Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ayden Healthcare Of Fairfield during CMS and state inspections, most recent first.
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 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.
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.
A resident with impaired vision and feeding difficulties did not receive necessary assistance with meals, leading to significant food spillage. Despite a care plan requiring meal assistance, staff set up meals and left the resident unattended, failing to provide the needed support.
The facility failed to invite residents to participate in activities, affecting three residents who expressed interest but were not invited. Despite care plans indicating a risk for alteration in activity participation, observations showed no activities taking place as scheduled, and staff interviews revealed a lack of effort in inviting residents. The facility's policy to promote well-being through activities was not effectively implemented.
The facility failed to supervise residents and store smoking materials properly, affecting resident safety. A resident with cognitive impairment was left unattended after a fall, while two others had smoking materials in their rooms against policy. Smoking areas lacked safety equipment, and staff did not adhere to supervision requirements.
A facility failed to maintain communication with a dialysis center for a resident requiring dialysis. Despite the resident's care plan and facility policy mandating communication forms for each dialysis visit, many forms were missing over a three-month period. The ADON confirmed the lapse in completing required documentation, which was against the facility's policy for ensuring safe and coordinated care.
A resident in a facility was affected by inaccurate documentation of medication administration, with duplicate orders for several medications. The MAR showed discrepancies in the administration of Potassium, Tamsulosin, and Omeprazole. Staff interviews confirmed the errors, with an LPN acknowledging the documentation inaccuracies and the DON recognizing the need to correct duplicate orders.
The facility did not conduct 90-day evaluations for STNAs, affecting all residents. Personnel records for two STNAs showed no evidence of evaluations, and the HR Director confirmed they were not completed due to her being new to the position.
The facility did not post daily staffing information for residents and visitors, affecting all 66 residents. An RN confirmed the absence of the staffing posting in its usual location, and it remained unposted throughout the morning.
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 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.
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.
Failure to Assist Resident with Meals
Penalty
Summary
The facility failed to provide timely and necessary assistance with meals to a resident, identified as Resident #51, who required limited assistance due to impaired vision and feeding difficulties. The resident, who had diagnoses including spinal stenosis and serous retinal detachment, was observed on multiple occasions struggling to eat meals independently. Despite having a care plan that included interventions such as explaining tray setup using a clock as a guideline and offering assistance with meals, these measures were not adequately implemented. On several occasions, Resident #51 was observed eating with his fingers or using a regular fork, resulting in significant food spillage on his lap and the floor. Staff members, including a State tested Nursing Assistant (STNA), were noted to set up meals and leave the resident without providing the necessary assistance, despite the resident's confirmed inability to see well enough to feed himself without dropping food. This lack of assistance was confirmed by an STNA who acknowledged the resident's visual impairment and feeding difficulties.
Failure to Invite Residents to Activities
Penalty
Summary
The facility failed to ensure that residents were invited and able to participate in activities outside of their rooms, affecting three residents. Resident #38, who was cognitively intact and dependent on transfers, expressed a desire to participate in activities but was not invited. His care plan indicated a risk for alteration in activity participation, with interventions to familiarize him with the nursing home environment and activity programs. However, his activity participation documentation only included computer, news, and television, and he stated he needed a slide board to get out of bed. Resident #58, also cognitively intact and requiring a two-person assist for transfers, was not invited to activities despite expressing interest. Her care plan similarly noted a risk for alteration in activity participation. Resident #319, who required limited assistance for transfers, was not assessed for activities and had not been invited to participate. Observations revealed no activities taking place as scheduled, and staff interviews indicated a lack of effort in inviting residents to participate. The facility's policy emphasized promoting residents' well-being through activity programming, but this was not effectively implemented.
Inadequate Supervision and Smoking Policy Violations
Penalty
Summary
The facility failed to provide adequate supervision and proper storage of smoking materials for two residents, leading to potential safety hazards. Resident #27, who has a history of cerebral infarction, epilepsy, and other medical conditions, was observed with multiple smoking materials in her room, despite her care plan requiring these to be kept at the nurse's station. Additionally, the designated smoking areas lacked necessary safety equipment, such as fire extinguishers, and Resident #27, a supervised smoker, was found smoking unsupervised in an area designated for independent smokers. Resident #44, who has severe cognitive impairment and a history of repeated falls, was found on the floor in the dining/activity room without staff assistance for eight minutes. Despite multiple staff members walking by, no one responded until a surveyor intervened. The resident was eventually assessed and sent to the emergency room, where no significant injuries were found, but a skin tear was treated upon return. Resident #65, who is cognitively intact, was observed with smoking materials in his room, contrary to the facility's smoking policy that requires such items to be stored at the nurse's station. Although the resident claimed to be an unsupervised smoker, a staff member later confirmed that smoking materials should be kept at the nursing station. These incidents highlight lapses in supervision and adherence to smoking policies, affecting the safety and well-being of the residents involved.
Failure to Maintain Communication for Dialysis Care
Penalty
Summary
The facility failed to maintain proper communication between the facility and the dialysis center for a resident who required dialysis services. The resident, who had diagnoses including pleural effusion, dependence on renal dialysis, and moderate protein-calorie malnutrition, was admitted to the facility and assessed to have moderately impaired cognition. The care plan indicated that the resident was to attend dialysis sessions on specific days of the week. However, a review of the dialysis communication forms revealed that forms were only completed for a few of the dialysis appointments attended by the resident over a three-month period. The Assistant Director of Nursing confirmed that the facility's policy required the completion of dialysis communication forms for each dialysis appointment, which was not adhered to in this case. The facility's policy, reviewed in August 2024, emphasized the importance of collaboration with the dialysis center and required an assessment of the resident before and after each dialysis visit. Despite this policy, numerous communication forms were missing, indicating a lapse in the facility's adherence to its own procedures for ensuring safe and coordinated dialysis care.
Medication Administration Documentation Deficiency
Penalty
Summary
The facility failed to ensure accurate documentation of medications administered to a resident, which was identified during an annual survey. This deficiency affected one resident who had duplicate medication orders for Guaifenesin, Glucagon, Loperamide, Omeprazole, Potassium, and Tamsulosin. The resident, who had diagnoses including spinal stenosis, serous retinal detachment of the right eye, and feeding difficulties, was assessed to have intact cognition. The Medication Administration Record (MAR) showed that Potassium and Tamsulosin were documented as being administered twice at the same time each day, and Omeprazole was documented as being administered at both 6:00 A.M. and 7:30 A.M. each day. Interviews with staff confirmed the discrepancies in medication administration. An LPN confirmed that only one dose of Potassium and Tamsulosin was administered, despite documentation indicating two doses. Additionally, the LPN confirmed that Omeprazole was administered and documented twice due to shifts overlapping. The Director of Nursing acknowledged the presence of duplicate orders for the medications and confirmed the need for correction.
Failure to Conduct 90-Day Evaluations for STNAs
Penalty
Summary
The facility failed to ensure that State tested Nurse Aides (STNA) received a 90-day evaluation, affecting all residents in the facility with a census of 66. Personnel records for two STNAs, both hired on the same date, showed no evidence of a 90-day evaluation being conducted. An interview with the Human Resource Director confirmed that the evaluations had not been completed, as she was new to the position.
Failure to Post Daily Staffing Information
Penalty
Summary
The facility failed to ensure that daily staffing information was posted for residents and visitors to view, which had the potential to affect all 66 residents residing in the facility. On the morning of September 15, 2024, an observation revealed that no daily staffing information was posted in the facility. A subsequent observation and interview with a registered nurse confirmed that the plastic holder, where the staffing information is usually placed, was empty, and the nurse was unable to locate the staffing posting to place in the holder. Further observation later that morning confirmed that the staffing information had still not been posted in the designated holder or any other conspicuous area of the facility.
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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 | ★★★★★ | 2 | 0 |
| Majestic Care Of Fairfield Llc | 2.6 mi | ★★★★★ | 0 | 0 |
| Advanced Health Care Of Cincinnati | 3.2 mi | ★★★★★ | 1 | 0 |
| Alois Alzheimer's Care Center | 3.2 mi | ★★★★★ | 7 | 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 July 2026) and official state health department websites.