Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Country Club Center I during CMS and state inspections, most recent first.
A resident with COPD, OSA, diabetes, and other chronic conditions experienced several days of urinary symptoms, not feeling well, poor intake, and refusal to get out of bed, which CNAs reported to nurses without evidence of a comprehensive assessment or timely provider notification specific to these complaints. The resident had prior NP orders for respiratory and antifungal treatments and later for a CXR, labs, Doxycycline, DuoNebs, and BID VS with parameters for notifying the provider, but there was no documentation explaining the rationale for these orders, no nursing or NP progress notes describing assessments, and no evidence the provider was notified of abnormal CXR findings. On the morning of the acute event, an RT and an RN documented fever of 102.1°F, HR 138, RR 24, SpO2 83% on RA, and bilateral rhonchi; oxygen, additional antibiotics, Tylenol, labs, and q4h VS were ordered, yet there was no subsequent documentation of the ordered VS monitoring or increased observation and interventions. Over ten hours later, an LPN starting the evening shift found the resident unresponsive-appearing, lethargic, hypotensive (55/31), febrile, with irregular respirations and on 3 L/min O2, prompting EMS transfer; hospital records showed severe septic shock, pneumonia, UTI, and acute hypoxic respiratory failure requiring ICU care. Surveyors found that nursing staff failed to follow ordered VS monitoring and that the facility did not ensure timely, comprehensive assessment and effective intervention for the resident’s change in condition, resulting in Immediate Jeopardy and actual harm.
The facility failed to protect a dependent, hemiplegic resident from a known aggressive roommate who had previously threatened to kill him over TV volume. Staff initially moved the aggressive resident to another room after he threatened to shoot his roommate, but, on direction from the DON and despite staff objections and the aggressor’s documented history of verbal and physical aggression, the two residents were placed back together without updating care plans or increasing monitoring. The aggressive resident later struck his roommate while he was in bed, causing bruising to the shoulder and arm and leading to fear, withdrawal, and self‑isolation. Documentation minimized the event as a verbal altercation, there was no timely evidence of physician or family notification, and the victim reported that no one followed up with him for a statement or investigation, contrary to the facility’s abuse policy requirements.
Failure to Provide Ordered Pain Management: The facility did not ensure ordered pain meds and comfort measures were provided for residents with chronic and acute pain. One resident missed a pregabalin taper dose and had severe neuropathic leg pain with crying, restlessness, and nausea; another had gabapentin and scheduled Norco omitted or delayed despite chronic pain and repeated missed doses; a third had fall-related hip/thigh pain, but ordered Tylenol ES and cold compresses were not documented as given.
The facility failed to maintain sufficient nursing staff to meet residents’ care needs, resulting in prolonged call light response times and missed ADL care, including bathing and toileting. On survey entry, staffing levels were significantly below the facility’s own assessment and staffing plan. Several residents reported waiting from 30 minutes up to two hours for call lights to be answered, remaining on bedpans for extended periods, becoming incontinent while waiting for assistance to the bathroom, and rarely being transferred into wheelchairs due to lack of staff. Staff described chronic understaffing, difficulty completing expected showers, and being told not to shower residents requiring mechanical lifts due to time constraints. Record reviews showed multiple residents with complex medical conditions and documented needs for assistance with bathing and hygiene who received far fewer showers than scheduled, with refusals not followed by documented interventions. Call light audits confirmed numerous response times over 30 minutes, some exceeding two hours, consistent with resident and staff reports of inadequate staffing.
Failure to address resident council and grievance concerns: The facility did not timely respond to resident concerns about dietary service, housekeeping, and staffing. Grievances were documented as resolved through staff education, but the facility could not produce the training records when surveyors asked. During an observed resident council meeting, residents said management did not listen, concerns were swept under the rug, and care and cleanliness were poor due to inadequate staffing. A resident also reported that the DON avoided speaking with him and left the building rather than hear his concerns.
Food and drink were not served at safe, appetizing temperatures. A resident reported meals were often cold because trays took too long to arrive, and two residents received room trays with food measured at 132 degrees Fahrenheit and 110 degrees Fahrenheit, respectively, with one stating the food was cold and did not taste good. A test tray also showed soggy, mushy, partially frozen, and flavorless food, while CNA and Dietary staff described the room-tray delivery process as disorganized, slow, and chaotic.
Improper Food Storage and Missing Hair Restraints. A dietary aide was observed without a hair restraint while working at the steam table, and the ADM confirmed hair restraints were not available in the kitchen. Food storage issues were also observed, including opened items that were not sealed or dated, hard boiled eggs not sealed or dated, expired carrots in the walk-in cooler, and opened hash browns in the freezer. The ADM confirmed the items were expired or not properly dated and sealed.
Surveyors found that multiple resident rooms had blue carpeting that was visibly stained, torn, snagged, and dirty, with damage and discoloration apparent from the hallway. A CNA reported that several carpeted rooms were not well kept and that prior attempts to clean the carpets with bleach had caused some of the staining, particularly in rooms that still had blue carpet rather than wood flooring. The Regional Maintenance Director confirmed that the carpets in these rooms needed replacement and noted that one apparent stain might actually be feces requiring prompt cleaning. Review of the facility’s room cleaning policy showed it addressed general room cleaning and disinfection but did not include any process for cleaning or maintaining resident room carpeting.
Multiple residents with significant medical conditions and documented dependence on staff for ADLs did not consistently receive scheduled showers or baths, and staff failed to document refusals or encouragement efforts as required by care plans and policy. Residents with osteomyelitis, diabetes, Parkinson’s disease, dementia, and other chronic conditions reported wanting showers but described staff saying they did not have time, or only washing limited body areas instead of providing full showers. Observations noted residents with disheveled, dirty hair, soiled clothing, and body odor, while records showed infrequent showers, unclear documentation of whether showers or bed baths occurred, and several missed scheduled bathing days. CNAs and an RN reported that residents were not getting showers per their preferences or care plans, cited inadequate staffing, and described being told not to shower residents requiring mechanical lifts, despite the presence of lift equipment, all contrary to the facility’s ADL policy requiring maintenance of grooming and personal hygiene.
The facility failed to prepare and provide food in the correct pureed consistency for several residents with physician-ordered pureed diets. During a lunch meal observation, pureed rice on the steam table was found to be gritty with large clumps instead of smooth, and the Dietary Supervisor confirmed it was not the correct puree texture. Review of the diet list showed multiple residents were ordered pureed diets, and facility policy defined therapeutic diets, including texture-modified diets, as physician- or practitioner-ordered as part of treatment for clinical conditions.
Failure to Maintain Resident Privacy During Assessments, Insulin Administration, and Record Access: A NP assessed three residents in a public dining area with other residents and staff nearby, and an RN performed blood glucose testing and gave insulin to a resident at a dining table while the resident was eating. In a separate event, an open eMAR on a med cart exposed residents' names, photos, and room numbers until the DON closed it; staff confirmed the privacy breaches.
Physician-ordered BP parameters were not followed for Midodrine administration for five residents. Residents with diagnoses including Parkinsonism, cerebrovascular disease, MS, dementia, respiratory failure, and COPD had orders to hold Midodrine above specific SBP or DBP limits, but MAR review showed the drug was repeatedly given when those limits were exceeded. An RN confirmed multiple administrations occurred when the ordered vital sign parameters were not met, and the facility policy required ordered monitoring parameters to be checked before med administration.
Incomplete flu and pneumococcal vaccination records were found for multiple residents. Records showed vaccinations or refusals without required consents, completed screening, VIS documentation, resident education, or proper signatures; in one case, a resident with multiple serious diagnoses had a flu form with blank screening questions and no resident or representative signature, while the DON signed the form.
Incomplete COVID-19 vaccination education and documentation were found for multiple residents and staff. Several residents had vaccine or refusal records with missing consent, incomplete screening questions, blank VIS dates, or unclear documentation of refusal versus administration, and the facility could not provide evidence that staff were offered COVID-19 vaccination or received related education.
Two moderately cognitively impaired residents sharing a room, one with left-sided hemiparesis, anemia, and on aspirin therapy, were involved in a physical altercation after ongoing conflict over TV volume. One resident later reported that his roommate came through the privacy curtain and hit him while he was in bed, and staff interviews indicated the aggressor had a history of verbal/physical aggression and admitted to slapping the other resident on the head or shoulder. Initial documentation by the DON, who was not on-site, characterized the event as only a verbal dispute, and the Administrator was informed there was no physical contact, so the incident was not promptly reported to the state agency. There was no timely documentation of physician or family notification, no immediate staff statements were obtained, and no investigation was completed within the facility’s abuse policy timelines, despite later observation of bruising on the injured resident and subsequent grievance interviews confirming physical contact.
Two residents with a history of conflict over TV volume, one highly dependent with hemiplegia and bleeding risk and the other with documented aggressive behaviors, were placed together in a shared room despite prior threats by the more independent resident to shoot his roommate. The dependent resident later reported being punched or slapped while in bed, and the aggressive resident admitted to hitting him, with staff observing the dependent resident as scared and later noting bruising to his shoulder and arm. However, the DON’s late entry progress note minimized the event as a verbal dispute with no harm, no timely injury assessment or witness statements were obtained, CNAs were not asked for statements, and there was no documented, timely abuse investigation as required by the facility’s abuse policy, resulting in a failure to thoroughly investigate the abuse allegation.
Surveyors found that the facility failed to ensure a comprehensive discharge process for a resident with multiple complex conditions and an active plan to return to the community, as the care plan was not updated to reflect discharge planning, the discharge summary lacked a reconciled medication list, and there was no documented evidence that prescriptions were accurately provided or transmitted at discharge. In addition, another cognitively intact resident who was transferred to the hospital and later readmitted had no documentation that they or their representative received a required bed-hold notice or were offered the option to hold the bed, contrary to facility policy.
Surveyors found that the facility did not consistently review and revise care plans and discharge plans to reflect residents’ current needs and status. One resident with multiple chronic conditions had a care plan that still addressed infection risk from an indwelling catheter long after the catheter had been discontinued, and the care plan and active orders continued to require mechanical lift transfers even though the resident had been independently transferring for about two weeks per therapy direction. Another resident, cognitively intact and working toward discharge, had a discharge planning care plan that continued to list long-term placement due to needs exceeding community resources and was never updated to show that staff were actively assisting with discharge back to the community; the plan was only cancelled after the resident left the facility.
Surveyors found that the facility failed to provide adequate ADL support and honor bathing preferences for two residents who were cognitively intact and required staff assistance with bathing. One resident, who preferred morning baths and was care planned to be kept clean, dry, and odor free, received only a few baths during a month, with no documented refusals and an instance where she only received a sponge bath late in the evening after repeatedly asking for a bath. Another resident, who preferred bed baths and refused showers, had an ADL care plan that was not revised to reflect specific bathing preferences or frequency, and documentation showed inconsistent bathing intervals and at least one shower given despite the stated preference. Staff interviews confirmed that care plans did not accurately reflect these residents’ bathing preferences or needed frequency of care.
Surveyors found that the facility failed to provide an ongoing, individualized activity program consistent with residents’ assessed preferences and the facility’s own policy. Two residents with multiple comorbidities had detailed activity assessments and care plans listing interests such as one-on-one visits, bingo, music, religious practices, social events, and other pursuits, yet their records showed only a few brief one-on-one contacts and long gaps with no documented activities. Activity calendars lacked scheduled one-on-one sessions for certain months, offered limited variety, and posted calendars were not always within residents’ view, resulting in residents spending extended time in their rooms without engagement despite documented goals and interventions for activity participation.
The facility failed to ensure safe mechanical lift use and accessible call lights for residents at risk of falls. A resident with dementia, severe ADL dependence, and a history of falls was transferred with a mechanical lift when she slid out of the sling and ended up on the floor; staff selected sling sizes visually or by weight alone, without documented measurements or sling size in the record, despite manufacturer instructions requiring proper sizing and use of compatible slings. Another dependent resident was observed being transferred in a mechanical lift with the brakes unlocked, and the CNA operating the lift acknowledged both the failure to lock the brakes and the lack of Hoyer training. Multiple CNAs and the PT reported that mechanical lift training and return demonstrations had not been provided as described by leadership, and there was no documentation of annual lift training, contrary to facility policy. In a separate incident, a resident with a recent fall and hip fracture, care-planned for fall risk with an intervention to keep the call light within reach, was observed with the call light in a bag on the bedside table and unable to reach it, which was confirmed by the CNA at the bedside.
A resident admitted with multiple conditions, including lung cancer, COPD, paroxysmal A-fib, diabetes with polyneuropathy, and a UTI, had detailed hospital discharge orders for several medications such as Betapace, Carafate, Lotrisone cream, Macrobid, Lantus insulin, Nystatin, Gabapentin, and PRN albuterol-budesonide. Although an NP reviewed and approved these orders on admission, facility records showed they were never transcribed into the electronic system or administered, and the resident did not receive ordered insulin or antibiotics during the assessment period. An RN confirmed the orders were “missed” despite an expectation that the DON would perform a second check of new admission orders, contrary to the facility’s admission policy requiring review of all transfer information and orders.
Surveyors found that the facility failed to maintain accurate and complete medical records related to both abuse and accident events. In one case, a dependent resident with hemiparesis and moderate cognitive impairment reported being punched by a roommate who had a documented history of verbal and physical aggression, including threats to kill him; staff accounts described prior threats, room changes, and a later physical assault, while the DON, who was not on-site, entered a late note describing only a verbal dispute with no harm and initially characterized the event to the Administrator as non-physical. In another case, a cognitively impaired, fully dependent resident was reportedly lowered to the floor during a Hoyer transfer, but later complained of significant thigh pain and stated she had actually fallen; an anonymous staff member reported the resident fell out of the lift and that leadership directed staff to document that she was lowered, and there was no post-fall documentation or entry on the incident log despite an on-call provider treating the situation as a new fall.
Failure to Maintain Resident Dignity During Bed Care: A resident with dementia, severe cognitive impairment, and total ADL dependence was observed lying in bed with her pants pulled down around her heel boots. The CNA confirmed this was done routinely to avoid wet clothing and make later care easier, and acknowledged it was not a dignified way for the resident to lie in bed and could make movement difficult.
The facility failed to notify residents of a change in Medical Director or give them a choice of physician, and failed to respect a resident’s choice in diabetes management. A resident with type 2 DM and other significant diagnoses had his continuous glucose monitor removed without documentation of notification, rationale, or choice, and staff confirmed residents were automatically changed to the new MD without being asked if they wanted to keep their current physician or choose another provider.
Failure to Provide Written Notice for Room Changes: The facility did not give two residents advance written notice explaining room changes or roommate reassignment. One resident had behavioral concerns and was moved so another resident could be placed in the room, but was only told verbally at breakfast. Another resident had two room changes documented with no written explanation provided. The facility policy required a Notice of Room or Roommate Change with the reason for the move and resident/staff signatures.
A resident admitted with hip fracture, metabolic encephalopathy, anxiety, and HF had conflicting code status records, including Full Code orders/forms, a spouse-signed but physician-unsigned DNRCCA form with an incorrect year, and a hospice-faxed DNRCC form. The resident’s care plan listed Full Code/CPR, and an RN confirmed the hospice DNRCC had not been transcribed or ordered at the facility when received.
Failure to issue beneficiary notice for a resident with planned therapy discharge. A resident with CVA, HTN, and neurogenic bladder progressed through OT, completed a home assessment and transfer training, and was discharged home with home health services after meeting goals. SSD said she did not think a liability notice was needed because the resident wanted to go home, while the Therapy Manager confirmed it was a planned discharge and the resident had not left AMA or run out of skilled days.
Inadequate indication for antipsychotic use: A resident who was cognitively intact and had no mood, psychosis, or behavioral symptoms was given Abilify 20 mg daily for mood/anxiety/depression without an approved diagnosis. The MAR showed daily administration with no documented behaviors, and an RN confirmed the resident lacked an approved indication for the antipsychotic.
Delayed Admission MDS Assessment: A resident admitted with septicemia, UTI, and HTN did not have the admission MDS completed within the required timeframe. Review showed the assessment was not submitted until late, and the Administrator confirmed it was missed.
The facility failed to accurately complete resident assessments for three residents. One resident was coded on the MDS as having a Stage III pressure ulcer present on admission even though the DON verified the skin was intact at admission and the ulcer developed later. Another resident was coded as receiving opioids and scheduled pain meds, but the MAR showed Norco was not administered during the reference period and an NP noted chronic pain with unstable pain control. A third resident’s BIMS score was entered late, resulting in an inaccurate score of zero.
The facility failed to notify the appropriate state agency for PASARR evaluation after a resident developed new mental health diagnoses. The resident was admitted with chronic respiratory failure, CHF, ESRD, and DM, and the MDS showed cognitive intactness, a psychotic disorder, and antipsychotic use without a serious mental illness requiring Level 2 screening. The record later added bipolar disorder, MDD, GAD, and schizoaffective disorder, bipolar type, but there was no evidence of a Resident Review being submitted after the resident's mental health decline was identified, and the DON verified this.
Baseline care plan not provided or acknowledged. A resident admitted with multiple chronic conditions, including DM, emphysema, HF, Afib, sleep apnea, HTN, and neuropathy, had intact cognition on the admission MDS. The resident stated he had not received a care conference, discharge planning meeting, or a copy of the baseline care plan. An LPN verified the baseline care plan lacked the resident’s signature and acknowledgement and was not dated by the DON.
Failure to Implement Pressure Ulcer Prevention Measures: A resident with CVA, hemiplegia, CHF, malnutrition, cognitive impairment, and incontinence was admitted with intact skin and assessed as at moderate risk for skin breakdown. The care plan did not include effective preventative skin interventions, and there was no documented turning/repositioning program or wheelchair pressure-relieving device in place. The resident later developed MASD to the sacrum and then a Stage III sacrum/right upper buttock pressure ulcer, while the MDS was incorrectly coded as showing the ulcer present on admission.
A resident with lung cancer, COPD, and OSA was ordered daily O2 and nightly BiPAP, but the facility did not establish the respiratory orders on admission and did not document BiPAP settings for weeks. The resident reported the BiPAP did not feel hooked up correctly, including the oxygen bleed-in, and an RN confirmed the resident did not receive BiPAP as ordered for seven days and that there was no documented RT evaluation.
Infection Control Lapse During Dressing Change: An LPN and the ADON failed to follow infection control procedures during a resident’s dressing change. Supplies were placed on the resident’s bed and bedside table without a barrier, an empty trash bag was placed on the floor, and the bag containing used dressing materials was later placed on the resident’s bed. The resident had an open wound, a vascular access device, dialysis orders, and enhanced barrier precautions for wound care.
Survey Results Not Readily Available for Review: The facility failed to keep completed survey results readily available for resident review. The Survey Results Book was observed near the reception area, but it did not include two complaint surveys that had deficiencies issued. The DON confirmed the surveys were missing, affecting all 52 residents.
A resident with diabetes, impaired cognition, decreased mobility, and incontinence, identified as at risk for skin breakdown, developed a new buttock pressure area that was documented as a small, painful open area but not followed by timely treatment orders or accurate documentation of wound location. For three days after the wound was first identified, no physician orders or specific interventions were implemented, and later NP wound care orders were delayed and in some cases incorrectly transcribed, while a wound culture result was never obtained or followed up. The wound progressed to an unstageable and then Stage III pressure ulcer with undermining, and the resident reported that dressings frequently fell off and were not consistently replaced. An RN was observed performing a dressing change without cleaning a visibly soiled overbed table, placing clean supplies and scissors on the dirty surface, and then using the contaminated scissors to cut and apply the dressing, contrary to facility wound care policy.
A resident with multiple complex conditions, including ESRD on dialysis, COPD, traumatic brain injury, and depression, requested help from CNAs to return to her room after dinner. One CNA stated she was busy passing trays, and another CNA used an expletive in connection with the request in front of the resident and others, which the resident reported as being directed at her and causing embarrassment and emotional distress. Witness accounts and the CNA’s own statement confirmed that the expletive was used within earshot of the resident. The resident reported crying herself to sleep afterward, yet nursing notes contained no documentation of the incident or of emotional support or counseling, despite a facility abuse policy that guarantees residents freedom from abuse, including verbal and emotional abuse.
A resident with intact cognition and multiple chronic conditions, including respiratory failure, COPD, PVD, DM, CKD, bipolar disorder, GAD, lymphedema, and gout, was observed to have their room door opened by maintenance staff without a prior knock while the staff member was performing fire watch rounds. The staff member acknowledged not knocking before entering. Facility policy on resident rights states that residents have the right, upon reasonable request, to have room doors closed and not opened without knocking, except in emergencies or when medically inadvisable as documented by the attending physician. No such exception was documented for this resident, resulting in a violation of the resident’s privacy rights.
Residents reported and records confirmed significant delays in call light response times, with some waiting over an hour for assistance. Despite staff education on timely response, there was no evidence of follow-up or monitoring, and grievances about the issue remained unresolved, affecting multiple residents.
Staff failed to follow infection control protocols during care for two residents, including not performing hand hygiene after glove removal and after contact with contaminated surfaces. These lapses occurred during wound care and incontinence care, despite facility policy requiring hand washing after glove removal and handling contaminated objects.
Multiple residents reported that their food was sometimes or always cold, and direct observation of meal service confirmed that hot foods dropped below required holding temperatures before being served. A test tray measured significantly below the facility's policy standard, and the food was confirmed to be cold by both thermometer and taste test, in violation of USDA guidelines and facility policy.
A resident with multiple chronic conditions and impaired cognition was not provided with a timely orthopedic referral as ordered, despite experiencing significant knee pain and awaiting further assessment. The facility administrator confirmed the appointment was not scheduled during the resident's stay.
A resident's room was found to be unclean and disorganized, with an empty medication cup on the floor, a basin containing a dried dark substance, clothes on the floor, brown discoloration and stool splatter on the toilet, and a suction machine container with a dried yellow substance. These conditions were confirmed by the Regional Maintenance Director during a facility tour.
A registered nurse failed to wear a gown, as required by Enhanced Barrier Precautions, while changing the dressing of a resident with a jejunostomy tube and recent tracheostomy removal. The resident's room had an EBP sign posted, and the facility's policy mandated both gown and glove use for high-contact care activities. The nurse acknowledged not following the policy during the observed dressing change.
The facility failed to serve meals at palatable temperatures, affecting all 55 residents. Multiple residents reported their meals were consistently cold. Observations confirmed that food temperatures dropped significantly by the time they were delivered. The Dietary Supervisor acknowledged the issue, and previous complaints about cold meals were noted in the facility's concern log.
The facility failed to maintain sanitary conditions in food storage and preparation, affecting all residents receiving meals. Observations revealed unlabeled and undated food items, inadequate sanitation practices, and a dish machine not meeting temperature requirements. Sanitation audits consistently scored below the desired goal, indicating ongoing issues with cleanliness and food storage practices.
The facility failed to maintain a clean and sanitary dumpster area, with debris including a Styrofoam plate, surgical gloves, and plastic utensils observed around the dumpsters. The Dietary Supervisor confirmed the debris, and a previous sanitation audit noted the area as unacceptable. The facility's policy prohibits trash on the ground.
The facility failed to provide appropriate diet consistency for residents on mechanically altered diets. A resident on a pureed diet received non-pureed potatoes, while another on a mechanical soft diet was served an intact hotdog. Two other residents received meals not consistent with their dietary needs. The dietary staff lacked guidance on diet consistencies, leading to these errors.
Failure to Monitor and Respond to Acute Change in Condition Leading to Septic Shock
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately assess a resident with multiple chronic conditions and to respond appropriately to an acute change in condition. The resident had diagnoses including GERD, hyperlipidemia, hypothyroidism, chronic gout, fatty liver, intellectual disabilities, OSA, COPD, fibromyalgia, insomnia, anxiety, diabetes mellitus, and panic disorder. Her care plan identified a potential for altered respiratory function related to COPD and OSA, with goals to prevent respiratory distress and infection, and interventions such as auscultating lung sounds, elevating the head of bed, encouraging fluids, coughing and deep breathing, and obtaining vital signs and pulse oximetry as ordered and as needed. Despite these identified risks and interventions, the facility did not ensure comprehensive assessment and monitoring when the resident’s condition changed. In the days leading up to the hospitalization, the resident and CNAs reported symptoms consistent with infection and decline. The resident stated she had a UTI for approximately two weeks and that she complained for four to five days of being unable to void and feeling unwell, but felt no one listened. CNAs reported the resident complained of itching, burning, frequent urge to urinate, not being cleaned or changed enough, not eating, and not getting out of bed, which was a change from her usual routine of getting up around the same time daily and walking to the bathroom. Staff reported these concerns to nurses and were told the resident would be given medications and monitored, but there was no evidence in the record that these complaints triggered a comprehensive nursing assessment or timely provider notification specific to these urinary and systemic symptoms. Provider orders were obtained on multiple occasions without corresponding documentation of assessment or rationale. On one date, the NP ordered Mucinex and percussive ventilation, and on another date ordered Diflucan and nystatin powder, both without any nursing or NP progress notes explaining why the orders were given or documenting a comprehensive assessment. Later, the NP ordered a chest x-ray, CBC, BMP, COVID test, Doxycycline, scheduled DuoNebs, and BID vital signs with specific parameters for notifying the provider if temperature, blood pressure, pulse, respiratory rate, or SpO2 were outside defined ranges. The chest x-ray subsequently showed diffuse bilateral lower lung opacities suggestive of pulmonary edema, atelectasis, and/or pneumonia, but there was no evidence the provider was notified of these abnormal results. The NP also documented the resident had respiratory congestion, increased temperature, and decreased oxygen saturation, and ordered monitoring of vital signs with instructions to alert the provider if changes were noted, but the facility did not document the required ongoing monitoring or follow-up. On the morning of the acute event, the respiratory therapist and an RN documented that the resident was febrile with a temperature of 102.1°F, tachycardic with a heart rate of 138, respiratory rate of 24, and SpO2 of 83% on room air, with bilateral rhonchi. The resident was placed on 3 L/min oxygen via nasal cannula, and the NP ordered Augmentin in addition to existing Doxycycline, Tylenol, laboratory tests, and vital signs every four hours for 24 hours. There was no documented rationale for adding a second antibiotic or a medical diagnosis to support the treatment, and no documentation that the abnormal vital signs were otherwise addressed beyond ordering Tylenol. After an 8:12 A.M. note showing post-nebulizer SpO2 of 91%, heart rate 121, respiratory rate 24, and persistent bilateral rhonchi, there was no documentation of the ordered q4h vital signs, no evidence of increased monitoring, and no documentation of interventions such as encouraging fluids, deep breathing, or upright positioning. More than ten hours later, an LPN starting the evening shift found the resident in a markedly worsened state. The LPN reported that the off-going nurse described the resident as sick but fine, yet upon walking rounds the LPN observed the resident with eyes rolled back, unresponsive, visibly lethargic, with irregular respirations and increased difficulty breathing. Vital signs at that time showed hypotension with a blood pressure of 55/31 mm Hg, temperature 102.3°F, heart rate 94, SpO2 90% on 3 L/min oxygen, and a mean arterial pressure of 39. EMS was called and the resident was transferred to the hospital. The facility’s own review concluded that nursing staff failed to follow the NP’s order for every four-hour vital sign monitoring, resulting in the resident’s decreasing blood pressure and declining condition not being recognized until the evening, and the surveyors determined that the facility failed to ensure the resident was comprehensively assessed and provided timely, necessary, and effective intervention in response to her change in condition. Hospital records documented that the resident was admitted with severe septic shock, acute cystitis, pneumonia, UTI, acute kidney injury, and acute hypoxic respiratory failure, requiring ICU-level care, vasopressor support, BiPAP, central venous catheter placement, and multiple IV antibiotics. The resident later reported that the emergency room physician told her it was almost too late and that she would have expired, and she described the experience as very traumatic. The facility census at the time was 52 residents, and this deficiency affected one resident reviewed for change in condition. The surveyors determined that the facility’s failure to timely and accurately assess the resident and respond to her acute change in condition resulted in Immediate Jeopardy and actual harm.
Failure to Protect Resident From Known Aggressive Roommate Resulting in Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse by not implementing appropriate interventions after clear threats and known aggressive behavior, which led to a resident‑to‑resident physical assault. One resident with left‑sided hemiplegia, significant dependence on staff for ADLs, and a care plan goal to remain free from bruising and injury was verbally threatened by his roommate, who stated he would kill or shoot him over TV volume. Staff, including a CNA and the Social Services Designee (SSD), were aware of the threat, and the aggressive resident was initially moved to a private room. Despite this, the DON later directed that the aggressive resident be returned to the same room, without documented assessment of the threatened resident’s feelings of safety, without documented room‑change orders, and without updating either resident’s care plan or instituting increased monitoring or other protective interventions. Multiple staff interviews confirmed that the aggressive resident had a history of verbal and physical aggression, including prior physical assault of staff and specific threats to choke, shoot, or kill his roommate. Staff voiced concerns to management that returning the aggressive resident to the same room was unsafe, particularly because the threatened resident was physically dependent and unable to defend himself. Nonetheless, the residents were placed back together. On the night of the incident, staff reported that the aggressive resident punched or slapped his roommate while he was lying in bed, with his affected left side toward the aggressor. The victim later described being hit in the left shoulder while dozing, and the aggressor admitted to hitting him in the head or shoulder after becoming angry about language used by the roommate. Following the altercation, the victim reported pain and later exhibited a yellow‑green bruise on the left bicep and a quarter‑sized bruise on the left shoulder, which he attributed to the assault and which a CNA verified. Progress notes and interviews showed that the DON, who was not present at the time of the incident, authored a late entry describing only a verbal altercation and initially reported to the Administrator that there had been no physical contact. There was no timely documentation of family or physician notification regarding the victim being hit, and the victim stated that no one followed up with him for a statement and that he was unaware of any investigation. Staff also reported that they were not asked to provide statements at the time of the incident. The facility’s own abuse policy required immediate protection of residents, reporting to the Administrator and state agency, thorough investigation, documentation, and care plan review and revision, but the report shows that these steps were not carried out in connection with the threats and subsequent physical assault between these two residents. The aggressive resident’s record documented a care plan for inappropriate behaviors, including verbal and physical aggression and delusions, with goals of no injury to self or others and interventions such as documenting behaviors and redirecting him. A progress note documented that he had threatened to shoot his roommate over TV volume, and the on‑call physician ordered medication and increased checks. However, there is no evidence that this known risk was translated into sustained environmental or supervision interventions to prevent further conflict, nor that the threatened resident’s vulnerability and bleeding risk were incorporated into protective planning. Staff accounts consistently indicated that the decision to reunite the residents in the same room, despite prior threats and staff objections, directly preceded the physical assault that caused bruising and psychosocial harm, including fear, withdrawal, and self‑isolation in the victim.
Failure to Provide Ordered Pain Management
Penalty
Summary
The facility failed to provide safe, appropriate pain management for residents who required it, affecting three residents reviewed for pain. The report states that effective pain management interventions were not implemented to adequately control resident pain, including failures to administer ordered medications, failures to transcribe or obtain ordered medications, and failures to provide non-pharmacological interventions when pain was reported. For one resident with chronic respiratory failure, end stage renal failure, diabetes with neuropathy, and dialysis dependence, the facility did not ensure the ordered Lyrica taper was available when the dose was reduced. The resident had been receiving pregabalin for neuropathic pain and was ordered to taper from 75 mg twice daily to 50 mg twice daily, then to 25 mg twice daily. The next dose was not available because the pharmacy had not received the prescription, and there was no evidence the physician, NP, or on-call provider was notified until later. During this gap, the resident was observed crying, restless, grabbing her legs, and reporting sharp, stabbing leg pain rated 10/10 with nausea. The record also showed missed doses of Lyrica and no evidence that PRN Tylenol or other pain interventions were provided during the period described. For another resident with chronic pain, encephalopathy, respiratory failure, pneumonia, diabetes, severe malnutrition, lung cancer, anxiety, and pressure injuries, the hospital discharge orders included gabapentin 600 mg three times daily and Norco 5/325 mg four times daily. Gabapentin was not transcribed onto the physician orders, and the first scheduled Norco dose was not administered until several days after admission. The record also showed additional missed or delayed Norco doses later in the stay, with no documentation explaining why the medications were not given and no documentation that the pharmacy or physician were notified. The resident reported severe chronic pain, including pain rated 9/10, and the MDS indicated frequent pain and no non-pharmacological interventions. For a third resident with severe cognitive impairment, dementia, anxiety, insomnia, mood disorder, osteoporosis, osteoarthritis, and a history of falls, a fall-related pain complaint was reported after the resident was lowered to the floor during a mechanical lift. A telehealth NP ordered Tylenol ES, cold compresses, and a STAT x-ray for right hip pain, but there was no evidence the Tylenol ES or cold compresses were transcribed or administered, and there was no documentation of a pain assessment on the day the pain was reported. The medical director confirmed the ordered Tylenol ES and cold compresses should have been given and that the record did not show they were provided.
Insufficient Nursing Staff Leading to Delayed Call Responses and Missed ADL Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain sufficient nursing staff to meet residents’ total care needs, including timely response to call lights and provision of routine ADL care such as bathing and toileting. On the initial survey entrance, there were four licensed nurses and five CNAs on duty for 52 residents, despite the facility assessment indicating a need for 4 licensed nurses providing direct care, 13 nurse aides, and 3 other nursing personnel, with a general staffing plan based on 1:12 day/evening and 1:20 night ratios. The facility’s own assessment and staffing plan called for higher staffing levels than were present. The facility also had a policy on resident dignity and respect, including allowing residents flexibility and honoring preferences, which contrasted with reports of delayed care and unmet preferences. Multiple residents reported long delays in call light responses and inadequate assistance due to short staffing. One resident who required a mechanical lift for transfers stated he could only get into his electric wheelchair about once a week because there was not enough staff to help, causing him to miss resident council meetings despite being the council president. Another resident reported call light response times ranging from 45 minutes to two hours, and a resident admitted for therapy due to weakness stated it had taken up to two hours for staff to answer call lights. A resident reported waiting up to 30 minutes for call light response at night and having to pull a bedpan out from under herself after sitting on it so long that it became painful. Another resident, who required assistance with transferring and walking to the bathroom, reported waiting so long for help that she became incontinent, leading to raw and painful skin on her legs and vaginal area, and stated that staffing was short among both nurses and aides, especially at night. Staff interviews further described chronic understaffing and its impact on resident care. CNAs reported that it was nearly impossible to complete the expected number of showers per shift along with other responsibilities, and that there were usually only three aides on day shift. One CNA stated she had been told not to shower residents requiring a mechanical lift despite the presence of a lift chair in the shower room, and recounted a resident requesting a shower but only having her hair washed because the aide said she did not have time. Another CNA stated she never felt there were enough staff to meet resident needs and noted that extra staff were added to the schedule because surveyors were present. An RN stated that call light responses should be within five minutes and that responses over 10 minutes required follow-up, and confirmed there were 16 residents requiring mechanical lifts, which need at least two staff. Other staff reported residents not getting showers, the DON coming in on a short-staffed night and sleeping in her office, and that staffing expectations and workload, including care for residents on ventilators and with many wounds, were excessive and could affect resident care. Record review and resident interviews showed that residents were not consistently receiving scheduled showers or adequate ADL assistance, and that refusals were not always addressed with appropriate interventions. One resident with osteomyelitis, diabetes with foot ulcers, repeated falls, and impaired cognition required partial/moderate assistance with bathing and toileting and needed leg wounds covered before showering. Documentation showed only two showers over a period of more than two months, with multiple recorded refusals but no documentation of interventions to encourage or explain the need for ADL assistance. The resident reported wanting showers but being told staff did not have time to cover both legs, leading him to decline and instead wipe off. Another resident with diabetes, lung cancer, COPD, weakness, and urinary incontinence was care planned for maximum assistance with bathing and scheduled for showers three times weekly, but records showed multiple missed showers/bed baths on scheduled days. This resident reported not always receiving scheduled showers and having only one shower in the prior week; observation noted greasy, uncombed hair and body odor, and an RN verified missed bathing in March. A further resident with multiple serious diagnoses, including sepsis, dysphagia, pneumonitis, respiratory failure, obesity, malnutrition, and repeated falls, was cognitively intact and required partial to moderate assistance with bathing and dressing. Her care plan aimed to keep her clean, dry, and odor free, with staff assistance for hair care, oral care, dressing, and bathing. Electronic records showed she received showers on only three dates over approximately one month, and her spouse reported that he was present all the time and assisted with all of her care because he did not feel staff did enough to help with ADLs. The administrator confirmed the available shower documentation for this resident. Additionally, facility call light audit reports for a one-week period showed 19 instances where call light response times exceeded 30 minutes, with the shortest of these being 37 minutes and the longest 144 minutes, corroborating resident and staff reports of delayed responses and insufficient staffing.
Failure to Address Resident Council and Grievance Concerns
Penalty
Summary
The facility failed to timely respond to resident concerns related to dietary, housekeeping, and staffing services, affecting all 52 residents in the facility. Review of grievances filed in December 2025, January 2026, and February 2026 showed that grievance resolutions stated the issues were resolved by education in all-staff meetings, but when surveyors requested the related training and education, the facility was unable to provide it. A grievance filed by a resident's family on 02/19/26 reported that food was cold and that the resident did not receive fruit even when it was circled on the menu; the documented action addressed only education to CNAs about getting fruit from the cooler and did not address the concern about cold food. During an observed Resident Council meeting on 04/01/26, residents voiced repeated concerns that they were not being listened to and that management was not addressing problems with care, cleanliness, and staffing. The Resident Council President asked where the DON and Administrator were, and Activities Supervisor #110 stated they had been told by the DON that she does not attend resident council meetings when state surveyors are present. Residents stated that conditions had gotten much worse, that they felt no one was listening, and that concerns were being swept under the rug. Residents also stated that they were not getting cleaned properly and were not getting care because of inadequate staffing. On 04/02/26, the Resident Council President stated that staff did not listen to resident concerns and that management knew about resident council meetings in advance but did not come, despite being invited. The resident described the facility as negative in every area and said concerns were ignored. On 04/06/26, a CNA reported that when the resident requested to speak with the DON, the DON asked staff to tell him she had left the building because she did not want to hear from him. The facility policy on Resident Dignity and Respect states residents are to be treated with kindness, dignity, and respect and that resident preferences are to be elicited and respected.
Food Served Cold and Unappetizing
Penalty
Summary
Food and drink were not served at palatable, attractive, and safe appetizing temperatures. During interview, Resident #3 stated the kitchen sometimes ran out of food and that meals were often cold by the time they were delivered because trays took a long time to reach residents. On observation, mashed potatoes on the steam table were 131 degrees Fahrenheit and ready for meal service, and a test lunch tray delivered to the surveyor had an unappetizing presentation with a dinner roll made soggy by vegetable medley juice. The vegetable medley on the test tray was described as having some vegetables mushy and others still frozen in the center, and it had no flavor. Resident #39 was served pizza in her room that measured 132 degrees Fahrenheit, and she stated the food was always cold by the time it was delivered to her room; CNA #485 confirmed that residents were sometimes served cold food. Resident #11 received a lunch tray in the room with vegetable medley at 110 degrees Fahrenheit and stated the vegetables were cold and did not taste good. CNA #485 stated many residents complained about cold food and explained that room trays were delivered four at a time across different halls, requiring repeated trips back to the kitchen, which made delivery disorganized and slow. The Dietary Supervisor stated the facility averaged about 30 room trays per meal and described the process as chaotic and hard on residents, CNAs, and dietary staff, while also noting the meal tray delivery process had been this way for about a month.
Improper Food Storage and Missing Hair Restraints
Penalty
Summary
Food was not stored in a manner to prevent contamination and spoilage, and staff did not consistently wear required hair restraints in the kitchen. During observation on 03/30/26 at 6:00 A.M., a dietary aide was seen standing at the kitchen steam table without a hair restraint in place. Dietary Assistant Manager #430 confirmed the aide was not wearing a hair restraint and stated there were none in the kitchen for the surveyor and that some would have to be obtained from supply. During a later observation at 6:10 A.M., an opened package of sliced pepperoni that was not sealed or dated and hard boiled eggs that were not sealed or dated were found in a silver stand-up refrigerator. The walk-in cooler contained five bags of unopened carrots with an expiration date of 03/05/26, and the freezer contained an opened package of hash browns that was not sealed or dated. At 6:20 A.M., Assistant Dietary Manager #430 confirmed the items in the refrigerator, cooler, and freezer were expired or not dated and properly sealed to prevent spoilage and/or contamination. Facility policy titled use of hair nets revised 07/31/14 stated all personnel will wear hair nets and/or hats in the kitchen and/or serving area for sanitary purposes.
Failure to Maintain Clean and Well-Kept Carpeting in Resident Rooms
Penalty
Summary
Surveyors identified a failure to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior environment for multiple residents. Observations of several resident rooms showed blue carpeting with multiple white stains, a brownish-red stain, and tears/snags at the entryway and throughout the rooms, with these conditions visible from the hallway. In one room shared by two residents, the carpet was described as stained and torn/snagged, and a CNA reported that several rooms with blue carpet were stained, torn, and dirty, and that attempts to clean them with bleach had caused some of the visible staining. The CNA also noted that these issues were primarily in rooms that still had blue carpeting, as most other rooms had wooden floors. Further observations of additional resident rooms confirmed that the blue carpeting was stained, torn/snagged, and not well kept, and these conditions were again visible from the hallway. The Regional Maintenance Director confirmed during the observations that the carpeting in these rooms needed to be replaced and acknowledged that one apparent stain might actually be feces on the carpet that required cleaning as soon as possible. Review of the facility’s “5 Step Resident Room Cleaning Procedure” policy, dated 10/2019, showed it addressed cleaning and disinfecting resident rooms but did not include any process for cleaning and maintaining carpeting in resident rooms. This combination of observed conditions, staff interviews, and policy review supported the finding that the facility failed to maintain a safe, clean, comfortable, and homelike environment for the affected residents.
Failure to Provide and Document Required ADL Bathing and Hygiene Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide and document assistance with activities of daily living (ADLs), particularly bathing and hygiene, for multiple residents who required staff support. Several residents had care plans and MDS assessments indicating needs for partial to total assistance with bathing, dressing, toileting, and personal hygiene, yet records and observations showed infrequent showers, missed scheduled baths, and inadequate documentation of refusals or encouragement efforts. For one resident with osteomyelitis, diabetes with foot ulcers, and impaired cognition, the care plan required staff assistance with ADLs and support for non‑compliant behaviors, but electronic records showed only two showers over a period of more than two months, and paper shower sheets documented multiple refusals without any notation of interventions to encourage or explain the need for care. This resident reported wanting showers but stated staff told him they did not have time to apply necessary wound‑protective devices, leading him to forego showers and instead wipe off. Another resident with Parkinson’s disease, dementia, and total dependence for ADLs had a documented preference for daytime showers three times weekly. In March, this resident was only bathed or showered on a few of the preferred days, and an observation found him in a wheelchair with disheveled, dirty‑appearing hair and soiled clothing, which a CNA confirmed. A resident with severe cognitive impairment and total dependence for ADLs had a care plan calling for assistance with bathing per preference and a documented preference for early morning showers three times weekly; however, March shower sheets showed only a few bed baths and multiple entries where it was unclear whether a bed bath or shower was provided. Another resident with moderate cognitive impairment and multiple medical conditions required partial to moderate assistance with showering and had a care plan goal to remain clean, dry, and odor free, yet he reported he did not always get to shower when he would like, could not safely shower in his room due to a slippery floor, and was observed disheveled with a dirty shirt. Additional residents with significant medical histories and documented ADL needs also did not receive showers or baths as planned. One cognitively intact resident who required partial to moderate assistance with bathing and dressing had electronic records showing only three showers over a one‑month period, and her spouse reported he was present all the time and provided all of her care, stating staff did not do enough to assist with her ADLs. Another resident requiring partial to moderate assistance with bathing and using a wheelchair had a care plan to remain clean, dry, and odor free and a preference for showers on specific days; records showed only one shower and two bed baths in March, and he reported it had been four weeks since he had been in the actual shower, stating staff only washed his groin area and that he did not feel clean. A newly admitted resident, cognitively intact and needing maximum assistance with bathing and moderate assistance with personal hygiene, was scheduled for showers three times weekly, but documentation showed multiple missed showers or bed baths, and she reported not always receiving showers as scheduled, stating she had only one shower in the prior week; she was observed with greasy, uncombed hair and body odor. Multiple CNAs and an RN reported that residents were not getting showers or baths per their preferences or care plans, cited insufficient staffing, and described expectations for a high number of showers per shift and instructions not to shower residents requiring mechanical lifts, despite available equipment. The facility’s ADL policy required provision of necessary services to maintain grooming and personal hygiene and adherence to care plan objectives, which was not met in these cases.
Failure to Provide Proper Pureed Diet Consistency
Penalty
Summary
The facility failed to ensure food was prepared in accordance with physician-ordered pureed diet consistencies for residents requiring texture-modified diets. During observation of the lunch meal service, pureed rice intended for residents on pureed diets was found in the warming table and, upon taste testing by the surveyor and the Dietary Supervisor, was noted to be gritty in texture with large clumps rather than smooth as required for puree consistency. The Dietary Supervisor confirmed that the rice did not meet the expected smooth, lump-free puree standard. Review of the facility diet list showed that six residents had physician orders for pureed diet consistency, and review of the facility’s therapeutic diet policy indicated that such diets are ordered by a physician, practitioner, or dietitian to alter the texture of the diet as part of treatment for a disease or clinical condition. This deficiency was cited under Complaint Number 2961570. The deficiency involved the facility’s failure to properly prepare and provide pureed food in the correct consistency for residents with physician-ordered pureed diets, as evidenced by the improperly prepared pureed rice and confirmation by the Dietary Supervisor that it did not meet puree standards.
Failure to Maintain Resident Privacy During Assessments, Insulin Administration, and Record Access
Penalty
Summary
The facility failed to maintain resident privacy during assessments and medication-related care. On 04/01/26, Nurse Practitioner #758 was observed assessing Residents #27, #45, and #49 in the dining area near the nurse's station while several dietary staff and multiple other residents were present in the area after lunch. She used her stethoscope over the residents' clothing on their chests in the public dining area. The Assistant Director of Nursing confirmed at the time of the observation that the assessments were being completed in a public area and that this did not protect the residents' privacy. The Nurse Practitioner later confirmed she had completed the initial assessments in the dining area and acknowledged others were in the general area. The facility also failed to protect privacy during blood glucose monitoring, insulin administration, and access to protected health information. Resident #65, who had diagnoses including diabetes mellitus and osteomyelitis of the left foot and ankle, had orders for blood glucose monitoring before meals and Humalog insulin with meals and per sliding scale. On 03/30/26, while the resident was eating lunch in the main dining room with other residents present, RN #955 checked the resident's blood glucose at the table and later administered insulin injection to the resident's right arm at the same table. RN #955 confirmed she completed the glucose test and administered insulin during the meal in the dining room. In a separate observation on 04/02/26, the electronic MAR on a medication cart was left open across from the DON's office, exposing residents' pictures, names, and room numbers until the DON closed the screen and turned over the report sheet; RN #385 confirmed she had left the screen open.
Physician-Ordered Blood Pressure Parameters Not Followed for Midodrine
Penalty
Summary
The facility failed to ensure physician-ordered parameters were followed for Midodrine administration for five residents. Resident #9 had diagnoses including secondary Parkinsonism, anxiety disorder, type 2 diabetes, hypertension, bipolar disorder, chronic pain, schizoaffective disorder, vascular dementia, and muscle weakness. The order directed staff to give Midodrine 10 mg three times daily for hypotension and to hold it for systolic blood pressure (SBP) greater than 120, but the medication administration record showed doses were given on multiple occasions when the SBP was above that hold parameter. Resident #42 had diagnoses including cerebrovascular disease, epilepsy, multiple sclerosis, sepsis, and pneumonia. The order directed Midodrine 5 mg three times daily and to hold if SBP was greater than 110, but the MAR showed the medication was administered on multiple dates when the SBP was greater than 110. Resident #55 had diagnoses including Parkinson's disease without dyskinesia, essential hypertension, spinal stenosis, major depressive disorder, generalized anxiety, auditory hallucinations, and dementia with behavioral disturbance. The order directed Midodrine 10 mg twice daily only if SBP was less than 100 and diastolic blood pressure (DBP) was less than 60, but the MAR showed the medication was given multiple times when SBP was greater than 100 and DBP was greater than 60. Resident #7 had diagnoses including vertebral osteomyelitis, chronic respiratory failure with hypoxia, generalized anxiety disorder, delirium, depression, Alzheimer's disease with early onset, essential hypertension, paroxysmal atrial fibrillation, insomnia, muscle weakness, and pain. The order directed Midodrine 10 mg three times daily and to hold if SBP was greater than 110, but the MAR showed the medication was administered multiple times when SBP was greater than 110. Resident #5 had diagnoses including peripheral vascular disease, hyperkalemia, muscle weakness, pain, essential hypertension, chronic obstructive pulmonary disease, and sepsis. The order directed Midodrine 2.5 mg, six tablets three times daily, and to hold for SBP greater than 101, but the MAR showed the medication was administered multiple times when SBP was greater than 101. An RN confirmed there were five residents taking Midodrine and that multiple administrations occurred when the ordered vital sign parameters were not met. The facility policy required vital signs or other ordered monitoring parameters to be obtained and recorded before medication administration and required the physician or prescriber to be notified when medications were held for abnormal vital signs.
Incomplete Flu and Pneumonia Vaccination Documentation
Penalty
Summary
The facility failed to provide and implement a comprehensive influenza and pneumonia vaccination program that included education, assessment, consent, and documentation for five residents reviewed for immunizations. For Resident #5, the record showed a flu vaccination on 10/09/25 and a PCV on 01/23/25, but there were no consents covering those dates. A 2024-2025 influenza vaccine form signed by the resident on 01/08/26 had an incomplete health screening, a blank date for the VIS, and indicated the resident refused the vaccination at that time. RN #956 confirmed these record issues on 04/13/26 and 04/14/26. For Resident #30, the record showed influenza vaccination on 10/23/25 and pneumococcal vaccination on 02/02/25, but there were no consents covering those dates. A pneumococcal informed consent dated 01/07/26 showed verbal consent but did not identify any medical contraindications or personal reasons for declining and only contained an x indicating refusal. The influenza form dated 01/07/26 also indicated refusal with verbal consent, but the health screening was not completed and there was no documentation of education or information provided. Resident #65 and Resident #18 both had records showing refusal of all vaccinations, but their pneumococcal and influenza forms lacked documentation of medical contraindications, personal reasons for declining, or education regarding influenza vaccination. Resident #1, who had diagnoses including metastatic right bronchus/lung cancer, obstructive sleep apnea, asthma, diabetes mellitus, and pneumonia, had a 2024-2025 influenza vaccine form dated 02/13/26 with blank screening questions, a refusal marked without resident or representative signature, and only the DON’s signature; RN #751 confirmed the screening questions were not completed.
Incomplete COVID-19 Vaccination Education and Documentation
Penalty
Summary
The facility failed to ensure a comprehensive COVID-19 vaccination program was implemented for residents and staff, including education, offering the vaccine, and documenting vaccination status. Record review showed that Resident #5 had documentation of a COVID-19 vaccination on 01/20/25, but there was no consent in the record and the immunization record did not show whether the vaccine was given elsewhere. A 2024-2025 Formula COVID-19 Vaccine Form in the record was signed but undated, had only the resident’s name at the top, had incomplete health screening questions, left the VIS date blank, and indicated the resident refused the vaccination at that time. Similar documentation problems were found for Resident #30, whose record showed a COVID-19 vaccination on 01/29/25 but no consent was located. The resident’s vaccine form was largely blank except for the name and a check mark showing declination, with incomplete screening questions, a blank VIS date, and a note indicating verbal consent dated 01/07/26. Resident #65 and Resident #18 both had immunization records showing refusal of all vaccinations, but their vaccine forms also had incomplete screening information and blank VIS dates, with each form indicating refusal. In addition, evidence that COVID-19 vaccination was offered to staff was requested but not provided, and a CNA stated the facility had no evidence of offering COVID-19 vaccinations to employees because a binder containing that information could not be located; this was confirmed by the ADON. The facility policy stated residents were to be offered the COVID-19 vaccine or booster, educational material provided at the time of offering, declinations documented in the medical record, and staff educated on the risks and benefits of the vaccine and how to obtain it.
Failure to Timely Report and Investigate Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report and investigate an allegation of resident-to-resident physical abuse to the Administrator and the State Survey Agency as required by policy and regulation. A cognitively impaired resident with left-sided hemiparesis, a history of stroke, anemia, and aspirin therapy, who required extensive assistance with ADLs and used a wheelchair, reported that his roommate came through the closed privacy curtain and punched him in the left shoulder while he was lying in bed dozing. The resident stated he did not know why he was hit and later reported being scared after the incident, fearing his roommate would find him again. He reported the incident to nursing staff but could not recall which nurse, and he stated that no one followed up with him or asked him for a statement, and he was not aware of any investigation. Multiple staff accounts and documentation showed that the incident was initially treated as a verbal altercation and not reported as physical abuse. A late entry progress note authored by the DON, who was not in the building at the time of the event, documented that the roommate was upset about TV volume and that no harm came to the resident. The Administrator reported that the DON informed her there had only been a verbal altercation and that the residents would be separated due to ongoing bickering about the TV, and based on this information the Administrator did not report the incident to the State Agency. The ADON, who was also not in the building at the time, confirmed there was no documentation of family or physician notification regarding the resident being hit, and acknowledged that the roommate was the aggressor. A CNA reported hearing a nurse yell for help and being told that the roommate was punching the resident; when the CNA asked the resident if he was okay, the resident said he could not talk about it because he did not want the roommate to "get" him again, and the CNA described the resident as scared and terrified. The CNA stated they were not asked to make a statement on the day of the incident or in the days following. Further interviews and grievance documentation later confirmed that the roommate admitted to physically striking the resident. The social services designee, who was not present when the incident occurred, learned of the altercation days later from CNAs and interviewed both residents. The injured resident described being hit in the shoulder and mentioned having a knot on his shoulder, which the designee did not verify. The roommate stated that he had heard the other resident use an expletive and that he went over and slapped him with an open hand on the head, later reiterating that he hit him in either the head or shoulder. The social services designee reported this information to corporate staff and completed grievance forms, which were eventually sent to the Administrator. Despite a text from the DON to the corporate VPO indicating there might be a self-reported incident and then stating "never mind" later that same day, there was no documented investigation by the DON. Subsequent observation revealed yellow-green bruising on the resident’s left bicep and a quarter-sized bruise on the left shoulder in various stages of healing, which the resident attributed to the altercation, and this was verified by a CNA. The facility’s abuse policy required timely reporting of all allegations of abuse to the Administrator and the state agency, protection of residents, notification of the physician and representative, and completion of an investigation within five working days, but these steps were not carried out as required for this incident. The second resident involved, the roommate, had a history of anxiety, heart failure, pulmonary embolism, and documented inappropriate behaviors including verbal and physical aggression toward staff and delusions. His care plan included goals for no injury to self or others and interventions such as documenting behaviors and redirecting him. His MDS showed moderate cognitive impairment and independence or supervision for mobility and transfers. A late entry progress note by the DON documented that he was yelling and verbally aggressive about TV volume and told his roommate to turn the volume down, but did not document the physical contact he later admitted. The combination of delayed recognition and documentation of the physical nature of the altercation, lack of timely reporting to the Administrator and State Survey Agency, absence of required notifications, and lack of a documented investigation within the facility’s specified timeframe led to the cited deficiency. The facility’s written abuse policy required that all incidents and allegations of abuse, neglect, exploitation, mistreatment, misappropriation, and injuries of unknown source be reported to the Administrator and to the state health department within specified timeframes, including within two hours for allegations of abuse or serious bodily injury and no later than 24 hours for other allegations. The policy also required immediate protective measures, psychosocial support via social services, documentation of assessments, notifications, and treatments in the nurse’s notes, and completion of an investigation within five working days. In this case, the allegation of resident-to-resident physical abuse was not promptly recognized, reported, or investigated in accordance with these requirements, resulting in noncompliance under the cited complaint numbers.
Failure to Thoroughly Investigate Resident-to-Resident Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate allegations of resident-to-resident abuse involving two residents. One resident with left-sided hemiplegia, chronic pain, anemia with aspirin therapy, and significant dependence on staff for ADLs reported that his roommate came through the closed curtain and punched him in the left shoulder while he was lying in bed dozing. His care plan included interventions to assist with transfers and mobility and to observe for bruising due to bleeding risk, and his MDS documented moderate cognitive impairment and extensive physical assistance needs. Despite this, the initial documentation by the DON, entered as a late entry, characterized the incident only as a disagreement over TV volume with no harm to the resident, and there was no contemporaneous documentation of a physical assault, assessment for injury, or immediate investigation. Multiple interviews and records later confirmed that a physical altercation had occurred and that the facility did not conduct a timely, thorough investigation as required by its abuse policy. The resident who reported being hit stated that he told a nurse about the incident but could not recall which nurse, and he reported that no one followed up with him or obtained a statement. The SSD learned of the incident days later, interviewed both residents, and documented that the dependent resident described being struck in the shoulder and having a “knot” on his shoulder, which the SSD did not verify. The alleged aggressor resident, who had a care plan for inappropriate behaviors including verbal/physical aggression and delusions, admitted in interviews and on a grievance form that he slapped or hit his roommate in the head or shoulder after being angered by the use of profanity. Staff interviews revealed that CNAs were aware of the physical assault, observed the dependent resident as scared and terrified, and were never asked to provide statements. Additional documentation showed that prior to the physical assault, the aggressive resident had threatened to shoot his roommate over TV volume, resulting in a temporary room change, and that staff questioned why the two residents were later placed back in the same room given ongoing issues. On observation weeks after the incident, the dependent resident had yellow-green bruising on the left bicep and a quarter-sized bruise on the left shoulder in various stages of healing, which he attributed to the altercation; this was verified by a CNA. The facility’s abuse policy required that all alleged violations of abuse, including resident-to-resident incidents, be investigated within five working days, with interviews of the resident, the accused, and all witnesses, collection of written statements, review of medical records, documentation of the investigation, and revision of care plans as needed. The Administrator and VPO confirmed there were no witness statements and no documented investigation by the DON, and the Administrator acknowledged that the investigation was not thorough, demonstrating noncompliance with the facility’s own abuse investigation policy. The second resident involved, who was more independent and had diagnoses including anxiety, hypertension, heart failure, and pulmonary embolism, had a care plan for inappropriate and aggressive behaviors with goals to prevent injury to self or others. Progress notes documented that he had previously threatened to shoot his roommate over TV volume, leading to physician notification and temporary relocation. Despite this history and staff concerns, the residents were returned to the same room, and when the subsequent physical assault occurred, the facility failed to promptly recognize, document, and investigate it as abuse. The lack of timely assessment, failure to obtain and document statements from involved staff and residents, and absence of a complete investigative record as required by policy formed the basis of the cited deficiency.
Failure to Ensure Comprehensive Discharge Planning and Bed-Hold Notification
Penalty
Summary
The deficiency involves the facility’s failure to ensure a comprehensive and accurately documented discharge process for one resident. A cognitively intact resident with multiple complex diagnoses, including hypertension, anxiety, cerebral infarction, peripheral vascular disease, gangrene, cardiomyopathy, diabetes, and other conditions, was discharged home after their health had improved sufficiently for a less skilled level of care. The resident’s care plan identified them as a long-term placement due to needs exceeding community resources and was not revised to reflect the facility’s active discharge planning back to the community, despite the MDS indicating an active discharge plan. The discharge planning care plan was only cancelled after the resident had already been discharged, with no documented updates showing the planned transition to home. At discharge, nursing documentation stated that discharge instructions were reviewed and that medications and prescriptions were provided as ordered. However, the discharge summary contained no evidence of the specific medications or prescriptions reviewed at discharge and no documented medication reconciliation for accuracy. The section of the discharge summary designated for post-discharge medications contained only a handwritten note stating “See List,” but no medication list was attached. The closed medical record did not contain copies of prescriptions or evidence of the medication orders being faxed to the pharmacy or provided to the resident on the day of discharge. Subsequent documentation showed that the resident’s power of attorney later reported that the prescriptions had not been received by the pharmacy, and the facility confirmed that the pharmacy had not received them, leading to a refax several days after discharge. The administrator confirmed that the discharge planning care plan lacked revisions reflecting the planned discharge back to the community and that the prescriptions had initially been faxed to a different number. Additionally, for another cognitively intact resident who was transferred to the hospital and later readmitted after a seven-day ICU stay, the record contained no documentation that the resident or their representative was given a bed-hold notice or the option to hold the bed or not at the time of transfer, despite facility policy requiring a bed-hold notice to be completed, delivered, and documented at the time of transfer.
Failure to Update Care and Discharge Plans to Reflect Current Resident Status
Penalty
Summary
The deficiency involves the facility’s failure to review and revise care plans after each assessment and in response to changes in residents’ needs, as well as failure to appropriately revise discharge plans of care. For one resident with diagnoses including acute systolic congestive heart failure, COPD, type 2 diabetes with polyneuropathy, muscle weakness, and a history of falls, the care plan revised on 03/04/26 still included a focus on risk of infection related to an indwelling medical device and an intervention to wear gown and gloves for high-contact care, despite the urinary catheter having been discontinued on 07/09/25 and no further catheter orders present. The same resident’s care plan and active orders required all transfers to be completed with a mechanical lift, with the mechanical lift intervention initiated on 01/18/26, yet on 03/30/26 the resident was observed independently transferring to a motorized scooter and into the restroom. A CNA confirmed the resident had been independently transferring for about two weeks based on therapy direction, but the order and care plan had not been updated. For another resident admitted with hypertension, anxiety, cerebral infarction, peripheral vascular disease, gangrene, and cardiomyopathy, the quarterly MDS assessment documented that the resident was cognitively intact for daily decision-making and had an active plan to discharge back to the community. However, the existing discharge planning care plan, dated 03/16/25, identified the resident as a long-term placement because his needs exceeded community resources and was not updated to reflect that the facility was assisting him with discharge back to the community. The discharge planning care plan remained unchanged and was only cancelled on 03/16/26 after the resident had already been discharged on 03/11/26, as confirmed by a nurse who verified that the discharge planning care plan was not revised when the facility assisted and ultimately discharged the resident back to the community.
Failure to Provide ADL Support and Honor Resident Bathing Preferences
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to support residents’ activities of daily living (ADLs), specifically bathing, in accordance with assessed needs and stated preferences. One resident with a BIMS score of 15, indicating no cognitive impairment, required assistance with multiple ADLs including bathing and toileting and was care planned to be kept clean, dry, and odor free, with staff assistance for hair care, toileting, and bathing as needed per preference. Shower/bed bath records for this resident in February 2026 showed only three baths provided during the month, with one missed due to lack of hot water and no documentation of refusals for the remainder of the month. The resident reported preferring morning baths and stated that on one day she repeatedly asked staff when she would be bathed, did not receive a bath during the day, and ultimately received only a sponge bath while on the toilet in the evening, leaving her feeling that her preferences and opinions did not matter. The Corporate Clinical Director confirmed the resident was not being bathed or showered per her preference or needed frequency. A second resident, who was cognitively intact and required moderate assistance with bathing, had an ADL care plan indicating a need for staff assistance with bathing per preference, but this care plan was not revised to reflect the resident’s specific bathing preferences or frequency. Another care plan addressing inappropriate behavior documented that this resident preferred bed baths and refused showers. Electronic ADL records for February and March 2026 showed that baths/showers were provided on several specific dates, with one documented refusal and at least one shower given despite the resident’s stated preference for bed baths. Interview with an RN confirmed that the ADL care plan was not updated to include the resident’s bathing preferences, including frequency, and that there were often five days between documented bathing. These findings, based on record review, staff and resident interviews, and documentation audits, demonstrate that the facility did not consistently provide ADL care, particularly bathing, in alignment with residents’ assessed needs and expressed preferences.
Failure to Provide Ongoing, Individualized Activity Program for Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide an ongoing, comprehensive activity program that met residents’ individual preferences and needs, as required by facility policy. Surveyors found that activity assessments and care plans identified specific interests and the importance of various activities for residents, but the facility did not implement or document activities consistent with those plans. Activity calendars lacked scheduled one-on-one activities for certain months, and there was little variety in daily activities from week to week. The facility’s own policy required admission activity assessments, ongoing updates, and individualized activity plans, including one-on-one activities to be completed per the activity calendar, but these were not carried out as written. One resident, identified as Resident #28, had multiple medical diagnoses including encephalopathy, heart failure, anemia, diabetes, and a fractured hip, and was cognitively intact per the MDS. The activity assessment for this resident documented numerous current interests and their importance, including one-on-one activities with animals/pets, beauty/barber services, exercise, family/friend visits, gardening, movies/TV, cooking, and current events, as well as small group interests such as bingo, cards, resident council, volunteering, walking, arts/crafts, community outings, and social parties. The care plan stated the resident was involved with activities little of the time and included interventions such as assisting the resident to activities, encouraging participation, inviting to resident council, breaking activities into manageable tasks, and providing an activity calendar. However, review of the medical record showed no evidence that the resident was offered or participated in the identified one-on-one or group activities during the review period. For Resident #28, the activity calendars for a specific month showed scheduled one-on-one visits on several dates and listed group activities such as weekly bingo, multiple weekly card/game sessions, weekly pet therapy, weekly outings, and a monthly spa day. Yet, the record of one-on-one activities contained only a few brief contacts, such as staff visiting while the resident’s husband was present, offering popsicles or snacks, and one instance of offering a word search that was declined by the husband when the resident was sleeping. The Activity Supervisor confirmed that these few documented contacts were all that had been provided since the resident’s admission. There was no documentation that the resident’s stated preferences for activities like bingo, pool, happy hour music, or other listed interests were implemented. Another resident, identified as Resident #2, had extensive medical conditions including CVA with hemiplegia, encephalopathy, chronic systolic CHF, respiratory failure, altered cognitive function, insomnia, sleep apnea, hypertension, atrial fibrillation, abdominal aortic aneurysm, and a prosthetic heart valve, and was severely impaired for daily decision-making per the MDS. The activity assessment documented current interests in individual activities such as animals/pets, current events, exercise, movies, music, and family/friend visits, as well as interests in religious studies, shopping, sing-alongs, social parties, volunteering, walking, and arts/crafts. Past interests included bingo, cards, cooking, creative writing, dominoes, educational programs, and reading. The care plan indicated the resident was involved with activities some of the time, with goals to participate in activities of choice and remain active with individual activities, and interventions similar to those for Resident #28, including assistance to activities, encouragement, and provision of an activity calendar. Despite these documented interests and care plan interventions, the record for Resident #2 showed only a few one-on-one activities, such as two visits where staff sat and talked with the resident for 10–15 minutes and one in-room manicure. There were documented gaps with no evidence of any activities provided over extended periods between specified dates. Observations showed the resident frequently lying in bed with no activities present in the room, and the resident stated she did not go out of her room much and did not know what she was going to do that day. The Activity Supervisor acknowledged that only a few one-on-one activities were documented since admission and stated the resident had cognitive impairment, did not want to join other activities, and only came out of her room for meals. The Administrator confirmed there were no documented activities in the electronic medical record for these residents beyond the few noted, that the calendars for several months did not include scheduled one-on-one activities, and that there was little variety in daily activities. Additional information from Social Services indicated that a separate Medicaid "Quality Moments" program provided emotional/behavioral support to certain qualifying residents, but this service was not provided by facility staff, was not available to all residents, and was not part of the residents’ activity care plans. Observations also showed that an activity calendar for Resident #2 was posted on the wall but not within the resident’s view. Overall, surveyors determined that, based on observation, record review, policy review, and interviews, the facility did not ensure that residents were provided with an ongoing, individualized activity program consistent with their assessed preferences and the facility’s own Resident Activities policy.
Unsafe Mechanical Lift Use and Inaccessible Call Light for Residents at Risk of Falls
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe use of mechanical lifts and proper access to call lights, resulting in unsafe transfers and fall risk for multiple residents. One resident with severe cognitive impairment, extensive ADL dependence, a history of falls, and limited lower extremity mobility was transferred using a mechanical lift when she began sliding out of the sling. Two CNAs reported that during the lift, the resident slid out of the pad, came out the side of the sling, and ended up on the floor after they unclipped the lift pad. The resident’s medical record did not contain documentation of the required sling size, and staff reported that sling size was chosen visually or based only on weight, without formal measurement or documentation. Manufacturer guidelines for the specific lift in use required selection of a sling that met the patient’s needs and maximum safety, use of only the manufacturer’s slings, and adherence to a sizing chart based on both height and weight, but the facility did not have documentation that these requirements were followed for this resident. Another resident, dependent for ADLs and using a wheelchair for ambulation, was observed being transferred via mechanical lift by two CNAs. During this transfer, the CNA operating the lift did not lock the lift’s brakes before lifting the resident from a recliner or before lowering him into his wheelchair, contrary to the manufacturer’s instructions and the facility’s own mechanical lift policy, which required the lift to be stable and locked prior to lifting. The CNA confirmed at the time of observation that the brakes had not been locked and also stated she had never received Hoyer lift training at the facility. Facility policies required that residents be measured for proper sling size per manufacturer instructions, that lifts be locked prior to lifting, and that staff be trained and demonstrate competency on the specific lift devices used. Interviews with facility leadership and staff revealed discrepancies and gaps in mechanical lift training and competency validation. The DON and ADON stated that all CNAs were trained on mechanical lifts at hire and that staff had been trained and checked off on the new bariatric lift, but there was no sign-in sheet or documentation of this education. The physical therapist responsible for orientation reported that she did not provide mechanical lift training and only discussed communication with therapy and issued gait belts. Multiple CNAs reported they had never received mechanical lift training at the facility, had only watched the DON use the new bariatric lift, or that orientation checklists were simply checked off when new staff were shown where the lifts were stored, without return demonstration. The Administrator later confirmed that Hoyer lift training was part of the orientation checklist and that CNAs were trained by another CNA, and also confirmed there was no annual Hoyer lift training documented in CNA education or employee files, despite facility policy requiring initial and annual education and competency. A separate deficiency involved a resident at risk for falls whose care plan required that the call light be kept within reach. This resident, who had a history of a recent fall resulting in a left hip fracture while returning from the bathroom to bed, reported that fall and injury during interview. On observation, the resident’s call light was not within reach; it was in a bag on the bedside table, and the resident confirmed she could not reach it. A sign indicating the call light for assistance was hanging on the wall, but the device itself remained inaccessible. A CNA present at the bedside confirmed that the call light was out of reach, sitting on the nightstand in a bag, contrary to the care-planned intervention to keep the call light within reach for this resident at risk for falls.
Failure to Transcribe and Administer Hospital Discharge Medication Orders
Penalty
Summary
The facility failed to ensure that medications were administered without significant error for one resident. A resident was admitted with multiple diagnoses including malignant right lower lung cancer, obstructive sleep apnea treated with BiPAP, paroxysmal atrial fibrillation, asthma, chronic pain, GERD, COPD, diabetes mellitus with diabetic polyneuropathy, and a urinary tract infection. The hospital discharge summary included specific orders to start Betapace 40 mg twice daily, Carafate 1 g four times daily, Lotrisone cream to the vaginal area twice daily for eight doses, Macrobid twice daily for five days for a UTI, discontinue Metformin 500 mg and start Lantus 4 units at bedtime, complete a course of oral Nystatin liquid, administer Gabapentin 600 mg three times daily, and provide albuterol-budesonide aerosol PRN. The nurse practitioner reviewed and approved these medications upon admission. Despite this approval, review of the electronic order summary showed that none of these discharge medication orders were transcribed or started as ordered. The admission MDS indicated the resident was cognitively intact and did not receive insulin or an antibiotic during the assessment period, and a later NP note documented that the resident was not on any diabetes treatment upon arrival and that diabetes was being managed with diet. During interview, an RN confirmed that the discharge summary had been approved but the medications were not transcribed or administered from admission through the time of survey, stating they were “missed” and acknowledging that the DON was supposed to be the second check for new admission orders. The facility’s admission policy required review of all transfer information and orders, but this process did not occur as required for this resident’s medications.
Inaccurate Documentation of Resident Altercations and Fall Events
Penalty
Summary
The deficiency involves the facility’s failure to maintain comprehensive and accurate medical records and safeguard resident-identifiable information, particularly in relation to abuse/altercation events and an accident. For one resident with left-sided hemiparesis, chronic pain, depression, and moderate cognitive impairment, the DON entered a late progress note documenting only a verbal disagreement about TV volume and stating that no harm occurred, even though the DON was not in the facility at the time of the incident. Punch records confirmed the DON was not present when the event allegedly occurred. In contrast, a grievance completed later documented that the resident reported being punched in the left shoulder by his roommate while lying in bed, and the resident later stated no one followed up with him or obtained a statement, and he was unaware of any investigation. Multiple CNAs and the SSD reported that the roommate had previously threatened to shoot and kill this resident over TV volume, that the residents were separated and then moved back into the same room on the DON’s direction, and that staff concerns about the move were disregarded. The SSD reported being told by CNA staff that the roommate threatened to shoot the resident and that the DON instructed that staff not document the incident in the progress notes, although the SSD stated she did not pass on that instruction and an agency nurse did document the threat in the aggressor’s record. The SSD and several CNAs described a subsequent physical altercation in which the more independent roommate struck the dependent resident, who could not use his left arm and was largely bed- or wheelchair-bound. Staff accounts indicated the aggressor had a history of verbal and physical aggression, including threats to choke, shoot, or kill his roommate, and that he was moved out of and then back into the shared room before the physical assault. The Administrator stated she was initially told by the DON that the altercation was only verbal and therefore did not believe it needed to be reported as abuse. Later, grievance information indicated the resident reported being hit, and interviews with both residents confirmed that the aggressor admitted to slapping or hitting his roommate in the head or shoulder. An observation days later showed bruising on the dependent resident’s left bicep and shoulder, which the resident attributed to the altercation, and this was verified by a CNA. A second component of the deficiency concerns another resident with dementia, severe cognitive impairment, a history of falls, weakness, and total dependence for ADLs, who was reportedly lowered to the floor during a Hoyer lift transfer from wheelchair to bed. The progress notes contained only a brief statement that the resident was lowered to the floor, with no post-fall documentation completed at the time of the incident. An eCare triage note later documented that an unnamed facility staff member told the on-call provider that the resident had been lowered to the floor earlier in the shift, but by the end of the shift the resident cried out in pain in the right inner thigh, requested not to be moved, and was then saying she had actually fallen rather than been lowered. The call was categorized as a new fall, and the NP ordered pain medication, cold compresses, and a STAT X-ray. The NP’s subsequent note did not reference the fall or pain complaint, and the facility’s incident log for several months showed no recorded fall or incident for this resident. An anonymous staff member stated the resident fell out of the mechanical lift and was not lowered, and that the DON and ADON told staff to report that the resident was lowered rather than that she fell. The medical director confirmed that the pain complaint was consistent with an injury from falling out of a Hoyer or incorrect transfer and that he considered the event a fall due to the drastic change in planes, yet there was no corresponding fall entry on the incident log.
Failure to Maintain Resident Dignity During Bed Care
Penalty
Summary
The facility failed to maintain the dignity of a resident by leaving her pants pulled down while she was in bed. Resident #30 had diagnoses including unspecified dementia with other behavioral disturbance, generalized anxiety disorder, psycho-physiologic insomnia, unspecified mood disorder, weakness, history of falling, muscle weakness, and difficulty walking. Her MDS showed a BIMS score of 7, indicating severe problems with thinking and memory, and she required a wheelchair for ambulation and was dependent for all ADLs. During observation, the resident was lying in bed with boots on both feet to protect her heels, and her pants were pulled down around the boots. The CNA confirmed this was the routine practice while the resident was in bed so her pants would not get wet if she was incontinent and her brief leaked, and so it would be easier to pull the pants up later. The CNA acknowledged that this made movement difficult for the resident and could pose a fall risk, and that it was not a dignified way for the resident to lie in bed. The facility policy stated that residents should be treated with dignity and respect and that privacy of the resident's body should be maintained during personal care.
Residents Not Informed of Physician Change and Diabetes Monitoring Choice Not Respected
Penalty
Summary
The facility failed to notify residents of a change in Medical Director and failed to provide residents with a choice of physician. Review of Resident #9’s record showed the physician of record changed from MD #750 to MD #1122, and the Director of Nursing confirmed the change. The Administrator stated she had asked for a letter to be sent with March billing statements informing residents of the Medical Director change, but she could not confirm the letters were actually sent. An undated letter to residents stated that MD #750 would no longer be the Medical Director and would be replaced by MD #1122. The Administrator also stated she did not believe residents or their representatives had been asked whether they wanted to continue with the new practitioners or choose a practitioner of their own. Resident #9 stated she was not aware her physician had changed. The facility also failed to ensure Resident #3 had the right to choose how diabetes mellitus was managed. Resident #3 had diagnoses including multiple sclerosis, type 2 diabetes, major depressive disorder, anxiety, and acute and chronic respiratory failure with hypoxia and hypercapnia. Physician orders included NovoLog by sliding scale before meals and NovoLog 14 units with meals. The quarterly MDS showed a BIMS score of 15 and that the resident received hypoglycemic medication. The record contained no documentation that Resident #3 was notified of discontinuation of the continuous blood glucose monitoring sensor, no rationale for discontinuing it, and no documentation that the resident was given a choice regarding blood glucose monitoring related to diabetes mellitus. Resident #3 stated the DON took away his Libre sensor and told him the facility was not using them anymore, without explaining why or offering another choice. He reported that he now had to have finger sticks multiple times a day and that they hurt and were causing calluses. Corporate Clinical Director #956 confirmed there was no documentation that residents or representatives were notified of the discontinuation of the continuous blood glucose monitoring sensors and no evidence of an investigation regarding accuracy of the sensors versus glucometers. ADON #390 stated the DON discontinued the sensors due to inaccuracy, but she was unsure whether any testing had been done to determine whether the sensors or glucometers were inaccurate.
Failure to Provide Written Notice for Room Changes
Penalty
Summary
The facility failed to provide residents and/or their representatives with written advance notice explaining why room or roommate reassignments occurred. Resident #65 had diagnoses including acute osteomyelitis of the left ankle and foot, type 2 diabetes mellitus with foot ulcer, repeated falls, pain in both hips, and major depressive disorder. A care plan addressed behavioral concerns such as inappropriate language, yelling out, and making growling sounds. A grievance documented by Social Service Designee #275 stated that Resident #65 was loud and yelling, and the resident was moved from one room to another on 03/19/26. The record showed the resident was told the room needed to change because another resident needed the room, but there was no indication that written notice was provided in advance or that follow-up with the resident occurred. Resident #52 also had room changes documented in the facility record, including a move on 03/11/26 and another on 03/20/26. The electronic record contained no documentation that the resident was given written notice explaining either room change. The facility policy required residents to be notified of room or roommate changes using a prepared Notice of Room or Roommate Change form that included the reason for the change and required resident and staff signatures. The Administrator confirmed by electronic communication that Resident #65 and Resident #52 did not receive this written notice.
Advance Directive Documentation Not Matched to Resident Wishes
Penalty
Summary
The facility failed to ensure advance directives were accurately documented according to the resident’s wishes for one resident who was admitted with diagnoses including a left hip fracture, metabolic encephalopathy, anxiety, and heart failure. The closed medical record showed conflicting code status documentation, including an electronic Physician Order listing the resident as Full Code, a signed paper Full Code form, and a paper DNR Comfort Care-Arrest form signed by the resident’s spouse but not signed by the physician and dated with the year 2029. The record also contained a hospice-faxed DNR Comfort Care form that was signed when hospice services were elected. The resident’s code status care plan identified the resident as Full Code and to receive CPR, and it was later discontinued. During interview, the RN confirmed the paper record contained the spouse-signed DNRCCA form without a physician signature, along with both electronic and paper Full Code forms. The RN also stated the hospice company had sent a signed DNRCC form indicating the resident elected DNRCC status, but this had not been transcribed or ordered at the facility until later.
Failure to Issue Beneficiary Notice for Planned Therapy Discharge
Penalty
Summary
The facility failed to issue beneficiary notices for a resident when required. Resident #43 was admitted with diagnoses including cerebral vascular accident, hypertension, and neurogenic bladder, and was reviewed for liability notices along with two other residents. The record showed the resident was discharged from therapy on 01/28/26 and later discharged home, but no beneficiary notice was issued. Social service documentation noted the resident went home with home health services, did not need medical equipment, and was transported by his son with discharge paperwork and appointment reminders provided. Therapy notes showed Resident #43 had ongoing skilled therapy services and was progressing toward a planned discharge home. On 01/19/26, the resident needed assistance with hygiene and grooming tasks such as fingernail care and shaving, and the COTA discussed a home assessment with the resident and his son. On 01/21/26, the resident completed functional mobility and car transfer training at SBA level, and OT documented that he had needed equipment for home going and that home health services and an alert system were recommended. On 01/28/26, the resident was able to stand for over 10 minutes with a FWW, complete transfers with SBA, and perform dressing tasks with assistance and verbal cues. During interview, the SSD stated she did not think a liability notice was needed because the resident wanted to go home, while the Therapy Manager confirmed the discharge had been planned over several weeks, the resident had met his goals, and he had not left AMA or exhausted skilled days.
Inadequate indication for antipsychotic use
Penalty
Summary
The facility failed to ensure that psychoactive medications administered had adequate indications for use for one resident out of five reviewed for unnecessary medications. Resident #1 was admitted with diagnoses including encephalopathy, generalized anxiety disorder, severe sepsis with septic shock, cystitis, hyponatremia, depression, acute respiratory failure with hypoxia, asthma, pain, diabetes mellitus, pneumonia, and insomnia. The admission MDS 3.0 assessment showed the resident was cognitively intact for daily decision-making and had no mood symptoms, psychosis, or behavioral symptoms. Despite this, Resident #1 was ordered Abilify 20 mg every morning since admission for a diagnosis of mood, and the Psychotropic Medication Risk Benefit Evaluation documented use for anxiety and depression. The MAR showed the resident received Abilify 20 mg daily from 02/15/26 through 04/08/26 with no documented behaviors. The policy required psychoactive medications to be administered in accordance with regulations and to include an appropriate diagnosis, and the manufacturer information identified aripiprazole as an antipsychotic used for schizophrenia, bipolar I mania, irritability associated with autism spectrum disorder, adjunctive treatment in major depressive disorder, and Tourette syndrome. On 04/08/26, an RN verified the resident did not have an approved diagnosis for the use of Abilify.
Delayed Admission MDS Assessment
Penalty
Summary
The facility failed to ensure a comprehensive assessment was completed in a timely manner for Resident #43, who was admitted with diagnoses including septicemia, urinary tract infection, and hypertension. Review of the resident’s admission MDS 3.0 assessment showed that it was not submitted until 12/31/25 at 9:32 P.M., and an electronic interview with the Administrator on 04/14/26 at 6:51 P.M. confirmed that the assessment was not completed within the required timeframe because it was missed.
Inaccurate Resident Assessments and MDS Coding
Penalty
Summary
The facility failed to ensure comprehensive assessments were accurately completed for three residents. For Resident #2, the admission assessment documented skin that was warm and dry, with normal color and turgor and no skin issues, yet the modified admission MDS coded a Stage III pressure ulcer as present on admission. The DON later verified that the resident’s skin was intact on admission and that the Stage III pressure ulcer developed two days after admission. For Resident #1, the admission MDS coded the resident as receiving opioids and scheduled pain medications, but the physician orders and eMAR showed Norco 5/325 mg was ordered for three days and was not administered between 02/13/26 and 02/19/26, with no other opioid ordered or given during that time. An NP note stated the resident had chronic pain, had not received Norco since arriving at the facility, and pain was unstable due to the lack of the Norco regimen. For Resident #55, the MDS dated 01/20/26 showed a BIMS score of zero, and the MDS LPN confirmed the score was entered late and that a zero score would have been inaccurate.
Failure to Notify State Agency of New Mental Health Diagnosis for PASARR Review
Penalty
Summary
The facility failed to notify the appropriate state agency of a newly diagnosed mental illness for PASARR evaluation for one resident. Resident #10 was admitted with chronic respiratory failure, CHF, ESRD, and DM, and the admission MDS showed the resident was cognitively intact for daily decision-making, did not have a serious mental illness requiring a Level 2 screening and/or evaluation, had a diagnosis of a psychotic disorder, and received antipsychotic medications. The medical record later showed new mental health diagnoses were added, including bipolar disorder, major depressive disorder, generalized anxiety disorder, and schizoaffective disorder, bipolar type. The record contained no evidence that the facility submitted a Resident Review due to a significant decline in condition that might require a Level 2 screening or evaluation, and the DON verified that no Resident Review was submitted after the resident's mental health decline was identified. The DON also stated the facility did not have a policy specific to completing a PASSAR.
Baseline care plan not provided or acknowledged
Penalty
Summary
The facility failed to provide a baseline care plan within the required timeframe for Resident #50, who was admitted with diagnoses including diabetes mellitus, emphysema, heart failure, atrial fibrillation, sleep apnea, hypertension, and neuropathy. The admission MDS 3.0 assessment showed the resident’s cognition was intact for daily decision-making. Review of the resident’s baseline care plan dated 03/12/26 showed no evidence that the resident was provided a copy or signed acknowledgement of the plan. During interview, the resident stated he had not had a care conference or a meeting regarding discharge planning and denied receiving any baseline care plans since admission. An LPN stated the baseline care plan had previously been the DON’s responsibility, but as of the prior week it was her responsibility, and she verified the resident’s baseline care plan was not signed by the resident or anyone except a signature she believed to be the DON’s, and that it was not dated by the DON.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to develop and implement a comprehensive, individualized, and effective pressure ulcer prevention program for a resident admitted with intact skin who was at moderate risk for skin breakdown. The resident had multiple diagnoses including CVA with left hemiplegia, encephalopathy, CHF, moderate protein calorie malnutrition, altered cognitive function, CKD stage 3, and was dependent on staff for many activities of daily living. The admission assessment documented no skin issues, and the initial care plan did not include extra skin care interventions, despite the resident’s risk factors and the facility policy requiring evidence-based interventions for residents at risk for pressure injuries. Record review showed the resident was dependent for rolling, transfers, toileting, hygiene, and bathing, used a manual wheelchair, and was always incontinent of urine and frequently incontinent of bowel. Although the order summary included a pressure redistribution mattress, barrier cream, and routine skin care, there was no documented evidence that a turning and repositioning program was implemented on admission or that a pressure-relieving device was provided for the wheelchair. PT documented positioning for pressure relief, but there was no indication of an ongoing turning schedule or the amount of time between repositioning. On the day skin breakdown was first noted, staff documented moisture associated skin damage to the sacrum with a red excoriated rash extending to the coccyx, and the record did not show an implemented plan for increased incontinence care or turning and repositioning at that time. The next day, wound care documented a Stage III sacrum/right upper buttock pressure ulcer measuring 3.5 cm by 4.0 cm by 0.1 cm, described as clustered full-thickness wounds with intact skin bridge, granulation tissue, epithelial tissue, and moderate serous exudate. The modified MDS indicated the resident was severely impaired for decision-making, dependent for many mobility and self-care tasks, incontinent, at risk for pressure ulcer development, and had a Stage III pressure ulcer, but it incorrectly coded the ulcer as present on admission. The DON later verified that the baseline care plan did not include preventative skin interventions and that the MDS indicated turning/repositioning and other skin treatments were not in place between admission and the development of the pressure ulcer.
Failure to Provide Ordered Oxygen and BiPAP
Penalty
Summary
The facility failed to provide ordered respiratory care for one resident with diagnoses including malignant right lower lung cancer, COPD, obstructive sleep apnea treated with BiPAP, paroxysmal atrial fibrillation, diabetes mellitus with diabetic polyneuropathy, and a urinary tract infection. The hospital discharge summary indicated the resident was to continue daily oxygen and nightly BiPAP, and the facility admission assessment documented oxygen at 2 liters per minute via nasal cannula and BiPAP. However, the modified admission MDS stated the resident had not been receiving oxygen or respiratory treatments, including BiPAP, upon admission or as a resident at the facility. The record showed the resident’s BiPAP was not established until after admission, and there was no documented evidence that BiPAP settings were established or ordered between admission and early April. The care plan listed CPAP/BiPAP as an intervention but did not document settings until later. A progress note documented that the resident had not been using BiPAP at night because she was concerned the device was not hooked up correctly, specifically regarding oxygen bleed-in, and feared not waking up if she fell asleep with it on. The note stated Respiratory Therapy was to ensure the BiPAP was properly working, but the record contained no documented evidence that RT evaluated the BiPAP. During interview, an RN confirmed the facility was unaware BiPAP had been ordered on admission, the resident did not receive BiPAP as ordered for seven days, and there was no evidence of BiPAP settings in the record until they were clarified and entered during the survey.
Infection Control Lapse During Dressing Change
Penalty
Summary
The facility failed to ensure infection control procedures were followed during a dressing change for Resident #4, who was admitted with diagnoses including heart failure, type 2 diabetes, malnutrition, chronic kidney disease, COPD, cellulitis of the right lower limb, and a chronic ulcer of the right heel. The resident had orders for dialysis every Monday and Friday and for enhanced barrier precautions requiring staff to wear gloves and a gown for high-contact care activities, including wound care. The care plan identified the resident as at risk for infection related to indwelling medical devices and an open wound, and the quarterly MDS noted moderate cognitive impairment, lower extremity impairment on one side, wheelchair use, and a vascular access device. During observation of the dressing change, the ADON and an LPN applied gloves and gowns, placed packaged supplies on the resident’s bed, and placed an empty plastic trash bag on the floor with no barrier. After the old dressing was removed, gloves were discarded into the trash bag on the floor and hand hygiene was performed. Additional supplies were opened and left in their packaging on the bedside table without a barrier. At the end of the procedure, the LPN picked up the trash bag from the floor containing dirty dressing and supplies used during treatment and placed it on the resident’s bed. Both staff members confirmed that no barrier was used between the trash bag and the floor and that the bag was placed on the resident’s bed after the dressing change. The facility policy stated wound care is to be provided in a manner to decrease potential for infection and/or cross-contamination.
Survey Results Not Readily Available for Review
Penalty
Summary
The facility failed to ensure completed survey results were readily available for resident review. During observation, the Survey Result binder was found next to the reception area near the entrance doors and labeled Survey Results Book. Review of the binder showed no evidence of the complaint surveys completed on 05/01/25 and 06/30/25, and both missing surveys had deficiencies issued. The Director of Nursing confirmed during interview that the complaint surveys were not in the Survey Results Book. This affected all 52 residents residing in the facility.
Failure to Timely Assess and Treat New Pressure Ulcer and Maintain Aseptic Wound Care Technique
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess and promptly obtain treatment orders for a newly developed, in-house acquired pressure ulcer, resulting in further decline of the wound. The resident involved had multiple diagnoses including diabetes, diabetic neuropathy, hypertension, atherosclerotic heart disease, repeated falls, altered mental status, and a history of a left buttock Stage III pressure ulcer. The care plan identified the resident as needing assistance with ADLs due to decreased mobility and as being at risk for skin breakdown related to decreased mobility, diabetes, and incontinence, with interventions such as turning and repositioning, staff skin checks, toileting assistance, and appropriate diet. A Braden Scale assessment documented the resident as at risk for pressure injuries, and a quarterly MDS showed moderately impaired cognition and the need for assistance with mobility, but no pressure injuries at that time. On 12/12/25, a Weekly Skin Observation note documented a new reddened, hard area on the buttock measuring 0.5 cm, and a progress note the same day described a small open area on the buttock that was hard and painful to touch. The area was cleaned and covered with a bordered foam dressing, and it was reported to the NP and wound team, but no treatment order was written at that time. There was no further documentation of a buttock pressure ulcer or any ordered or completed treatments until 12/15/25, when a physician order was finally obtained for cleansing, topical antibiotic, dressing changes, and systemic antibiotics, and the location was documented as the left gluteal fold rather than the right buttock. The DON and the former wound nurse later acknowledged that the original documentation of the wound as being on the right buttock was incorrect and that the wound had always been on the left buttock, and the DON verified that no treatment orders or interventions were put in place for three days after the wound was first identified. Subsequent wound care NP notes documented that the buttock wound progressed to an unstageable ulcer and then a Stage III pressure ulcer, with measurements showing a significantly larger wound than initially described, the presence of slough, and later undermining. Orders for specific wound treatments, including Anasept gel, calcium alginate, silicone bordered foam dressings, Mesalt, and antibiotics, were written over time, but there were transcription errors and delays in initiating some NP orders. The DON confirmed that the NP’s 12/18/25 order for Anasept gel and moist gauze was not initiated until 12/23/25 and that the order for a silicone bordered foam dressing was incorrectly transcribed as a dry sterile dressing. A wound culture was obtained, but the facility never received or followed up on the results. During a later observation, the resident’s buttock wound was found without a dressing in place after the resident reported that dressings frequently fell off and were not always replaced when she requested. During the observed dressing change, the RN failed to prepare a clean, dry work area as required by policy, placed clean supplies and scissors on a visibly soiled overbed table, and used scissors that had been placed directly on the dirty surface to cut the dressing before applying it to the wound, contrary to the facility’s wound and skin care procedures.
Failure to Protect Resident From Verbal Abuse by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal abuse by a CNA. The resident had multiple complex medical conditions, including traumatic subdural hemorrhage, COPD, asthma, respiratory failure, diabetes, blindness, heart failure, end-stage renal disease on dialysis, major depressive disorder, generalized anxiety disorder, cannabis use, hypertension, hypothyroidism, and traumatic brain injury. A recent MDS assessment documented intact cognition and no behaviors. On an evening in the dining room, the resident requested assistance from staff to return to her room. One CNA stated she would help when finished passing trays, while another CNA was reported to have responded with an expletive directed at or in front of the resident, in the presence of others, causing the resident to feel embarrassed and humiliated and to be tearful throughout the night. Multiple accounts described the same core event: the resident asked to be taken back to her room after dinner, one CNA indicated she was busy, and the other CNA used the word “[expletive]” in connection with the request. The resident reported that the CNA yelled “[expletive] you” at the dinner table and that she did not like this CNA because she was not nice and seemed to hate her. A social services designee documented that the resident said the CNA said “[expletive] you,” threw her arms down, and that another aide eventually pushed the resident back to her room, where the resident cried herself to sleep in her wheelchair. A witness CNA reported that the CNA in question said, “[expletive] I do not wanna do this,” in a manner that the resident heard, and the resident stated she would report the CNA to the DON. The CNA involved acknowledged in a written statement that she used the expletive in front of the resident after the resident requested to be put to bed, stating she was talking to another CNA and did not realize the resident heard her, and that she later went to the resident’s room to apologize. The facility’s abuse policy states that residents have the right to be free from abuse, including emotional or verbal abuse. Despite the resident’s report of crying herself to sleep and feeling embarrassed and humiliated, review of nursing progress notes for the period around the incident showed no documentation of the incident, emotional distress, or provision of emotional support or counseling. The social services designee stated she followed up with the resident the next day but confirmed there was no documentation in the chart of this follow-up for emotional support.
Failure to Knock Before Entering Resident Room Violates Privacy Policy
Penalty
Summary
The deficiency involves a failure to maintain resident privacy and confidentiality when staff did not knock before entering a resident’s room, contrary to facility policy and resident rights. Resident #16, who had intact cognition and multiple medical diagnoses including respiratory failure, COPD, peripheral vascular disease, diabetes, chronic kidney disease, bipolar disorder, generalized anxiety disorder, lymphedema, and gout, had been admitted to the facility prior to the survey. During an observation and interview on 01/17/26 at 10:12 A.M., Maintenance #106 opened Resident #16’s room door without knocking while conducting fire watch rounds and confirmed at that time that she had not knocked before entering. Review of the facility’s “Ohio Resident Rights and Facility Responsibilities” policy showed that residents have the right, upon reasonable request, to have room doors closed and not opened without knocking, except in emergencies or when not medically advisable as documented by the attending physician, conditions which were not documented for this resident. This failure to knock prior to entering the resident’s room constituted a breach of the facility’s own policy and the resident’s right to privacy, affecting one resident reviewed for privacy out of three sampled.
Failure to Resolve Resident Grievances Regarding Call Light Response
Penalty
Summary
The facility failed to ensure that resident grievances regarding the timely answering of call lights were resolved appropriately and within a reasonable timeframe. Multiple records, including in-service documentation, grievance logs, and resident council minutes, indicated ongoing concerns about delayed call light responses. Specific incidents were documented where residents waited extended periods, ranging from over 26 minutes to more than two hours, for their call lights to be answered. Residents consistently reported long wait times during interviews, and the issue was also raised during resident council meetings. Despite staff being in-serviced on the importance of timely call light response, there was no evidence of follow-up audits or monitoring to ensure compliance. The facility's grievance policy required immediate action to prevent further violations of resident rights, but the lack of timely resolution and monitoring led to repeated and unresolved complaints from residents. This deficiency affected nine residents and was substantiated through multiple sources, including direct resident interviews and review of facility records.
Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
The facility failed to implement infection control standards during resident care, as evidenced by observations involving two residents. For one resident with chronic kidney disease, necrotizing fasciitis, and Fournier gangrene, a wound nurse was observed touching a trash can with gloved hands and then proceeding to perform wound care without changing gloves or sanitizing hands. Additionally, after handling a soiled colostomy bag, the nurse changed from soiled to clean gloves without performing hand hygiene in between, contrary to the facility's hand washing policy which requires hand washing after handling contaminated objects and after removing gloves. In a separate incident, a certified nurse assistant provided incontinence care to another resident with metabolic encephalopathy, COPD, diabetes, and vascular dementia. During care, the CNA changed contaminated gloves but did not perform hand hygiene before immediately donning new gloves to continue care. This action was also inconsistent with the facility's hand washing policy, which specifies that hands should be washed after removing gloves. Both staff members confirmed these practices during interviews.
Failure to Maintain Safe and Palatable Food Temperatures
Penalty
Summary
The facility failed to maintain palatable and appetizing food temperatures for residents, as evidenced by multiple complaints and direct observations. Resident council minutes documented a complaint about cold biscuits and gravy, and several residents reported that their food was sometimes or always cold. During a meal service observation, food items were initially prepared at appropriate temperatures, but a test tray placed on a food cart and distributed last was found to have significantly dropped in temperature. The BBQ chicken measured 122°F, the vegetable blend 107.5°F, and the mashed potatoes and gravy 112°F, all below the facility's policy requirement of holding hot foods at 135°F or above. The facility's policy, consistent with USDA guidelines, requires hot foods to be held at or above 135°F to prevent bacterial growth. However, the observed meal service process allowed food temperatures to fall into the 'danger zone' as defined by the USDA, with the test tray food confirmed to be cold by both thermometer and taste test. The deficiency was identified through resident interviews, review of council minutes, direct observation of meal service, and review of facility policy and USDA guidelines.
Failure to Arrange Ordered Orthopedic Consultation
Penalty
Summary
A deficiency occurred when the facility failed to arrange an orthopedic consultation as ordered for a resident who was admitted with multiple diagnoses, including congestive heart failure, hypertension, atherosclerotic heart disease, atrial fibrillation, venous insufficiency, diabetes, spinal stenosis, hypothyroidism, and anemia. The resident was transferred from assisted living to the skilled nursing facility due to increased difficulty with ambulation, and a new order was received for an orthopedic referral and pain management with Tramadol. Documentation in the medical record and occupational therapy evaluation indicated the resident was experiencing significant right knee pain and was awaiting an orthopedic appointment. Despite the physician's order for an orthopedic referral due to worsening knee pain, there was no evidence in the medical record that the referral was set up during the resident's stay. The resident, who had moderately impaired cognition, continued to report pain and was awaiting further assessment. The facility administrator confirmed that the orthopedic appointment was never scheduled, citing the short duration of the resident's stay as the reason.
Resident Room Not Maintained in Clean and Sanitary Condition
Penalty
Summary
The facility failed to maintain a resident's room in a clean, organized, and sanitary condition. During a facility tour with the Regional Maintenance Director, it was observed that the resident's room contained an empty medication cup on the floor, a basin on the sofa with a dried dark brownish red substance, clothes scattered on the floor, brown discoloration in the toilet with a splattered spot of stool on the toilet tank, and a dried yellow substance in the bottom of the suction machine container at the bedside. The Regional Maintenance Director confirmed these observations, verifying that the room was not clean, organized, or sanitary at the time of inspection. This deficiency was identified during an investigation under a specific complaint number and affected one resident in a facility with a census of 62.
Failure to Use Required PPE During Dressing Change Under Enhanced Barrier Precautions
Penalty
Summary
A deficiency occurred when a registered nurse failed to use appropriate personal protective equipment (PPE) during a dressing change for a resident with multiple medical conditions, including a malignant neoplasm of the esophagus, dysphagia, tracheostomy status, and a jejunostomy feeding tube. The resident had an order for the J-tube site to be cleaned and dressed three times daily, and a recent tracheostomy removal required daily bandage changes. During observation, the nurse donned gloves but did not wear a gown while changing the dressing, despite the presence of green drainage on the dressing and the resident's clothing. The resident's room had an Enhanced Barrier Precaution (EBP) sign posted, and the facility's EBP policy required both gown and glove use during high-contact care activities, such as device and wound care, for residents at risk of multi drug-resistant organism (MDRO) acquisition. The nurse acknowledged not wearing a gown during the procedure, which was inconsistent with facility policy and the posted precautions. This event was identified during a survey and affected one resident out of a facility census of 62.
Facility Fails to Serve Meals at Palatable Temperatures
Penalty
Summary
The facility failed to ensure that meals were served at a palatable temperature, affecting all 55 residents who received meals from the kitchen. Multiple residents, including those with various medical conditions such as atrial fibrillation, diabetes, and chronic kidney disease, reported that their meals were consistently served cold. Observations and interviews confirmed that residents found the food to be cold and unappetizing, with specific complaints about the temperature of the meals. During a tray line observation, it was noted that while food items were initially at a safe serving temperature, by the time they were delivered to residents, the temperatures had dropped significantly. For instance, the brussel sprouts were at 115 degrees Fahrenheit, and the ham was at 120 degrees Fahrenheit, both of which were not considered warm. The Dietary Supervisor confirmed these findings, noting that the food items were not warm enough. Additionally, the facility's concern log indicated previous complaints about cold room trays, and the facility's policy did not address the palatability of meals.
Sanitation and Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and served under sanitary conditions, potentially affecting all 55 residents who received meals from the kitchen. During an observation of the kitchen, several issues were noted, including unlabeled and undated food items in the walk-in cooler and freezer, such as hamburger patties, mashed potatoes, spaghetti sauce, taco meat, and carrots. The dry stock area had an opened bag of gravy mix not dated when opened, and the sandwich cooler had a buildup of shredded cheese. Additionally, the refrigerator/freezer combination unit contained several undated and open-to-air food items, including pickles, parmesan cheese, fish patties, potato wedges, tater tots, and breakfast sausage patties. The Dietary Supervisor confirmed that items should be dated when opened, not open to air, and discarded after seven days. The facility's sanitation audits consistently scored below the desired goal of 90%, indicating ongoing issues with kitchen cleanliness and food storage practices. Multiple audits revealed that a significant number of pieces of equipment in the cook's work area were not acceptable in terms of cleanliness. Additionally, there were repeated findings of undated, uncovered, or unlabeled food items, including moldy hotdogs and pasta. Despite the facility's policy requiring an action plan and follow-up review for scores below 90%, the sanitation scores remained low, with the most recent audit scoring 80%. The dish machine in the facility was also found to be non-compliant with temperature requirements for sanitization. The machine's rinse temperature did not meet the minimum requirement of 180 degrees Fahrenheit, as observed during a facility tour. Despite attempts to rerun the machine, the temperature did not exceed 150 degrees Fahrenheit for the rinse cycle. The facility's policy required manual washing or the use of disposable products if the dishwasher did not meet the proper temperatures. Additionally, the puree process was observed to be inadequate, as the dietary staff did not properly sanitize equipment by submerging it in a sanitizer solution, as required by the facility's procedure.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to maintain the dumpster area in a clean and sanitary manner, which had the potential to affect all residents residing in the facility. During an observation of the dumpster area, a buildup of debris was noted around the base of two dumpsters. The debris included a Styrofoam plate, an empty box of oatmeal cream pies, multiple blue surgical gloves, two large clear fast food plastic cups, a white carafe lid, a plastic shopping bag, several plastic drinking straws, numerous plastic utensils, two small plastic drinking cups, and a medicine cup. The Dietary Supervisor confirmed the presence of the debris during the observation. A review of the facility's Nutrition Services Quality Validation-Kitchen Sanitation document, dated two months prior, indicated that the area was previously noted as unacceptable due to trash around and behind the dumpster. An interview with the Dietitian confirmed that she conducted monthly sanitation audits in the facility kitchen and identified numerous cleanliness concerns. The facility's policy, dated five years prior, stated that trash should not be deposited on the ground for any reason.
Inadequate Diet Consistency for Mechanically Altered Diets
Penalty
Summary
The facility failed to ensure that residents requiring mechanically altered diets were served the appropriate diet consistency, affecting four residents. Resident #12, who had severe cognitive impairment and was on a pureed diet, was served non-pureed au gratin potatoes. The dietary staff did not have a spreadsheet to indicate what each diet was allowed, leading to the error. Similarly, Resident #42, with moderately impaired cognition and on a mechanical soft diet, was served an intact hotdog instead of a ground one, which was corrected after the surveyor's intervention. Resident #153, on a mechanical soft diet, was served tacos with lettuce cut into small square pieces instead of shredded, which was not appropriate for their diet. The dietary staff again lacked a spreadsheet to guide them on diet consistencies, resulting in the improper meal preparation. Resident #202, on a mechanical soft diet, was served ham that was cut up with a knife instead of being ground, which was corrected after the surveyor's intervention. The dietary staff were unsure of the requirements for a mechanical soft diet, contributing to the error. Additionally, the puree process for ham was observed to be inadequate, as the final product was not smooth and had bits sticking to the tongue. The dietary staff did not routinely test the puree consistency, leading to the initial improper preparation. The facility's policy on therapeutic diets, which should match resident orders, was not effectively implemented, resulting in these deficiencies.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 358 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Dover
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| New Dawn Rehabilitation And Healthcare Center | 0 mi | ★★★★★ | 7 | 0 |
| Amberwood Manor | 1.9 mi | ★★★★★ | 0 | 0 |
| Park Village Health Care Center Inc | 2.2 mi | ★★★★★ | 9 | 0 |
| Hennis Care Centre Of Dover | 2.3 mi | ★★★★★ | 0 | 0 |
| Park Village Hc Np Llc | 3.6 mi | ★★★★★ | 0 | 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.