was discharged, but the facility’s resident fund account remained open with a balance still in it. The RBOM confirmed the account had not been closed after discharge and stated resident financial accounts should be closed within 30 days, consistent with facility policy.
Failure to prevent recurrent falls: A resident with COPD, seizures, psychiatric diagnoses, nicotine dependence, and moderate cognitive impairment had two falls, including one witnessed fall entering the building and one unwitnessed fall in the smoking area where he was found face down. The care plan identified fall risk, but after the falls it contained only limited interventions such as fall risk assessment and orthostatic BPs, with no additional resident-centered interventions documented despite the recurrent events.
Unsecured insulin pen left in resident room: Two residents were involved when a Toujeo Max SoloStar insulin pen labeled for one resident was found sitting unsupervised on another resident’s over-bed table. An RN confirmed the pen had been left there by the night shift, and facility policy required meds to be stored safely and securely in designated areas with access limited to authorized staff.
The facility's QAPI committee failed to perform any QAPI activities for all of 2025. Review of facility records found no QAPI meeting minutes for the year, and the Administrator confirmed there was no documentation of QAPI meetings. The facility policy stated the QAPI program was to be ongoing and facility-wide.
Unsafe, Unclean, and Damaged Resident Rooms: Surveyors found multiple resident rooms with sticky floors, wall damage, broken or missing fixtures, splintered furniture, debris buildup, and stained linens. Residents with diagnoses including COPD, dementia, diabetes, CHF, hemiplegia, and malnutrition reported dissatisfaction with the conditions, and the DON verified several of the findings, including a stained pillowcase and debris in the room entry area.
Misappropriation of Resident Property and Controlled Medications: A resident with severe cognitive impairment had a missing cell phone that police later recovered from a CNA's home, and the CNA was charged with theft. In addition, controlled meds delivered for three residents were not accounted for, and the DON confirmed the narcotic cards and sign-in sheets were missing and that the facility substantiated the medications had been misappropriated.
Menu Not Followed for Texture-Modified Diets: A staff member served torn bacon to residents on mechanical soft diets and did not provide sausage to residents on puree diets, despite the meal spreadsheet showing sausage and puree sausage were ordered. The DM verified the ordered items were not served and that the puree residents received no puree meat; the staff member stated sausage was unavailable.
A facility failed to follow EBP precautions for several residents with indwelling devices, wounds, or infection-related orders, with CNAs observed providing high-contact care while wearing gloves but no gown and, in some cases, with missing or removed EBP signage and no PPE cart available. The DON and MDSC confirmed active EBP orders for some residents, while an LPN stated one order should have been discontinued. In addition, a CNA delivered lunch trays to eight residents without performing hand hygiene between rooms, and the CNA confirmed no hand hygiene was done.
Kitchen stove and dishwasher equipment were not functioning or being accurately monitored. A stove had only one working burner and a nonoperational grill, and staff verified meals were delayed and some foods had to be altered because the equipment was not fully working. The dishwasher’s gauges were not operational, temperature logs were inaccurate, and sanitizer testing was not completed as required.
Unclean and Damaged 200 B Hall Environment: Surveyors observed a dirty, damaged, and poorly maintained hallway and entry area affecting all residents on the 200 B hall. Findings included peeling paint on room doors and trim, heavy blackened debris at room thresholds and floor transitions, a large section of dark buildup near the NS, a splintered wall guard at walking and wheelchair height, debris in the entryway, missing coverings on ceiling lights, and damaged elevator railing covers. The ADM and Maintenance Dir verified the areas were in disrepair, with the entry and door conditions reportedly in that state for nearly two years.
Failure to Document Resident Notification for Psychotropic Medications: The facility did not document that residents were informed of the risks and benefits of psychotropic meds. A cognitively intact resident with bipolar disorder had Zyprexa ordered, another resident with dementia and depression had Zoloft ordered, and two other cognitively intact residents had orders for antidepressants and antipsychotics including Prozac, Trintellix, Trazodone, Risperdal, and Lexapro. The DON confirmed the records lacked documentation that the residents or their representatives were informed in advance of the risks, benefits, or treatment alternatives.
Failure to Hold Routine Care Conferences: The facility did not conduct routine care conferences for five reviewed residents. Records showed multiple MDS assessments but only two documented care conferences for several residents, no documented care conferences for one resident, and a resident representative reported being contacted only once. An LPN verified the limited documentation, and the facility policy required care conferences with the resident, resident representative, and IDT after admission, routinely, and with changes in condition.
The facility failed to supervise smoking safely for three residents: one resident kept a cigarette and lighter on his person, another was observed smoking despite being listed as a non-smoker, and a third had cigarettes and a lighter left in the room despite needing supervision and locked storage of smoking materials. The facility also left a resident’s room with an exposed heater hazard after the cover was removed, and a resident with repeated falls did not have ordered nonskid interventions in place, including bedside strips and wheelchair anti-slip material.
Missing Documentation for Food Substitutions: A dietary aide served bacon to residents on mechanical soft diets when sausage was unavailable, despite the menu calling for sausage and puree sausage for puree diets. The aide did not consult the DM or RD and did not know how to record the substitution. The DM verified no substitution logs were available for the prior year or current year, and the RD stated substitutions should have been documented on a log.
Food was improperly handled, stored, and prepared, and the kitchen was not sanitary. A CNA delivered multiple meal trays without washing or sanitizing hands between rooms, and a staff member preparing mechanically altered diets handled food and surfaces with the same gloves. Kitchen and resident refrigerator observations found unlabeled and undated foods, missing temperature logs, debris buildup, standing liquid in the garbage disposal, uncovered equipment, and multiple uncleanable or damaged surfaces in food service areas.
Failure to Report Abuse Allegations: The facility did not report a possible staff-to-resident sexual abuse allegation involving a resident with impaired cognition and ADL dependence, and it also delayed reporting a resident-to-resident abuse incident involving another resident with intact cognition and multiple chronic conditions. The Administrator confirmed the first allegation was not reported to the state agency and the second was reported late, despite the facility policy requiring immediate reporting of abuse allegations.
Failure to investigate an allegation of staff-to-resident abuse involving a CNA and a resident with impaired cognition and ADL dependence. A letter dictated by a receptionist stated the resident alleged the CNA had sexually abused her almost every night and that she had feared him for months. The facility did not report the allegation to the state agency, and the Administrator stated the facility did not investigate because the resident had a history of making false allegations, despite policy requiring all abuse allegations to be thoroughly investigated.
Delayed Behavioral Health Services: A resident with severe cognitive impairment, alcohol dependence, and combative behaviors did not receive timely psychiatry and substance use disorder services after an order was placed. The resident was described as paranoid, disorganized, agitated, and threatening toward staff, and the DON confirmed the delay was due to a consent form submission issue and that the resident was not enrolled in the facility’s substance use disorder program.
Cold and Unpalatable Meal Service: Three residents with diagnoses including DM, malnutrition, dysphagia, hemiplegia, and muscle weakness were affected when breakfast foods were served at acceptable temperatures initially but cooled to cold, unpalatable temperatures during service. The DM verified the hot food temperatures and stated hot foods should be around 135 degrees F to remain palatable, while also noting the facility lacked insulated bottoms for the meal delivery system. The residents stated breakfast was cold and that other meals are often cold and unpalatable.
Failure to honor a resident's bathing preference. A cognitively intact resident with TIA, COPD, DM2, and morbid obesity preferred showers but was repeatedly given bed baths or had showers refused because staff said a Hoyer lift was needed and there was not enough staff available to safely use it. Shower records showed several bed baths and refusals, and a CNA confirmed the resident did not always receive showers per his preference.
Two residents with intact cognition and ADL support needs were required to make personal calls at the nurses' station because the only phone available on the unit was a desk phone that did not provide privacy. Both residents stated they had no room phone or personal cell phone and were not offered a portable phone, and the UM confirmed the desk phone was the only option for resident calls. The facility policy stated residents had the right to reasonable access to a telephone for private communications.
Failure to Issue SNF ABN After Medicare Part A Ended: The facility did not issue SNF ABN notices to two cognitively impaired residents after Medicare Part A services ended and they remained in the facility. Records showed each resident had a NOMNC indicating Part A coverage had ended, but there was no documentation that the resident or representative received the required SNF ABN, and the MDS Coordinator confirmed the notices were not issued.
Failure to provide privacy during toileting care. A cognitively intact resident who required substantial toileting assistance was observed receiving care with the room door open to the hallway while a CNA exposed the resident's bottom during washing and brief application. The CNA confirmed visual privacy was not provided and that the door should have been shut before care.
A resident with severe cognitive impairment and diagnoses including communicating hydrocephalus and alcohol dependence was transferred to another SNF, but the chart lacked documentation of the transfer location, reason for transfer, resident or representative notification, discharge planning, and a discharge summary. The AD confirmed she arranged the move to a SNF with a behavioral unit and did not document the transfer in the medical record.
A resident with diagnoses including dysphagia, depression, bipolar disorder, epilepsy, and GERD had an inaccurate PASRR record, with no determination notice found for an earlier PASRR and later psychiatric diagnosis changes not reflected in timely PASRR completion. The MDS LPN confirmed the facility did not receive the earlier determination results and acknowledged the PASRRs were not completed timely and accurately after the resident developed persistent mood disorder and later bipolar disease.
A resident with CVA and left-sided hemiplegia had OT splint instructions for a left wrist splint to be worn daily and at night, but staff did not apply it and several staff members said they were unaware of the need. The splint was later found on a windowsill, and the resident stated staff never asked or attempted to put it on. In a separate event, a severely cognitively impaired resident with hydrocephalus and alcohol-related diagnoses fell during an altercation, sustained a bleeding head laceration, and the CNA did not notify nursing or obtain an assessment; the DON and LPN were unaware of the fall.
Unnecessary narcotic pain medication administration was identified for a resident with acute kidney failure and Hodgkin's lymphoma. The resident received Roxicodone PRN even when pain was below the ordered threshold, including when pain was zero, and the MAR did not show whether one or two tablets were given. A later Roxicodone order lacked a stop date, and the DON confirmed the medication was given multiple times outside the ordered pain parameters; three additional residents ordered narcotic pain meds were also identified as potentially affected.
Expired naloxone nasal spray was found in a medication cart for resident rooms on the second floor. An LPN confirmed the medication had expired and should not have been stored ready for use. The resident involved had an order for naloxone PRN for opioid reversal, and the facility policy required medications to be stored safely, securely, and properly.
A resident with dysphagia, depression, bipolar disorder, epilepsy, and GERD had a dental evaluation showing residual root tips that required referral to an oral surgeon for surgical removal. The resident was on a mechanical soft diet, had no upper teeth, reported waiting a long time for the recommended mouth surgery, and still had pain when eating. An MDS LPN verified the facility had not attempted to schedule the oral surgical appointment recommended by the dentist.
Failure to follow up on recommended oral surgery for a resident with intact cognition, max ADL assistance, and a mechanical soft diet. A dental exam found residual root tips and recommended referral to an oral surgeon for extractions and surgical removal, but the facility did not attempt to schedule the appointment. The resident reported waiting a long time for the mouth surgery, had no upper teeth, and said she still had pain when eating.
Two residents did not receive ordered fluid restriction communication between nursing and dietary. One resident with CHF and hyponatremia had a 1500 mL fluid restriction, but meal tickets did not list the meal-time amounts and CNAs were not informed of the breakdown. Another resident with COPD and CHF had a 64-ounce fluid restriction, but meal tickets also lacked the dietary allowance and an 800 mL water pitcher was found at bedside despite the restriction.
Surveyors observed a shower room where a single shower chair with a fixed toilet seat had a section of PVC pipe underneath that was smeared with brown fecal matter, despite staff indicating the chair had been cleaned. An LPN confirmed the substance was feces and acknowledged that shower equipment and the room were supposed to be cleaned after each use, while the DON stated that staff providing showers were responsible for cleaning equipment between residents. This failure to maintain clean shower equipment had the potential to affect multiple residents who used the second-floor shower room.
The facility failed to notify residents and their representatives and invite them to participate in care conferences, and lacked documentation of such notifications. One resident with COPD, anxiety, hemiplegia, and osteoarthritis, who was cognitively intact and identified as full code, had a care plan calling for education of the resident and responsible party, yet neither the resident nor the power-of-attorney daughter were listed as attendees on the care conference sheet, and both reported not being informed of care conferences. Another cognitively intact resident with type 2 DM, morbid obesity, and mental health diagnoses had no record in progress notes of any care conference notification and stated he was not invited. A third resident with hypertension, COPD, stroke, and impaired cognition had a care plan requiring communication with family about needs, but progress notes showed no evidence that the resident or emergency contacts were notified of quarterly care conferences. The DON and Administrator confirmed for all three cases that there was no documentation of notifications or invitations.
A resident with type 2 DM, morbid obesity, and mental health diagnoses was admitted on insulin therapy with existing orders from a prior facility for BID blood sugar monitoring. On admission, these blood glucose monitoring orders were not transcribed into the EHR, and admission physician orders were silent regarding blood sugar checks. Active orders did not include glucose monitoring until a daily fasting blood sugar order was entered more than a month later. The DON confirmed that the monitoring order should have been transcribed at admission and that no blood sugar checks were performed for the resident during this interval.
A resident with intact cognition, hemiplegia, bowel and bladder incontinence, and a care plan requiring maximal assistance for toileting was documented as incontinent almost daily, yet the medical record lacked evidence that staff consistently provided or attempted incontinent and toileting care or recorded refusals. Electronic documentation showed multiple days when toileting tasks did not occur and other days when the resident was marked as needing only supervision, contrary to the care plan. Surveyors observed CNAs offer toileting once, after which the resident refused and no further attempts were made over more than two hours. Later, the resident was seen with visibly wet clothing and reported going outside repeatedly without staff offering toileting reminders or assistance, despite being unable to transfer independently. Leadership confirmed that documentation of offers of care, refusals, and incontinent care was incomplete and that facility ADL policy expectations for managing resisted care were not followed.
Two residents receiving antianxiety medications experienced multiple medication administration errors when staff failed to follow physician orders and facility policy. One resident with anxiety and depression had clonazepam ordered twice daily, but controlled drug records showed missed doses, incorrect dosing (splitting a 2 mg dose into two 1 mg tablets), and administration of the bedtime dose in the morning, as well as a missed morning dose when the facility lacked medication. Another resident with COPD, respiratory failure, and anxiety had Xanax ordered three times daily, yet controlled records documented doses given at inconsistent times and more frequently than ordered. The DON confirmed that these medications were not administered as ordered and that multiple errors occurred for both residents.
A resident with multiple medical conditions fell during a transfer using a Hoyer lift due to a CNA conducting the transfer alone and failing to properly secure the lift pad. The facility's protocol requires two aides for such transfers, which was not followed, leading to the resident landing on her shoulders.
A resident with a history of opioid abuse and other conditions did not receive prescribed Methadone on multiple occasions due to unavailability and lack of timely prescription processing. The facility's procedure for handling unavailable medications was not adequately followed or documented, leading to a significant medication error.
The facility failed to maintain effective pest control, with multiple observations of flies and gnats in resident rooms and the kitchen. Flies were seen on meal trays, food, and residents' sheets, confirmed by residents and staff. In the kitchen, flies were observed on the steam table and around the dishwasher, verified by dietary staff. The facility's Pest Control Policy was not effectively implemented, leading to a deficiency.
The facility did not provide resolutions for issues raised in Resident Council meetings, affecting all attending residents. Meeting minutes from over a year showed no documented resolutions. The new Activity Director could not find past resolutions, and residents reported that their complaints were not addressed. The Administrator admitted to not following up on concerns or documenting actions, despite a policy requiring a response form to track issues.
The facility failed to conduct proper medication regimen reviews for five residents, missing documentation for March 2024. Residents with various medical conditions, including cerebral infarction, diabetes, and spinal stenosis, were affected. Additionally, a delay in physician response to a pharmacy recommendation for a resident with duplicate Mirtazepine orders was noted, exceeding the facility's 30-day policy.
The facility failed to provide residents with daily menus, leaving them unaware of their meal options. Interviews with several residents revealed they did not receive menus and were unsure of their daily meals. Staff confirmed that while preferences were recorded, residents did not have access to choose from the menu, leading to a deficiency in communication and meal planning.
The facility failed to provide residents with meal alternatives, affecting several residents who were unable to choose different meals if they disliked the ones served. Observations and interviews revealed a lack of posted alternative menus and staff unawareness of available options. In one case, a resident requested a hot dog but received a hamburger due to unavailability, highlighting a disconnect between the facility's policy and its implementation.
The facility's kitchen was found to be unsanitary, with a large puddle of dirty water under the dishwasher and a dusty vent above the steam table. Ceiling tiles near the steam table were drooping and discolored due to a leaking roof. These issues were confirmed by dietary staff, and the facility's policy required maintaining cleanliness and sanitation in dining and food service areas.
The facility failed to maintain essential kitchen equipment, affecting nearly all residents. Observations revealed a non-functional garbage disposal, leaking dishwasher, broken oven and refrigerator, and a malfunctioning three-compartment sink. Dietary staff confirmed these issues, with the dishwasher leaking for months and requiring a wet vacuum for drainage. Rags were used to keep the sink filled, and the broken oven and refrigerator remained in the kitchen.
The facility failed to provide adequate nutritional care to several residents, leading to significant weight loss and unimplemented dietary recommendations. Residents did not receive prescribed supplements during meals, and weekly weights were not documented as ordered. The facility ran out of dietary supplements, and the Registered Dietitian confirmed concerns about the implementation of dietary recommendations and weight monitoring.
The facility failed to serve meals at safe and palatable temperatures, affecting nearly all residents. Observations showed that food temperatures dropped significantly from the kitchen to the residents, with items like chicken and mashed potatoes falling to 100°F. Breakfast trays were delayed in distribution, resulting in scrambled eggs and grits being served at unpalatable temperatures. The Dietary Supervisor confirmed these deficiencies, which violated the facility's policy requiring hot food to be served at a minimum of 135°F.
The facility failed to maintain a clean and homelike environment, with residents reporting sticky floors, rust in showers, and cobwebs. A resident's room had a strong urine odor and a damaged mattress, while another room had food debris and exposed wall space. Staff confirmed these issues, indicating inadequate cleaning practices.
The facility failed to maintain accurate advance directives for two residents, resulting in unclear code status for one and incomplete admission documentation for another. This was confirmed by the DON and Regional Director of Clinical Services, indicating a breach in the facility's policy on advance care planning.
A facility failed to hold care conferences for a resident with multiple diagnoses, including diabetes and dementia, as required. The resident had not had a care conference documented in over a year, despite needing assistance with daily activities. Interviews confirmed the absence of care conferences, contrary to the facility's policy.
Failure to Close and Convey Resident Funds After Discharge
Penalty
Summary
The facility failed to convey a discharged resident’s personal funds in a timely manner. Resident #124 was admitted to the facility with diagnoses including dementia, hypothyroidism, and hyperlipidemia, and the most recent quarterly MDS indicated the resident’s cognitive status was unable to be fully assessed, the resident did not reject care or wander, and required moderate to maximal assistance with ADLs. The resident was discharged on 03/16/26, but review of the Resident Statement Landscape from the Resident Fund Management Service showed the resident’s financial management account had not been closed or frozen and still had a balance. During interviews, the RBOM confirmed the account remained open after discharge and stated that resident financial accounts should be closed within 30 days of discharge. Facility policy titled Management of Personal Funds stated the facility will reconcile and close all accounts within 30 days of discharge and send funds to an appropriate agency.
Failure to Prevent Recurrent Falls
Penalty
Summary
The facility failed to provide supervision, care, and services to reasonably prevent falls for one resident with a history of falls. Resident #39 was admitted with chronic obstructive pulmonary disease, convulsions, alcohol dependence, paranoid schizophrenia, generalized anxiety disorder, major depressive disorder, and nicotine dependence, and the most recent MDS showed moderate cognitive impairment with a BIMS score of 10. Functional assessment showed the resident needed assistance or supervision with multiple activities of daily living, and the care plan identified the resident as being at increased risk for falls related to impaired physical mobility. The resident had a witnessed fall when entering the building from the patio after stating he lost his balance, with pain to the back and elbow, and later had an unwitnessed fall while in the smoking area, where he was found lying face down after another resident reported he had lost his balance, fallen, and hit his head. Review of the care plan showed only limited interventions were added after the falls, including fall risk assessment and orthostatic blood pressures, with no additional interventions documented after the first fall. The DON confirmed she would have expected the care plan to include new shoes and resident education about taking a break between cigarettes, and the facility policy required resident-centered interventions and additional or different interventions if falling recurred.
Unsecured insulin pen left in resident room
Penalty
Summary
Medication storage was not maintained safely for two residents. Resident #64, admitted with diagnoses including Type II diabetes with complications, cognitive communication deficit, dysphagia, diastolic heart failure, obesity, and osteoarthritis, had an MDS showing cognitive intactness with a BIMS score of 13 and required varying levels of assistance with activities of daily living. Resident #66, admitted with diagnoses including Type II diabetes, cognitive communication deficit, unspecified arthritis, major depressive disorder, hyperlipidemia, and GERD, had an MDS showing moderate cognitive impairment with a BIMS score of 12 and required assistance with eating, oral hygiene, personal hygiene, toileting hygiene, bathing, dressing, bed mobility, and transfers. During an interview in Resident #64’s room, a Toujeo Max SoloStar insulin pen was observed sitting on the over-bed table unsupervised. The pen was labeled for Resident #66. RN #731 confirmed the medication was left on the over-bed table and stated the night shift had left it there. Facility policy required medications to be stored in a medication cart or other designated area and to be stored safely, securely, and properly, with access limited to authorized personnel.
Failure to Conduct QAPI Activities
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) committee failed to perform any QAPI activities for the entirety of 2025. Review of facility documents on 05/05/26 with the Administrator found no documentation of QAPI meeting minutes for all of 2025. During an interview on 05/05/2026, the Administrator verified that there was no documentation of QAPI meetings for 2025. Review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI) Program dated 04/28/25, showed the facility was to develop, implement, and maintain an ongoing, facility-wide QAPI program that builds on the Quality Assessment and Assurance Program to actively pursue quality of care and quality of life goals.
Unsafe, Unclean, and Damaged Resident Rooms
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for multiple residents. During observations, surveyors found resident rooms with sticky floors, damaged walls, broken or missing room fixtures, and debris buildup. The cited conditions included a large hole in a wall near a bed, a broken window shade, an overbed light without a pull chain, split and raised flooring, splintered and broken furniture, missing shower curtain, detached wall cove base, and a heater cover that was not attached. Several residents were interviewed and confirmed dissatisfaction with the conditions in their rooms. One resident stated the hole in the wall, broken shade, and nonworking overbed light were upsetting, and another said the sticky floor and broken items were not how she lived at home. Other residents reported concern that the detached cove base could catch a scooter wheel, that the heater cover had come off during the night, and that they did not want to lie on a pillowcase with a large dried brown stain. The DON also verified the stained pillowcase, sticky floor, and debris buildup in the entry corner. The affected residents had diagnoses including COPD, dementia, cerebral infarction, diabetes, heart failure, hemiplegia, dysphagia, malnutrition, anxiety disorder, PTSD, polyneuropathy, morbid obesity, xeroderma pigmentosa, and lymphedema. MDS assessments showed varying levels of cognitive and ADL dependence, including intact cognition, impaired cognition, partial assistance, supervision, maximum assistance, and total care needs. The facility policy titled Quality of Life Homelike Environment stated residents should be provided a safe, clean, comfortable, and homelike environment, and the Administrator and Maintenance Director verified the rooms needed repairs and cleaning.
Misappropriation of Resident Property and Controlled Medications
Penalty
Summary
The facility failed to ensure residents' belongings and medications were not misappropriated. Resident #71, who had Huntington's disease, major depressive disorder, dysphagia, anxiety disorder, severely impaired cognition, and required staff assistance with ADLs, was identified as being at risk for exploitation and personal item loss due to impaired mobility and cognitive changes. A police report showed CNA #600 was issued a summons for theft after Resident #71's missing cell phone was recovered from the CNA's home. Facility documentation showed staff reported the phone missing, the family notified police and the facility, and police later arrived at the facility with the phone. Interviews with the detective, RDO, and ADON confirmed CNA #600 had possession of the resident's phone, and the facility policy stated it should assist residents in safeguarding personal property. The facility also failed to account for controlled medications delivered for three residents. Pharmacy packing slips showed 30 oxycodone 5 mg tablets for Resident #12, 30 hydrocodone 5-325 mg tablets for Resident #40, and 30 oxycodone 5 mg tablets for Resident #62 were delivered to the facility but were not registered as received. A police report documented the facility reported theft of residents' narcotic medications, and an email to the pharmacy stated the facility had a narcotic diversion affecting these three residents. The DON verified the narcotic cards and sign-in sheets dated 07/15/25 were not turned in by RN #550 and the medications were not at the facility, and stated the facility suspected RN #550 took the medications as they were delivered. The DON confirmed the facility substantiated that the medications for Residents #12, #40, and #62 had been misappropriated.
Menu Not Followed for Texture-Modified Diets
Penalty
Summary
The facility failed to follow the planned menu for residents receiving pureed and mechanical soft consistency diets. Twelve residents had physician orders for a mechanical soft consistency diet, two residents had orders for a puree diet, and one of those residents had an order for a mechanical soft diet with puree meats. During breakfast meal service, the staff member serving the meal provided torn pieces of bacon to residents on mechanical soft diets and did not provide sausage to residents receiving the puree diet. Review of the meal spreadsheet showed that the mechanical soft diets were ordered to receive sausage and the puree diets were ordered to receive puree sausage. During interview, the staff member serving the meal stated sausage was not served for the mechanical soft and puree consistency diets because there was no sausage available. The Diet Manager verified that the mechanical soft diets were ordered to receive sausage and the puree diets were ordered to receive puree sausage, and also verified that the residents on the puree diet did not receive any puree meat. Facility policy titled Portion Control Guidelines stated food portions are written on the menus and recipes, and the Menu Substitutions policy stated all changes to the menu must provide equal nutritive value.
Failure to Follow EBP and Hand Hygiene Procedures
Penalty
Summary
The facility failed to follow precaution procedures for residents with orders for Enhanced Barrier Precautions (EBP) and failed to ensure hand hygiene was completed while passing food trays. This affected four of five residents reviewed for infection control and eight residents during tray delivery observations, with the facility census at 68. Resident #07 had diagnoses including acute kidney failure, Hodgkin's lymphoma, and urinary retention, and was ordered to be in EBP due to multiple wounds and an indwelling Foley catheter. When a CNA entered the room and provided personal care, the CNA was wearing gloves but no gown. There was no EBP sign posted at the doorway and no PPE cart near the room. The CNA stated he did not know the resident was in EBP, and the resident stated staff only wore gloves and had never worn a gown. The MDSC verified the resident was in EBP and confirmed there was no sign or PPE cart at the room. Resident #19 had diagnoses including COPD, type 2 diabetes, and morbid obesity, and had an active EBP order related to ESBL infection in urine. A CNA was observed providing care in the room with gloves but no gown, and the CNA confirmed the resident was in EBP but no gown was worn. An LPN stated the EBP order should have been discontinued because it had been ordered for a healed wound, and the EBP sign was removed from the door. The DON later verified the resident still had an active EBP order related to infection in the urine and the sign should not have been removed. Resident #05 had an active EBP order related to a G-tube, but no sign was posted until after the surveyor identified the issue. Resident #02 had an order for Foley catheter changes every 30 days and was observed receiving dressing change, transfer assistance, and catheter/incontinence care without a gown, despite staff acknowledging the resident was in EBP and that the door sign directed gown use for high-contact care. During lunch tray delivery, a CNA delivered trays to eight residents without performing hand hygiene between rooms. The CNA confirmed she did not sanitize or wash her hands between delivering trays to those residents. The facility policy for Enhanced Barrier Precautions required gowns and gloves for high-contact care activities, and the infection prevention and control policy stated residents with an infection or communicable disease shall be placed on transmission-based precautions.
Kitchen Stove and Dishwasher Not Functioning or Properly Monitored
Penalty
Summary
The facility failed to ensure essential kitchen equipment was working safely when the kitchen stove was not fully functional. Observations from 04/27/26 through 05/05/26 showed that of the six top burners, only one burner could heat food and the grill top was nonoperational. During an interview, a staff member verified breakfast was scheduled to start at 8:30 A.M. but the meal could not be completed on time because the stove was not working fully. The Diet Manager also verified the burners did not fully function and the grill was not operational, and stated some foods had to be altered to a less fresh form, such as grilled cheese, because the grill was not working. The Administrator later verified the stove was not working properly and that the most current bid for replacement had expired on 03/20/25, with no current stove bids or approval for a new stove. The facility also failed to ensure the dishwasher was properly monitored and documented. Review of March and April 2026 logs showed wash temperatures of 150 degrees F or 160 degrees F, rinse temperatures of 150 degrees F, 155 degrees F, or 160 degrees F, and sanitizer readings of 50 PPM. The May 2026 log showed wash temperatures of 150 degrees F and 150 degrees F and rinse temperatures of 155 degrees F and 160 degrees F, but there were no dinner water temperatures and no sanitizer testing recorded for 05/01/26 through 05/03/26. On observation, the dishwasher temperature gauges were not operational and were stuck at 130 degrees F for wash and 150 degrees F for rinse, while the machine plate identified it as a low temperature machine requiring a wash cycle at 140 degrees F and rinse cycle at 120 degrees F with sanitizing chemical required. The Diet Manager verified the gauges were not operational, the dishwasher required sanitizer, the water temperatures were not obtained with another device, the logs were not accurate, and sanitizing testing was not completed for May 2026.
Unclean and Damaged 200 B Hall Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment on the 200 B hall, affecting all 23 residents living in rooms 201 through 214. Observations made at random times from 04/27/26 through 05/04/26 showed room entry doors and door trim with removed and peeling paint, and the entry corners and floor transition strips of each resident room had heavy blackened buildup of debris. A section of flooring near the nursing station, approximately 12 feet long by 12 inches wide, also had dark, blackened buildup. Additional observations identified a wall guard near the floor in the hallway near one resident room that was splintered with jagged edges measuring about six by three inches at walking and wheelchair height. The facility entryway had carpeting with heavy debris buildup, wallpaper and cove base removed, and two ceiling lights without coverings. The elevator had three sections of splintered and missing railing covers, and the Administrator and Maintenance Director verified the elevator, entry area, hallway, and resident room entry areas on the 200 unit B hallway were in disrepair, with the entry area and door conditions having been in disrepair for nearly two years.
Failure to Document Resident Notification for Psychotropic Medications
Penalty
Summary
The facility failed to ensure residents were informed of the risks and benefits of treatment with psychotropic medications. Medical record review showed that Resident #64, who was cognitively intact and had diagnoses including bipolar disorder, had an order for Zyprexa 10 mg at bedtime, but the record did not include documentation that staff informed the resident of the risks and benefits of that treatment. Resident #3, admitted with diagnoses including major depressive disorder, dementia, and chronic kidney disease, had an order for Zoloft 75 mg, and the record did not include documentation that staff informed the resident of the risks and benefits of treatment with Zoloft. Resident #2, who was cognitively intact and had diagnoses including type two diabetes mellitus, major depressive disorder, and generalized anxiety disorder, had orders for fluoxetine HCl 40 mg and Trintellix 20 mg, also identified as psychotropic medications, but the record did not include documentation that staff informed the resident of the risks and benefits of treatment with Prozac and Trintellix. Resident #54, who was cognitively intact and had diagnoses including type two diabetes mellitus, major depressive disorder, and anxiety disorder, had orders for Trazodone 100 mg, Risperdal 1 mg, and Lexapro 10 mg, and the record did not include documentation that staff informed the resident of the risks and benefits of treatment with those medications. The DON confirmed that the medical records for these residents contained no documentation indicating the resident or the resident's representative were informed in advance of the risks and benefits of psychotropic medications and/or other treatment alternatives.
Failure to Hold Routine Care Conferences
Penalty
Summary
The facility failed to conduct care conferences with residents or resident representatives on a routine basis for five reviewed residents. Record review showed that Resident #02, who had diagnoses including nontraumatic subarachnoid hemorrhage, type II diabetes mellitus, chronic kidney disease stage III, neuromuscular dysfunction of the bladder, major depressive disorder, generalized anxiety disorder, and drug induced constipation, had multiple quarterly MDS assessments but only two documented care conferences. Resident #57, with diagnoses including fracture of the lower end of the left femur, polyneuropathy, hemiplegia and hemiparesis following cerebral infarction, acute kidney failure, major depressive disorder, anxiety disorder, psychotic disorder with hallucinations, and opioid dependence, also had multiple MDS assessments but only two documented care conferences. Resident #21, who was severely cognitively impaired and had diagnoses including COPD, type II diabetes mellitus, Wernicke's encephalopathy, cerebrovascular disease, altered mental status, and protein-calorie malnutrition, had only two documented care conferences, and the resident's representative stated she was contacted once for a care conference. Resident #54, admitted with diagnoses including type II diabetes mellitus, muscle weakness, cognitive communication deficit, dysphasia, major depressive disorder, adjustment disorder, unspecified mood disorder, and anxiety disorder, had no documented care conferences. Resident #03, who was moderately cognitively impaired and had diagnoses including sepsis, history of TIA, cognitive communication deficit, chronic DVT, major depressive disorder, dementia, pressure ulcer, and chronic kidney disease stage III, had only two documented care conferences despite multiple quarterly, annual, and significant change MDS assessments. During interviews, LPN #190 stated care conferences should be conducted quarterly in conjunction with MDS assessments and verified the limited or absent documentation for these residents. The facility policy stated care conferences were to include the resident, resident representative, and interdisciplinary team as soon as possible after admission, routinely, and with a change in condition.
Unsafe Smoking Supervision, Environmental Hazard, and Fall Intervention Failures
Penalty
Summary
The facility failed to ensure staff provided the necessary level of supervision for safe smoking for three residents. One resident with diagnoses including toxic encephalopathy, type 2 diabetes, polyneuropathy, and delusional disorder was documented as a smoker and was supposed to have smoking items kept at the nurses’ station, yet was observed in the common area with a cigarette in his mouth and a lighter on his person. The DON confirmed the resident was not supposed to keep smoking materials, but he had them with him at the time of observation. A second resident with schizophrenia, schizoaffective disorder, Parkinson’s disease, bipolar disorder, and nicotine dependence was listed on the smoking assessment as a non-smoker, but the care plan still identified increased injury risk related to smoking and required smoking items to be kept at the nurses’ station. The resident was observed in the hallway with a cigarette in his mouth and a lighter in his hand. The DON confirmed the resident had smoking products on his person and stated the resident had stopped smoking when the assessment was completed but had since started smoking again, with no new assessment completed when smoking resumed. A third resident with encephalopathy, COPD, respiratory failure, anxiety disorder, and nicotine dependence had a smoking evaluation stating the resident used vape products and lacked the fine motor skills to securely hold tobacco or other smoking items, but the care plan did not include smoking status. Cigarettes and a lighter were repeatedly found on the bedside table in the resident’s room, and staff confirmed the items should have been locked behind the nurses’ station. The facility also failed to keep the environment free of accident hazards when a resident reported scratching a toe after kicking off a heater cover; observations showed the heater cover removed with jagged metal exposed near the bed. In addition, a resident with diabetes, malnutrition, muscle weakness, unsteady gait, repeated falls, heart failure, reflux uropathy, glaucoma, and epilepsy had multiple falls and ordered nonskid interventions, but observations showed the bedside nonskid strips and wheelchair anti-slip material were not in place, and the floor strips near the toilet were missing or not fully adhered despite the resident’s repeated falls.
Missing Documentation for Food Substitutions
Penalty
Summary
The facility failed to maintain a record of food substitutions for residents receiving meals from the kitchen, affecting all 67 residents who received food from the kitchen. During breakfast meal service, the dietary aide served torn pieces of bacon to residents on mechanical soft diets even though the spreadsheet indicated those diets were to receive sausage and the puree diets were to receive puree sausage. The dietary aide verified that sausage was not available and stated he substituted bacon for sausage for the mechanical soft diet without obtaining or consulting the Diet Manager. He also stated he did not know whether bacon was a substitute for sausage and did not know how to record the substitution on a substitution log. The Diet Manager verified that the mechanical soft diets were to receive sausage and the puree diets were to receive puree sausage, and stated there were no substitution logs available for 2025 or 2026. The Diet Manager also verified the dietary aide did not request confirmation of the substitution from the Diet Manager or the RD. The RD stated a substitution log should have documented changes when food is substituted and denied being consulted about any food substitution, including the bacon served in place of sausage. Review of the facility policy titled Menu Substitutions stated changes shall be of equal nutritive value and made by the diet manager or dietary professional, and that all menu changes will be documented using a substitution log reflecting the items substituted and reason for the substitution.
Food Storage, Preparation, and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to properly prepare and store food and maintain a sanitary kitchen. During observation, a CNA delivered lunch trays to multiple residents’ rooms without sanitizing or washing hands between tray deliveries. The CNA confirmed that hand hygiene was not performed between deliveries and stated that trays are delivered even when residents are not in their rooms, including residents who may be outside smoking during lunch tray delivery. Kitchen observations identified multiple sanitation and storage problems. The ice machine scoop was stored in a non-draining container with the scoop side up, the garbage disposal contained standing brown liquid with a strong odor, two handwashing areas lacked working hands-free towel dispensers, and the non-in-use meat slicer was not covered. In dry storage and the walk-in refrigerator, there were opened food containers without open dates, ceiling light fixtures without protective coverings above food shelves, refrigerator fans with brown debris buildup, and soaked boxes of thawing meat without catch pans. Food and refrigerator temperatures were not documented for several consecutive days, and the food service area had vents, a floor fan, walls, door frames, and ceiling areas with heavy debris, gouges, missing door jambs, drywall, and exposed wood studs with uncleanable surfaces. Additional observations showed improper food handling and resident food storage practices. A staff member preparing mechanically altered diets wore gloves while tearing up bacon and biscuits, touched counters, lids, and other surfaces, and did not change gloves between handling food items. Resident-designated refrigerators contained unlabeled and undated foods, an unidentified lunch bag, open foods without labels or dates, and no thermometer or temperature logs. Facility staff confirmed that resident refrigerators should be used only for resident food storage and that items should be labeled and dated, while the Administrator verified the uncleanable kitchen surfaces. Facility policies also stated that gloves must be clean and fresh when handling foods and that perishable foods must be labeled, dated, and stored under documented temperature control.
Failure to Report Abuse Allegations
Penalty
Summary
The facility failed to report a possible staff-to-resident abuse allegation involving a resident with anxiety disorder, major depressive disorder, essential hypertension, moderately impaired cognition, and a need for staff assistance with ADLs. A letter dictated by a receptionist and placed in a CNA’s personnel file stated that the resident alleged the CNA had sexually abused her almost every night and that she had feared him for almost three months. The facility’s SRIs showed no report was made to the state agency regarding this allegation, and the Administrator confirmed the allegation was not reported because of the resident’s history of making false allegations. The facility also failed to timely report a resident-to-resident abuse allegation involving a resident with hemiplegia affecting the left side, diabetes, heart failure, depression, bipolar disorder, intact cognition, and moderate ADL assistance needs. The incident between the resident and another resident was discovered on 04/22/26, but the SRI was not reported to the state agency until 04/24/26. The Administrator confirmed the delay and stated allegations of potential and suspected abuse should be created within two hours of discovery if serious injury is involved and within 24 hours for all other allegations. The facility policy stated staff should report all incidents and allegations of abuse immediately to the Administrator or designee, and the facility would notify the state agency immediately, but not later than two hours after the allegation is made or the serious bodily injury is identified.
Failure to Investigate Allegation of Staff-to-Resident Abuse
Penalty
Summary
The facility failed to investigate an allegation of staff-to-resident abuse involving a CNA and Resident #62. Resident #62 was admitted on 03/06/25 with diagnoses including anxiety disorder, major depressive disorder, and essential hypertension, and an MDS assessment dated 03/14/26 showed moderately impaired cognition and a need for staff assistance with ADLs. A letter dated 03/28/26, dictated by Receptionist #125, stated that Resident #62 alleged the CNA had sexually abused her almost every night and that she had feared him for almost three months. Review of the facility SRIs showed no report was made to the state agency regarding the allegation, and the Administrator confirmed on 05/04/26 that the facility did not investigate the allegation because of the resident's history of making false allegations. The Administrator also confirmed that Receptionist #125 turned the letter over to him on 03/29/26. The facility policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property stated that all allegations of resident abuse would be thoroughly investigated.
Delayed Behavioral Health Services
Penalty
Summary
The facility failed to timely start behavioral health services for one resident reviewed for behavioral services. The resident had an admission date of 03/19/26 and a discharge date of 04/30/26, with diagnoses including communicating hydrocephalus, cognitive communication deficit, and alcohol dependence with intoxication delirium. The MDS dated [DATE] showed the resident was severely cognitively impaired and had physical and verbal behaviors. The care plan initiated on 03/20/26 documented a history of alcohol abuse and combative behaviors, with psychiatry consultation as needed. A physician order dated 04/07/26 directed that the resident be evaluated by psychiatry services, but the psychiatric consult did not occur until 04/21/26. The psychiatric consult described the resident as a new patient for diagnostic evaluation and noted paranoia, disorganized thinking, homicidal ideation, and severe agitation requiring constant redirection. The consult also stated that a PASRR completed on 03/19/26 indicated no serious mental illness and/or developmental disability and no Level II referral was made, although dementia, alcohol abuse, and brain bleed were listed. During observation on 04/27/26, the resident came out of his room, grabbed a wet floor sign, and threatened a CNA that he was going to hit her with it. The CNA stated the resident was upset because the nurse had taken his beer the day before and that he was confused and thought she was the nurse who took it. The DON verified the facility used Stepping Stone for substance use disorder services, that the resident was not signed up for those services, and that there was a delay in getting the consent form correctly submitted, which delayed psychiatry services.
Cold and Unpalatable Meal Service
Penalty
Summary
The facility failed to serve foods at a palatable temperature for three residents, identified in the report as residents #15, #52, and #66. Resident #15 had diagnoses including diabetes, malnutrition, muscle weakness, unsteady gait, repeated falls, heart failure, reflux uropathy, glaucoma, and epilepsy, and the MDS showed intact cognition with supervision needed for ADLs and a carbohydrate-controlled diet. Resident #52 had diagnoses including muscle weakness, anxiety, PTSD, polyneuropathy, and iron deficiency anemia, with intact cognition and supervision needed for ADLs and a regular diet. Resident #66 had diagnoses including left-sided hemiplegia, dysphagia, muscle weakness, and malnutrition, with intact cognition, partial assistance needed for ADLs, use of a motorized scooter, and a regular diet. On 04/30/26, the meal spreadsheet listed breakfast as biscuit and gravy, scrambled eggs, and hot cereal. Before meal service, the biscuit and gravy measured 190 degrees F, the hot cereal 161 degrees F, and the eggs 175 degrees F. During the test tray observation 30 minutes after start of service, the biscuit and gravy measured 101 degrees F, the hot cereal 103 degrees F, and the eggs 93 degrees F, and taste testing found the food cold and unpalatable. The DM verified the temperatures and stated hot foods should be around 135 degrees F to be palatable, and also stated the facility only had insulated tops for the plates and did not have the insulated bottoms of the meal delivery system to maintain food temperatures. The three residents interviewed stated the breakfast was cold and unpalatable, and they stated breakfast is always cold and other meals are often cold and unpalatable.
Failure to Honor Resident Bathing Preferences
Penalty
Summary
The facility failed to honor a resident's choice regarding bathing by not consistently providing showers as preferred. Resident #19, who was cognitively intact and admitted with diagnoses including transient cerebral ischemic attack, COPD, type 2 diabetes, and morbid obesity, required partial/moderate assistance with bathing and substantial/maximal assistance with shower transfers. Review of shower sheets showed multiple instances where the resident received bed baths or refused care instead of showers. The resident stated he preferred showers but had been told several times that he had to have a bed bath because he required a Hoyer lift for showers. A CNA confirmed the resident needed a Hoyer lift for shower transfers and that there were times he did not receive a shower per his preference because the facility did not have enough staff available to safely use the Hoyer lift. The facility policy on Resident Rights stated residents had the right to self-determination and participation.
Lack of Private Telephone Access for Residents
Penalty
Summary
The facility failed to provide an accessible private area for residents to make phone calls, affecting two residents reviewed for phone privacy. Resident #9 was admitted with diagnoses including hemiplegia affecting the left side, diabetes, bipolar disorder, polyneuropathy, and vascular disease, and her MDS assessment showed intact cognition and moderate assistance with ADLs. Resident #13 was admitted with diagnoses including schizoaffective disorder, anxiety disorder, Parkinson disease, and a below-the-left-knee amputation, and his MDS assessment showed intact cognition and supervision with ADLs. Observations from 04/27/26 through 05/05/26 showed the only phone available for residents on the 200 unit was a desk phone at the nurses' station, which did not allow privacy during calls. Resident #13 stated he did not have a room phone or personal cell phone, had to make personal calls at the nurses' station, and was not offered a portable phone for private calls. Resident #9 gave the same account, stating she had to make personal calls at the nurses' station and was not offered a portable phone. The Unit Manager verified that the desk phone at the nurses' station was the only phone available for residents on the 200 unit and did not allow privacy. The facility policy stated residents had the right to reasonable access to a telephone for private communications.
Failure to Issue SNF ABN After Medicare Part A Ended
Penalty
Summary
The facility failed to issue Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) forms after it initiated discharge from Medicare Part A services for two residents whose Medicare-covered stays had not exhausted their benefit days. Resident #83 had diagnoses including Marfan syndrome, seizure disorder, and cognitive communication deficit, and the MDS identified the resident as cognitively impaired. The NOMNC showed Medicare Part A services ended for this resident, and the record contained no documentation that a SNF ABN was issued when the resident remained in the facility. Resident #84 had diagnoses including nontraumatic intracerebral hemorrhage, type 2 diabetes, and cognitive communication deficit, and the MDS also identified the resident as cognitively impaired. The NOMNC showed Medicare Part A services ended for this resident as well, and the record likewise contained no documentation that a SNF ABN was issued when the resident stayed in the facility. The MDS Coordinator confirmed in interview that SNF ABN notices had not been issued to either resident or their representatives when Medicare Part A services ended, despite the facility policy stating that a SNF ABN was to be given if a resident remained in the facility after the last traditional Medicare A covered day.
Failure to Provide Privacy During Toileting Care
Penalty
Summary
Privacy was not provided during toileting care for one resident who was cognitively intact and required substantial assistance with toileting. The resident had been admitted with diagnoses including acute kidney failure, Hodgkin's lymphoma, and persistent mood disorder. During observation, a CNA was assisting the resident with toileting in the resident's room while the room door was open to the hallway, and the CNA exposed the resident's bottom while washing the resident and applying a clean incontinence brief. In interview, the CNA confirmed that visual privacy had not been provided and stated the door should have been shut before care was given. The facility policy on Resident Rights stated employees should treat all residents with kindness, respect, and dignity.
Missing Transfer and Discharge Documentation
Penalty
Summary
The facility failed to provide proper documentation for a resident’s discharge/transfer. Resident #30 had diagnoses including communicating hydrocephalus, alcohol use, cognitive communication deficit, and alcohol dependence with intoxication delirium, and the MDS assessment identified the resident as severely cognitively impaired. The care plan stated the resident wished to discharge to the community and included interventions to evaluate prognosis for independent or assisted living and to arrange community resources to support independence after discharge. The medical record contained no documentation of where the resident was transferred, the reason for the transfer, notification to the resident or resident representative, the discharge planning process, or a discharge summary. During interviews, the MDS Coordinator verified that none of this documentation was present and confirmed the resident was transferred to another SNF. The Admissions Director stated she arranged the transfer to another SNF with a behavioral unit that would be a better fit, and verified that she did not place any documentation of the transfer in the medical record.
Incomplete PASRR Review for Resident with Changing Psychiatric Diagnoses
Penalty
Summary
The facility failed to complete an accurate Pre-admission Screening and Resident Review (PASRR) for one resident reviewed. Resident #40 was admitted with diagnoses including dysphagia, depression disorder, bipolar disorder, epilepsy, and gastro reflux disease, and the record showed a new diagnosis of bipolar disease on 01/01/25 and persistent mood disorder on 07/01/20. Review of the PASRR application dated 06/06/19 showed diagnoses of mood disorder and anxiety, but there was no determination notice from the approving agency for the resident’s continued stay in the facility, including a Level II determination, based on that application. The resident’s MDS comprehensive assessment showed intact cognition and maximum assistance needed for ADLs, with setup assistance for feeding and oral care. A later PASRR application dated 04/29/26 listed mood disorder, panic and severe anxiety disorder, personality disorder, bipolar, and persistent mood disorders, and the determination notice from that date showed the resident was referred to a Level II evaluation. During interview, the MDS LPN verified the facility did not receive determination results for the 06/06/19 PASRR and stated the resident had significant diagnosis changes that would require PASRR completion when persistent mood disorder was diagnosed and again when bipolar disease was diagnosed. The MDS LPN stated the PASRRs had not been completed timely and accurately for the resident.
Failure to Apply Ordered Splint and Failure to Report and Assess a Fall
Penalty
Summary
The facility failed to ensure a left wrist splint was ordered and applied for one resident with a history of CVA with left-sided hemiplegia, diabetes, muscle weakness, malnutrition, heart failure, depression, bipolar disease, polyneuropathy, and vascular disease. The resident’s MDS showed intact cognition and moderate assistance needs with ADLs, and the resident used a motorized scooter for mobility. The record included OT splint schedule instructions stating the left wrist splint was to be applied daily for four hours and at night to decrease contractures, and therapy later confirmed there was no change to those instructions. Despite the splint schedule instructions being provided to nursing, there was no active physician order for the left wrist splint in the chart, and staff on day and night shifts stated they had no knowledge the resident was supposed to wear one. Observations on multiple days showed the resident was not wearing the left wrist splint, and the left fingers were contracted and touching the palm of the hand. When OT entered the room, the splint was found sitting on the windowsill and was applied without refusal. The resident stated staff did not ask or attempt to apply the splint and said the resident knew it should be worn at night and some during the day. The facility also failed to report and timely assess a resident after a fall. A resident with communicating hydrocephalus, alcohol use, cognitive communication deficit, and alcohol dependence with intoxication delirium was observed upset and threatening a CNA, with a small bleeding laceration on the head. The CNA later stated the resident had swung at her, missed, and fell to the floor, sustaining the head injury, but she did not alert anyone and the resident was not assessed. The DON stated she was unaware of the fall, and the assigned LPN stated she was never notified. Facility policy required staff to notify the nurse immediately and complete a full assessment when an accident occurs.
Unnecessary Narcotic Pain Medication Administration
Penalty
Summary
The facility failed to ensure residents were free from unnecessary medications when Resident #07 received Roxicodone orders that were not properly limited and were administered outside the ordered pain parameters. Resident #07 was admitted with diagnoses including acute kidney failure and Hodgkin's lymphoma, and the physician ordered Roxicodone 5 mg, two tablets by mouth every six hours as needed for severe pain rated 7 to 10, with an additional instruction to take one to two tablets every six hours as needed for severe pain for up to five days. The April 2026 MAR showed the medication was given seven of 10 times even when the resident’s pain was below 7, including one administration when the resident reported zero pain. The MAR did not show whether one or two tablets were given, and there was no documented non-pharmacological pain intervention ordered or attempted. A later physician order dated 04/15/26 again listed Roxicodone 5 mg, two tablets by mouth every six hours as needed for severe pain, with the same instruction to take one to two tablets every six hours as needed for severe pain for up to five days, but the order did not include a discontinuation or stop date. The April 2026 MAR showed the medication was administered 34 times between 04/15/26 and 04/29/26, including 19 times when the resident’s pain level was below 7 and one time when the resident reported zero pain. The DON confirmed the order should have had a stop date, that the medication should only have been given when pain was higher than 7, and that the MAR did not indicate whether one or two tablets were administered. The report also identified three additional residents ordered narcotic pain medications as having the potential to be affected.
Expired Naloxone Found in Medication Cart
Penalty
Summary
The facility failed to store a medication properly. During observation of the second-floor medication cart for resident rooms 201-214, naloxone nasal spray 4 mg/0.1 ml was found in the cart in a box with an expiration date of 06/2024. The cart contained two units per box, and the expired box was the only one present in the cart. An LPN confirmed the naloxone had expired in 2024 and should not have been in the storage cart ready for use. Resident #9 was admitted with diagnoses including major depressive disorder, anxiety disorder, bipolar disorder, and weakness. The resident had a physician order for naloxone nasal spray 4 mg/0.1 ml, one spray alternating nostrils every three minutes as needed for opioid reversal, with additional doses every two to three minutes if needed. The facility policy titled, Storage of Medications, stated medications and biologicals are to be stored safely, securely, and properly, following manufacturer recommendations or those of the supplier.
Delayed Dental Follow-Up for Needed Oral Surgery
Penalty
Summary
The facility failed to provide timely follow-up for needed dental services for one resident. Resident #40, who was admitted with diagnoses including dysphagia, depression disorder, bipolar disorder, epilepsy, and gastroesophageal reflux disease, had a dental visit report dated 10/27/25 stating the resident needed referral to surgery because the remaining root tips were at or below the level of bone and would require surgical removal by an oral surgeon. The resident’s MDS assessment showed intact cognition, dependence on staff for all ADLs, and a mechanical soft diet. During observation on 04/27/26, the resident was eating a mechanical-soft diet, had no upper teeth, and stated she had been waiting a long time to hear about the recommended mouth surgery and still had pain when eating. On 04/30/26, the MDS LPN verified the facility had not attempted to schedule the oral surgical appointment recommended by the dentist.
Failure to Follow Up on Recommended Oral Surgery
Penalty
Summary
The facility failed to provide or obtain dental services for a resident after a dentist recommended referral to oral surgery for extractions and surgical removal of residual root tips at or below the level of bone. Resident #40 was admitted with diagnoses including dysphagia, depression disorder, bipolar disorder, epilepsy, and gastroesophageal reflux disease. The resident’s MDS assessment showed intact cognition, maximum assistance needed for ADLs, setup assistance for feeding and oral care, and a mechanical soft diet. A dental visit report dated 10/27/25 stated the resident needed referral to an oral surgeon because extractions were needed and residual root tips remained at or below the level of bone, requiring surgical removal and closure. During observation on 04/27/26, the resident was eating a mechanical soft diet, had no upper teeth, and stated she had been waiting a long time to hear about the mouth surgery recommended months earlier. She said the mechanical soft diet helped with mouth pain but she still had pain when eating and did not like needing the diet because the oral surgery had not been completed. On 04/30/26, the MDS LPN verified the facility had not attempted to schedule the oral surgeon appointment recommended by the dentist.
Failure to Follow Ordered Fluid Restrictions
Penalty
Summary
The facility failed to provide fluid restrictions as ordered by the physician for two residents reviewed for hydration. One resident had diagnoses including hypoosmolality and hyponatremia, chronic heart failure, muscle weakness, anxiety, abnormal gait, and cachexia, and was ordered to receive a regular diet with a 1500 mL fluid restriction divided between nursing and dietary. On observation, the resident’s breakfast meal ticket did not list the 360 mL breakfast fluid allowance, and a CNA verified the restriction was not listed on the meal ticket and that CNAs provided fluids from the meal trays. The diet manager later verified there had been no communication about the meal-time fluid restriction until several weeks later, and the DON confirmed the restriction had not been clarified during that period. A second resident with diagnoses including COPD, morbid obesity, and CHF was ordered to receive a carbohydrate-controlled, no-added-salt diet with a 64-ounce daily fluid restriction divided between nursing and dietary. During breakfast observation, the resident’s meal ticket did not list the dietary fluid allowance, and an 800 mL water pitcher was present and filled on the overbed table. A nurse manager verified the resident was on fluid restriction and should not have had a water pitcher at bedside, and the diet manager stated nursing had not sent a diet communication form to clarify the restriction for dietary services. Review of meal tickets showed no fluid restriction listed for any meal, and the DON verified the pitcher should not have been at bedside and dietary should have received clarification for the fluid allowance.
Unclean Shower Chair and Inadequate Cleaning Practices in Shower Room
Penalty
Summary
Surveyors found that the facility failed to ensure the second-floor shower room equipment was clean and in good repair for residents who used that area. Observation of the shower room revealed a single shower chair with a non-movable toilet seat, and under the seat was a section of white PVC pipe covered with brown smeared matter. An LPN confirmed that the chair had been cleaned and verified that the brown smeared matter was fecal matter, and also stated that the shower room and equipment were supposed to be cleaned after each use. In a separate observation and interview, the DON stated that staff providing showers were responsible for cleaning the equipment between residents. This deficiency had the potential to affect 17 identified residents who used the second-floor shower room. The facility census at the time was 72 residents, and the issue was investigated under a specific complaint number related to this non-compliance.
Failure to Notify Residents and Representatives of Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to notify residents or their representatives and invite them to participate in care conferences, as required for development and review of the comprehensive care plan. For one resident with COPD, anxiety, hemiplegia, abnormal posture, and bilateral osteoarthritis, the quarterly MDS showed intact cognition and a need for assistance with ADLs, and the care plan identified the resident as full code with interventions including education of the resident and responsible party and review of advance directives. The face sheet listed the resident as responsible party and identified an emergency contact with power of attorney, yet the care conference signature sheet did not include the resident or representative, and progress notes over several months contained no documentation that the family was notified of the quarterly care conference. The resident reported that only once had the facility called the daughter to talk by phone and otherwise had not invited them to care conferences, and the daughter confirmed she had not received information regarding care conferences. The DON acknowledged awareness that the family wanted notification and that they had reported not being notified of recent care conferences, and the Administrator confirmed there was no documentation of notifications or invitations. For a second resident with type 2 diabetes mellitus, morbid obesity, depressive disorder, panic disorder, and anxiety, the admission MDS showed intact cognition and a need for set-up assistance with eating, toileting, bed mobility, and transfers. Progress notes over several weeks were silent regarding any notification to the resident or representative about participation in care conferences. The DON and Administrator both verified there was no documentation of notification or invitation for this resident, and the resident stated he was not notified of or invited to participate in a care conference. For a third resident with hypertension, COPD, and stroke, the quarterly MDS showed impaired cognition and a need for assistance with eating, bed mobility, transfers, and toileting; the care plan noted impaired cognitive functioning and included interventions to communicate with the resident and family regarding capabilities and needs. The face sheet listed the resident as responsible party with three emergency contacts, but progress notes over several months contained no documentation that the resident or representative was notified of the quarterly care conference. The resident stated the facility would let his family know if something was going on with his health but could not recall receiving notification of care conferences or invitations to participate. The DON and Administrator again verified there was no documentation of notification or invitations for this resident.
Failure to Transcribe and Implement Blood Glucose Monitoring Orders
Penalty
Summary
The facility failed to follow physician orders for blood glucose monitoring for one resident with type 2 diabetes mellitus, morbid obesity, depressive disorder, panic disorder, and anxiety. The resident was admitted from another LTC facility with a discharging physician order dated 10/01/25 for blood sugar monitoring two times a day. The admission MDS showed the resident had intact cognition, required setup assistance for eating, toileting, bed mobility, and transfers, and received insulin injections during the assessment period. However, review of the admission physician orders dated 10/31/25 showed no order for blood sugar monitoring, and the active physician orders did not include blood glucose checks until an order for a daily fasting blood sugar was written on 12/04/25. On interview, the DON confirmed that the blood sugar monitoring order from the prior facility was not transcribed into the electronic health record at admission and acknowledged that it should have been. The DON also verified that no blood sugar checks were completed for this resident from admission until 12/04/25, when the daily fasting blood sugar order was entered. This failure to transcribe and implement blood glucose monitoring orders resulted in the resident not receiving ordered blood sugar checks during that period, as identified under Complaint Number 2662752.
Failure to Provide and Document Toileting and Incontinent Care for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff consistently offered and documented incontinent and toileting care, including refusals, for a dependent resident with bowel and bladder incontinence. The resident had diagnoses including COPD, anxiety, hemiplegia, hemiparesis, abnormal posture, and bilateral osteoarthritis, with intact cognition and a care plan indicating maximal assistance for toileting hygiene using a stand-up lift with two staff. The care plan also included interventions such as application of barrier cream after perineal care, use of disposable briefs, and monitoring for UTIs. The physician orders contained no specific toileting orders. Electronic health record review showed the resident was incontinent daily over a one‑month period with only four continent episodes, and behavior documentation was silent for any refusals or rejection of care. Toileting task documentation showed multiple days where the task was marked as not occurring, and several days where the resident was documented as completing toileting tasks with only supervision, despite the care plan indicating a need for maximal assistance. On the day of surveyor observation, two CNAs offered to take the resident to the toilet, and the resident refused; no further attempts to provide care were observed over the following 2 hours and 15 minutes. The ADON and DON confirmed that toileting documentation for the resident was incomplete, that nurses’ notes lacked detail about what care was refused, and that there was no other documentation showing staff offers of toileting assistance or refusals, despite daily documentation of incontinence without corresponding incontinent care entries. Later that day, the resident was observed wearing jeans with a large wet area from the perineal area to mid‑thighs and reported having been in and out of the facility all day to smoke, stating that staff did not come outside to remind or offer toileting and that she could not transfer herself from the wheelchair to the commode due to left‑sided weakness. Review of the facility’s Activities of Daily Living policy showed that staff were expected to attempt alternative approaches when residents resist care, but this was not followed as written for this resident.
Multiple Medication Administration Errors with Antianxiety Drugs
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered in accordance with physician orders and its own medication administration policy for two residents receiving antianxiety medications. One resident with type 2 diabetes, morbid obesity, depressive disorder, panic disorder, and anxiety had intact cognition and required setup assistance for activities of daily living. This resident had physician orders for clonazepam 1 mg every morning and 2 mg every night. Record review showed clonazepam was generally documented on the MAR as given twice daily in November, but the controlled narcotic count sheets revealed multiple missed and incorrect doses. The 1 mg morning dose was not administered on a specific date when the last available tablet had been given the prior evening, and a refill was pending. The 2 mg bedtime dose was not signed out as administered on several dates, and on another date the resident received two separate 1 mg doses at bedtime instead of the ordered 2 mg tablet. Additionally, the 2 mg clonazepam dose was signed out as administered in the morning on multiple dates, contrary to the bedtime order. The resident reported receiving clonazepam on one night but not at the correct dose and stated the facility did not have the ordered morning dose the following day while waiting for a new prescription. Another resident with chronic obstructive pulmonary disease, respiratory failure, and an anxiety disorder, and with impaired cognition, had an order for Xanax 1 mg by mouth three times daily for anxiety. The MAR for this resident showed Xanax as administered as ordered, but the controlled drug administration record documented administration at times and frequencies that did not match the three-times-daily order. On multiple dates, Xanax 1 mg was given four times in a day or at times inconsistent with the ordered schedule. In interviews, the DON confirmed that for both residents, clonazepam and Xanax were not administered as ordered and that multiple medication administration errors occurred. Review of the facility’s “Administration Procedures for all Medication” policy indicated staff were required to complete the five rights of medication administration, but the facility failed to follow this policy in these instances.
Improper Mechanical Lift Transfer Leads to Resident Fall
Penalty
Summary
The facility failed to ensure proper transfer procedures using a mechanical lift, specifically a Hoyer lift, for a resident. The resident, who was cognitively intact and required substantial assistance for daily activities, experienced a fall during a transfer. The resident's medical history included conditions such as cerebral infarction, hemiplegia, epilepsy, and major depressive disorder. During the incident, the resident was being transferred from a wheelchair to a bed when the CNA, who was alone, did not properly secure the Hoyer pad, resulting in the resident falling backward and landing on her shoulders. The facility's investigation revealed that the CNA conducted the transfer without assistance, which was against the protocol that required two aides to be present for mechanical lift transfers. The Director of Nursing confirmed that the CNA admitted to performing the transfer alone and that the resident reported being dropped due to improper clipping of the Hoyer pad. The incident was documented in a progress note and a post-fall evaluation, both indicating the lack of adherence to safety procedures during the transfer.
Failure to Administer Methadone as Prescribed
Penalty
Summary
The facility failed to administer Methadone as prescribed to a resident, resulting in a significant medication error. The resident, who had a history of paraplegia, opioid abuse, auditory hallucinations, delusional disorders, and congestive obstructive pulmonary disease, was admitted with an order for Methadone 10 mg to be given every 12 hours for pain. However, the medication was not administered on several occasions, specifically on 11/13/24 at 9:00 P.M., 11/23/24 at 9:00 A.M. and 9:00 P.M., 11/24/24 at 9:00 A.M. and 9:00 P.M., and 11/25/24 at 9:00 A.M. and 9:00 P.M. The nursing notes indicated that the Methadone was unavailable and required a signed prescription, which was sent to the physician but not promptly returned. The Director of Nursing confirmed that the medication was not administered as ordered and explained the procedure for when medications are unavailable, which includes checking the Pyxis machine and notifying the practitioner. However, there was a lack of documentation regarding these actions in the resident's record, contributing to the deficiency.
Pest Control Deficiency in Facility
Penalty
Summary
The facility failed to maintain effective pest control, as evidenced by multiple observations of flies and gnats in resident rooms and the kitchen area. On several occasions, flies were seen crawling on meal trays and landing on food, tray tables, and residents' sheets. Residents confirmed the persistent presence of flies and gnats, which interfered with their ability to eat meals without insects landing on their food. Staff members, including a State Tested Nursing Assistant (STNA), also acknowledged the issue, indicating a widespread problem throughout the facility. In the kitchen, flies were observed flying and landing on the steam table during tray line service, and around the dishwasher and three-compartment sink. These observations were verified by the Dietary Supervisor and a Dietary Aide. The facility's Pest Control Policy, dated August 2016, emphasizes the importance of pest control in maintaining a safe and healthy living environment for residents. However, the facility's failure to adhere to this policy resulted in a deficiency that was investigated under specific complaint numbers.
Failure to Provide Resolutions for Resident Council Meetings
Penalty
Summary
The facility failed to ensure that resolutions were provided to residents following Resident Council meetings, potentially affecting all residents who attended these meetings. A review of the Resident Council Minutes from August 28, 2023, through August 30, 2024, showed that while meetings were held, no resolutions to the problems discussed were documented. An interview with the Activity Director (AD) revealed that she had been in her position for three weeks and could not find any resolutions for past meetings. During a Resident Council Meeting, two residents expressed that although meetings were held, their complaints were not addressed, and they did not receive feedback on their concerns in subsequent meetings. The Administrator confirmed that she had not followed up on all concerns from the meetings and had not documented any actions taken. The facility's policy required the use of a Resident Council Response Form to track issues and resolutions, but this process was not followed.
Failure in Medication Regimen Reviews and Physician Response
Penalty
Summary
The facility failed to conduct proper medication regimen reviews by a licensed pharmacist as required, affecting five residents. For Residents #27, #44, #57, #51, and #13, the facility could not provide evidence of a medication regimen review being completed for March 2024. Interviews with the Director of Nursing (DON) confirmed the absence of these reviews, indicating a lapse in the facility's adherence to its medication review policies. Resident #27, with multiple medical diagnoses including cerebral infarction and epilepsy, was found to have no documented medication review for March 2024. Similarly, Resident #44, diagnosed with conditions such as diabetes mellitus type II and Alzheimer's disease, also lacked evidence of a medication review for the same month. Resident #57, who had severe cognitive impairment and a history of chronic conditions like congestive heart failure and myocardial infarction, was similarly affected by the absence of a documented review. Additionally, Resident #51's case highlighted a delay in physician response to a pharmacy recommendation. The resident, with diagnoses including spinal stenosis and feeding difficulties, had a pharmacy recommendation to discontinue a duplicate order for Mirtazepine, which was not reviewed by the physician until 38 days later, exceeding the facility's policy of a 30-day response time. Resident #13, with a range of diagnoses including type two diabetes mellitus and vascular dementia, also had no documented medication review for March 2024, further underscoring the facility's failure to comply with its medication review protocols.
Failure to Provide Residents with Daily Menus
Penalty
Summary
The facility failed to ensure that residents were informed about their daily meals, as evidenced by interviews and observations involving six residents. These residents reported not receiving menus and being unaware of what meals they would be served each day. Observations confirmed the absence of menus in their rooms. This issue was identified during interviews conducted over several days, with residents expressing their lack of knowledge about their meal plans. Staff interviews revealed that the dietary manager and nursing staff were responsible for gathering residents' food preferences and ensuring meals were served according to the menu. However, it was noted that residents did not have the opportunity to choose from the menu, and there was no system in place to provide them with daily menus. This lack of communication and transparency regarding meal options contributed to the deficiency identified by the surveyors.
Failure to Provide Meal Alternatives
Penalty
Summary
The facility failed to ensure that residents were able to choose alternative meals, affecting six out of eight residents reviewed for food alternatives. Observations and interviews revealed that there were no postings for meal alternatives, and residents were not provided with options if they did not like the meals served. Several residents, including Resident #59, #64, #4, #38, #58, and #319, reported being unable to choose from an alternative menu, and no alternatives were observed in their rooms. Staff members, including an LPN and an STNA, were unaware of where the list of alternatives was located, and it was confirmed that it was not posted for residents to see. Additionally, a new admission, Resident #319, did not receive the alternative menu upon admission. In another instance, an STNA delivered a meal tray to a resident who requested an alternative meal. The STNA informed the resident that hamburgers and hot dogs were available as alternatives, but upon returning, only a hamburger was provided as the kitchen did not have hot dogs available. The residents involved confirmed they did not want a hamburger but ate it due to uncertainty about other available options. The facility's policy on offering food replacements at meal times was reviewed, revealing that the director of food and nutrition services is responsible for maintaining a list of meal alternates, which should be provided to the nursing staff. However, the nursing staff was not aware of the available alternatives.
Sanitation Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen, which had the potential to affect 65 out of 66 residents, as one resident had not consumed food from the kitchen. During an observation of the kitchen, a large puddle of dirty water was found bubbling and pooling under the dishwasher, extending to the middle of the walkway between the dishwasher and the three-compartment sink. This was verified by a dietary aide present at the time. Additionally, a dusty vent was observed above the steam table where food is served, and ceiling tiles near the steam table were drooping and discolored. The dietary director confirmed these observations and stated that a leaking roof caused the issues with the ceiling tiles. A review of the facility's undated policy on cleaning and sanitation revealed that staff were expected to maintain the cleanliness and sanitation of dining and food service areas.
Kitchen Equipment Malfunction
Penalty
Summary
The facility failed to ensure that essential kitchen equipment was functioning properly, which had the potential to affect 65 out of 66 residents. Observations made on September 18, 2024, revealed several issues in the kitchen, including a non-functional garbage disposal, a leaking dishwasher, a broken oven and refrigerator, and a three-compartment sink that did not fill and drain properly. Interviews with the dietary staff confirmed these malfunctions. The Dietary Aide mentioned that the dishwasher had been leaking for months, requiring the use of a wet vacuum to drain the sink. The Dietary Supervisor reported that rags were used to keep the sink filled, and the Dietary Director confirmed the broken oven and refrigerator, as well as the non-functional garbage disposal, necessitating the use of trash cans or a wet vacuum for food waste cleanup.
Failure to Provide Adequate Nutritional Care
Penalty
Summary
The facility failed to provide adequate nutritional care and services to prevent a decline in the nutritional status of several residents. Resident #20 experienced significant weight loss and was supposed to receive a health shake three times a day as per physician orders. However, observations revealed that the resident did not receive the prescribed nutritional supplements during meals, and there were no records of weekly weights being obtained as recommended by the Registered Dietitian. The facility had run out of dietary supplements, and the Director of Nursing confirmed that the recommendations for re-weighing and obtaining weekly weights were not implemented. Resident #51 also experienced significant weight loss and was ordered to receive supplements such as Magic Cup and Boost with meals. Observations showed that these supplements were not provided during meals, and weekly weights were not documented as ordered. The facility's dietary staff failed to supply the necessary supplements, and the Registered Dietitian confirmed concerns about the implementation of dietary recommendations and weight monitoring. Resident #44 was ordered a regular diet with double portions and house supplements due to weight loss concerns. However, observations indicated that the resident was served single portions without the required supplements. Similar issues were noted for Resident #3 and Resident #34, where nutritional recommendations, including supplements and weekly weights, were not implemented. Interviews with the Registered Dietitian and the Director of Nursing confirmed the facility's failure to follow through with nutritional care plans and recommendations.
Failure to Serve Meals at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to ensure that meals were palatable and served at appropriate temperatures, affecting 65 out of 66 residents. Observations and interviews with several residents revealed that the food was often cold and not cooked properly. On one occasion, meal temperatures were recorded before the start of meal service, showing that the chicken thigh, mashed potatoes, and green beans were initially at safe temperatures of 184, 183, and 181 degrees Fahrenheit, respectively. However, a subsequent test tray observation showed these items had dropped to 100 degrees Fahrenheit, which was verified by the Dietary Supervisor as below the required 135 degrees Fahrenheit. Additionally, the rice served was found to be undercooked, as confirmed by the Dietary Supervisor. Further observations highlighted delays in meal service, with breakfast trays left unattended in the hallway for an extended period. The meal cart was observed sitting at the end of the hallway without staff present to distribute the trays promptly. It took several minutes before staff began passing out the trays, resulting in scrambled eggs and grits being served at temperatures of 80 and 98 degrees Fahrenheit, respectively. These temperatures were confirmed by the Dietary Supervisor to be unpalatable for residents. The facility's policy required all hot food items to be served at a minimum of 135 degrees Fahrenheit, which was not adhered to in these instances.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for its residents, as evidenced by numerous observations and interviews. Residents reported sticky floors, rust in showers, peeling wallpaper, and cobwebs in their rooms. Several rooms had issues with water damage, improper sealing of windows, and broken blinds. Maintenance and housekeeping staff confirmed these observations, indicating a lack of proper upkeep and cleaning in the facility. In one instance, a resident's room was found to have a strong odor of urine and a mattress with large cuts on its surface. Despite multiple observations over several days, the room's condition remained unchanged, and the Director of Nursing verified the issues. This suggests a failure to address basic hygiene and maintenance needs in a timely manner. Another room shared by two residents was observed to have a large amount of food debris on the floor, black film, and dirt in various areas. The cobase behind one resident's bed had fallen off, exposing the empty space behind the wall. A State tested Nursing Assistant confirmed the room's unclean state, highlighting the facility's inadequate cleaning practices.
Failure to Ensure Accurate Advance Directives
Penalty
Summary
The facility failed to ensure accurate advance directives were in place for two residents, leading to a deficiency in honoring residents' rights to make decisions about their care. For one resident, the medical record showed conflicting information regarding their code status, with both a Do Not Resuscitate (DNR) order and a full code status present in different parts of the record. This discrepancy was confirmed by the Director of Nursing, indicating a lack of clarity in the resident's advance directive documentation. Another resident's records revealed that the facility did not complete the necessary screening for advance directives upon admission. The resident's electronic health record indicated a full code status, but there was no documentation in the paper chart to confirm the resident's preferences or any completed admission documents. This oversight was verified by the Regional Director of Clinical Services, highlighting a failure to adhere to the facility's policy on advance care planning and documentation.
Failure to Hold Required Care Conferences
Penalty
Summary
The facility failed to hold care conferences as required, affecting one resident. Resident #13, who was admitted with multiple diagnoses including type two diabetes mellitus, myasthenia gravis, cardiac murmur, and vascular dementia, had not had a care conference documented in over a year. The quarterly Minimum Data Set (MDS) assessment indicated that Resident #13 had moderately impaired cognition and required assistance with various activities of daily living. Interviews with the resident and the Director of Nursing confirmed the absence of care conferences for months, despite the facility's policy stating that care plan meetings should be scheduled at convenient times for residents and their families.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Fairfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Carecore At The Meadows | 1.7 mi | ★★★★★ | 0 | 0 |
| Maple Knoll Village | 2.4 mi | ★★★★★ | 7 | 0 |
| Majestic Care Of Fairfield Llc | 2.6 mi | ★★★★★ | 18 | 0 |
| Advanced Health Care Of Cincinnati | 3.2 mi | ★★★★★ | 0 | 0 |
| Alois Alzheimer's Care Center | 3.2 mi | ★★★★★ | 2 | 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.