Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Kimes Nursing And Rehab Llc during CMS and state inspections, most recent first.
Failure to Assess and Escalate Care After Fall: A resident with AFib, cirrhosis, weakness, and anticoagulant use had repeated falls and bruising, but staff did not complete a thorough skin assessment or document physician notification. After an unwitnessed fall from bed, the resident later developed hypotension, bradycardia, pallor, blood around the mouth, gurgling respirations, hypothermia, and low O2 saturation, and was ultimately sent to the hospital where he was found to have a C4 fracture, abdominal wall hematoma, acute blood loss anemia, and acute respiratory failure.
The governing body failed to ensure uninterrupted administrative oversight when the facility was left without a licensed NHA with an active Ohio license after the prior administrator resigned. Corporate staff reported the owner’s Ohio NHA license was inactive, BELTSS confirmed the inactive status, and the facility also lacked a full-time onsite DON, relying instead on an interim DON and other offsite corporate support.
A resident with atrial fibrillation, cirrhosis, and anticoagulant use developed bruising after a fall, but the bruise was not fully assessed, the cause was not documented, and no investigation was started or physician notification noted. The resident later deteriorated with blood around the mouth, hypotension, hypothermia, and respiratory distress, and hospital records identified an abdominal wall hematoma, acute blood loss anemia, and a C-4 fracture. The DON confirmed a thorough investigation for injury of unknown origin had not been completed.
A resident with multiple medical conditions and increasing assistance needs experienced repeated falls, including falls from bed and near the bathroom, but the record did not show a comprehensive, individualized fall-prevention program or timely updated interventions. After the first fall, bruising to the abdomen was documented without measurements or a clear cause, and after later falls there were missing vital signs, incomplete skin assessments, and only one neuro check completed. The DON confirmed the fall investigations were not thorough and lacked complete documentation and monitoring.
A resident admitted for placement after hospitalization had discharge instructions for PT and OT to evaluate and treat, along with orders for assisted ambulation and out-of-bed activity. However, the resident was never evaluated or treated by therapy during the stay, and nursing notes later documented that the resident was not currently being treated by therapy despite needing more help with walking, transfers, and toileting. Admissions and the DOR confirmed the resident did not receive therapy, even though referral information included therapy instructions.
The facility failed to provide timely respiratory assessment, provider notification, and treatment for two residents with acute changes in condition. One resident with sleep apnea and severe desaturations had no overnight documentation, and the next shift found abnormal vitals, lethargy, and rales before sending the resident to the hospital for bilateral PE. Another resident with COPD, CHF, COVID, and pneumonia had persistent low O2 sats and abnormal labs without timely provider notification or comprehensive assessment before being transferred and admitted with multifocal pneumonia, acute on chronic hypoxic respiratory failure, and symptomatic anemia. The report also noted lesser skin care issues, including a wound treatment not performed as ordered and delayed identification/treatment of skin impairments.
Failure to administer the facility effectively and efficiently was cited after surveyors found overdue vendor bills, late property tax payment, and a gas shut-off notice, along with gaps in HR screening and QAPI oversight. The facility had not checked the State nurse aide registry for abuse findings for multiple non-nursing employees, had no evidence of an FBI background check for an RN who had not lived in the state for the prior 5 years, and had not shared the facility assessment with the QAPI committee. The Administrator and DON also reported that QAPI was not yet effective and that no current PIPs were in place.
The facility failed to complete required pre-employment screening for multiple new hires. The State nurse aide registry was not checked for 30 non-nursing employees, an RN who had not lived in the state for the prior five years did not have an FBI background check completed, and no reference checks were done for 90 employees. HR confirmed these checks were not being performed for the affected staff, and the facility policy required background checks for employees with disqualifying findings.
Failure to Maintain Required RN Coverage: The facility did not ensure RN coverage for eight consecutive hours and did not maintain the required RN staffing pattern. The facility assessment called for three nurses on day shift and two at night, but the DON was the only RN scheduled and worked only a partial shift. The DON confirmed there was no RN coverage for eight consecutive hours, and the staffing report showed excessively low weekend staffing and a one-star staffing rating.
The facility failed to complete annual performance evaluations for multiple CNAs. Review of personnel files showed several CNAs had no annual evals on file, and HR confirmed the evaluations were not completed on or within 30 days of their due dates. The DON job description identified responsibility for assisting HR with performance evaluation schedules and annual reviews for the nursing service department.
Unsanitary Dry Food Storage Room: The kitchen dry storage room door was propped open despite having a self-closing mechanism, and loose uncooked pasta and an unpeeled potato were found on the floor under a storage shelf near a rodent trap. The Dietary Manager confirmed the door should not have been propped open and acknowledged the food on the floor was not helping with rodent issues.
Inadequate QAPI and QA Program Oversight: The facility failed to maintain an adequate QA and program improvement program for all 56 residents. The facility assessment was not shared with the QAPI committee by the time of survey, and the DON and Administrator stated the QA committee met monthly and reviewed trends such as falls, wounds, behaviors, infections, and ADLs, but there were no current PIPs in place. They also stated QAPI was not yet effective and described it as a work in progress.
Infection control practices were not followed for wound care, device care, and water management. An LPN did not use a gown for residents on EBP, placed treatment supplies on unclean surfaces, used and reused a non-disposable tape measure during wound care, failed to wash hands between glove changes, and handled gauze that had fallen on the floor. The facility also did not follow its Legionella water management procedure for outlet cleaning, chiller service, or water sampling, and a resident’s CPAP equipment was observed stored directly on the bedside table instead of in a sanitary bag.
Failure to provide required annual CNA in-service education. Review of personnel files showed that multiple CNAs had no evidence of completing the required 12 hours of annual in-service training, and HR confirmed the missing documentation. This deficiency affected all residents in the facility.
Resident trust funds were not consistently accessible after business hours for residents whose money was managed by the facility. The BOM said petty cash should be available at all times through a lock box and the rehab charge nurse, but an LPN working as the charge nurse said she was unaware of any petty cash box and did not know how to obtain cash for residents when the business office was closed.
Care plans were not consistently reviewed and revised by the full IDT after assessments. A resident with ESRD, diabetes, and HTN reported no care plan meeting in months, and the last documented conference included only the resident and SW. Another resident with multiple neuropsychiatric diagnoses had no documented care conferences since admission, and a family member wanted to participate in discussions about declining mobility. A resident with Alzheimer’s disease had a conference documented with only the resident, son, and SW, while another resident’s skin-protection care plan was not updated after he was observed not wearing ordered Geri-sleeves.
A facility failed to keep several residents’ drug regimens free from unnecessary medications. One resident received prednisone longer than ordered, two residents continued on antibiotics without completed infection surveillance or documented symptoms supporting ongoing treatment, and a resident with chronic pain had PRN acetaminophen and oxycodone orders without parameters to guide administration based on pain level. The DON confirmed the medication-order and surveillance issues.
Incorrect Dessert Portion for CCD Residents: Two residents on a CCD were served a full pre-packaged lemon bar instead of the half-serving listed on the specialty menu. During tray line observation, meal tickets confirmed the residents' CCD orders, and the dessert was placed on their trays with the rest of the meal. The Dietary Manager confirmed the portion error and noted that other residents on CCD were also subject to the same menu requirement.
Inaccurate resident documentation in skin, oxygen, and nail care records. The facility charted skin assessments that did not match bedside findings for two residents with bruising, documented oxygen tubing changes that staff confirmed had not occurred for a resident on O2, and recorded nail care for another resident even though the LPN later admitted it was not done. The DON and ADON confirmed the records were inaccurate.
A resident with severe cognitive impairment and transfer dependence was sent to an eye appointment with only a driver, despite needing staff assistance for transfers and toileting; the resident was anxious, unable to explain why she was there, and office staff had to help her to the restroom. Another resident with a history of falls was observed without the Dycem and footwear interventions listed in the care plan, and staff confirmed the fall-prevention measures were not in place.
Failure to Obtain Informed Consent for Psychotropic Medication: A resident with dementia, depression, and anxiety was prescribed multiple psychotropic medications, including an antidepressant, but the record lacked documented informed consent from the legal guardian for the new antidepressant before it was started. The DON confirmed there was no evidence consent had been obtained, despite facility policy requiring discussion of the medication’s risks, benefits, alternatives, and right to refuse before initiation.
Resident funds were not accurately accounted for when the facility deducted $970 from a cognitively impaired resident’s account for personal items, but had no receipts and stated the money was never actually used. The BOM said the amount should have been credited back but had not been, and the resident’s daughter reported she was unclear how the amount was determined and was later told there was no money in the account.
Failure to Notify Provider of Respiratory Decline Two residents had significant changes in condition with low O2 saturations, but staff did not promptly notify the provider in one case and did not document or escalate the overnight decline in the other. One resident with pneumonia, COPD, CHF, and acute on chronic respiratory failure had O2 sats in the low 70s to 80s, while another resident with sleep apnea and CPAP needs was lethargic with O2 sats in the 70s to 80s and abnormal vitals before the physician was finally contacted for ER transfer. Interviews confirmed the physician expected notification for sats in the 70s and a full assessment when vitals were abnormal.
Failure to provide required Medicare coverage notices for three residents when skilled services ended. Two residents did not receive NOMNCs because their discharge plans were to go home, and one resident with a LTC plan received a NOMNC but no ABN. The BOM stated she was not aware the notices were required and had not received training on NOMNCs or ABNs.
Failure to Provide Written Bed-Hold Notice at Transfer: A resident with CVA, DM, RA, and HTN was transferred to the hospital for stroke-like symptoms, but the facility did not provide the resident or representative written notice specifying the bed-hold policy duration at the time of transfer. The BOM confirmed there was no evidence the required notice was given, despite the facility policy requiring written notice when a resident is transferred for hospitalization or therapeutic leave.
MDS assessments were coded inaccurately for three residents. One resident’s diabetes medication, Mounjaro, was incorrectly counted as insulin on the MDS, another resident’s Plavix was incorrectly coded as an anticoagulant instead of an antiplatelet, and a third resident who wore glasses was coded as having adequate vision with no corrective lenses despite reports that she needed replacement glasses.
PASARR assessments were not accurately completed or updated for multiple residents with mental health diagnoses. One resident’s PASARR did not reflect depression, anxiety, or psychotic disorder; another resident’s PASARR left the mood disorder field blank despite bipolar disorder; and a third resident’s PASARR missed personality disorder and delusional disorder, resulting in no Level II referral. The AD acknowledged the omissions and stated some PASARRs had not been completed accurately.
Care plans were not fully implemented for two residents. One resident with BLE edema had physician orders for leg elevation and compression stockings, but no care plan addressed the edema and she was observed up in her wheelchair with swollen legs, no stockings, and her feet dependent. Another resident with a fall-risk care plan was observed without Dycem in her reclining wheelchair and later wearing non-skid footwear that was not in place, despite the plan calling for Dycem and appropriate footwear when out of bed.
A facility failed to ensure residents received needed hygiene care, including showers, facial hair removal, and nail care. One resident with dementia had long chin hair that staff delayed removing, another resident with Parkinson's disease missed scheduled showers, and a third resident with Parkinson's disease had long facial hair and fingernails despite orders for weekly nail care and assistance with shaving.
Failure to ensure access to vision services: Two residents did not receive needed eye care or follow-up. One resident needed replacement glasses, but the facility did not arrange an eye appt or transportation, and the mobile vision provider had no set schedule. Another resident had an eye consult recommending artificial tears and a return visit for cornea eval, but the drops were not provided and no follow-up eye visit occurred.
Failure to provide ordered oxygen therapy and maintain respiratory equipment affected two residents. One resident with COPD had weekly oxygen tubing and humidifier changes documented even though the tubing and bottle were found dated weeks earlier, and an LPN and ADON confirmed the documentation did not match what was actually done. Another resident with severe cognitive impairment was observed with the nasal cannula in place but the oxygen concentrator turned off, and the resident said she was having a hard time breathing until a CNA turned the oxygen back on.
The facility failed to ensure pharmacy recommendations from monthly med regimen reviews were timely addressed for two residents. One resident with COPD and multiple mental health diagnoses had delayed physician response to recommendations about Valium, Buspar, and Advair instructions, while another resident with psychosis, dementia, and PTSD had repeated pharmacist concerns about Wellbutrin SR that were not implemented or adequately addressed by the physician.
Failure to obtain and review ordered lab results for a resident with severe anemia. The resident had COPD, CHF, respiratory failure, pneumonia, and repeated critically low Hgb values, and the MD ordered CBC/retic, iron studies, and occult stool testing to evaluate the cause. Nursing notes showed the blood work was drawn and sent out, but the results were not received or reviewed by the facility for an extended period, and the occult stool samples were not obtained.
Failure to monitor antibiotic use: The facility did not complete required antibiotic surveillance reviews for three residents who received antibiotics for suspected or diagnosed UTIs. In two cases, culture results and nursing findings showing no urinary symptoms were not discussed with the physician to determine whether antibiotics should continue, and in another case there was no evidence of the required surveillance form being completed for a resident treated with Bactrim DS.
Failure to offer and document flu and pneumonia vaccines for a resident. A resident admitted with acute and chronic respiratory failure, morbid obesity, HTN, and schizoaffective disorder had no record of education or offering of the influenza or pneumococcal vaccines, and the ADON confirmed there was no evidence this was done. Facility policy required vaccine education and offering on admission or within the specified timeframe.
Failure to Educate and Offer COVID-19 Vaccine: A resident with acute and chronic respiratory failure, morbid obesity, HTN, and schizoaffective disorder was admitted without evidence of COVID-19 vaccine education or an offer of the vaccine. The record showed no prior immunization, and the ADON confirmed there was no evidence the vaccine had been offered on admission despite facility policy requiring education and documentation.
An agency LPN prepared and administered evening medications for two roommates at the same time in a dark room, placing both sets of pills into labeled cups and later admitting this practice. As a result, a resident who had no orders for benzodiazepines or opioids was erroneously given his roommate’s Xanax, Percocet, and Gabapentin, while his own ordered medications were documented as given. Shortly after administration, the roommate reported to a CNA that his pain medications did not feel like they had worked, and later stated that he believed the medications had been mixed up. The affected resident became increasingly lethargic over the evening, but despite abnormal presentation and staff concern, the LPN did not promptly notify a physician or report a suspected med error, and only contacted the on-call provider and EMS after the resident became unresponsive, hypotensive, and bradycardic. EMS and hospital records documented unresponsiveness, pinpoint pupils, hypotension, bradycardia, treatment with Narcan and Atropine, ICU admission, and a urine drug screen positive for benzodiazepines and oxycodone, confirming a significant medication error and associated deterioration in the resident’s condition.
The facility did not update the state survey agency regarding changes in its administrative leadership, including an interim Administrator who served for several months and the current Administrator. A review of the EIDC website showed that these administrators were not listed as required, and the current Administrator acknowledged that the facility had failed to report these changes. This non-compliance affected all residents and was identified during a complaint investigation.
The facility did not maintain an effective training program for new CNAs, as evidenced by two CNAs lacking required education in compliance and ethics, the QA program, behavioral health, and effective communication. Review of personnel files showed missing training modules for these staff members, and HR confirmed that the required training had not been completed. This issue was identified as an incidental finding during a complaint investigation affecting all residents.
A cognitively intact resident with multiple chronic conditions, who was not ordered any benzodiazepines or opioids, became progressively lethargic and then unresponsive after an agency LPN prepared and administered bedtime medications for him and his roommate at the same time. The roommate later reported he believed their medications had been switched, noting his usual gabapentin and oxycodone were missing and that he did not experience his typical pain relief, while his roommate quickly became "out of it" and difficult to arouse. Staff initially attributed the affected resident’s lethargy to fatigue from a room change, did not promptly notify the physician when the change in condition was first observed, and allowed his condition to worsen over several hours before calling EMS, who found him hypotensive, bradycardic, unresponsive with pinpoint pupils, and later documented a urine drug screen positive for benzodiazepines and oxycodone—drugs ordered for the roommate but not for the affected resident. Despite these findings and consistent reports from the roommate and family, facility leadership did not substantiate a medication error or clearly correlate the resident’s change in condition to a suspected medication mix-up.
A resident with intact cognition reported to staff, through her son and in her own interview, that one of several lottery tickets she had received, which she believed to be a $250 winner, was missing while the other non-winning tickets remained in her room. The resident and her son searched the room without finding the ticket, and multiple staff, including CNAs, RNs, and the ADON, later confirmed seeing lottery tickets on the bedside table but could not account for the missing winning ticket. The situation was recognized by the social worker, Administrator, and DON as a potential misappropriation that should be reported to the state under facility policy, yet neither the Administrator nor the DON submitted the required state report within the mandated timeframe, resulting in a failure to report an allegation of misappropriation.
The facility failed to provide scheduled showers to three dependent residents who required staff assistance with ADLs due to conditions such as dementia, muscle weakness, hypertension, cancer, osteoarthritis, cognitive deficits, and pain. Care plans and MDS assessments documented that each resident needed staff help with bathing/showering, and the facility’s shower schedules specified twice-weekly showers on designated shifts. However, shower records showed multiple missed shower dates for each resident, and the ADON confirmed that these residents did not receive their scheduled showers and that no additional documentation existed to show the care was provided.
A resident with type II DM, hidradenitis suppurativa, and MASD had a care plan and physician orders for daily non-pressure wound care, including cleansing with chlorhexidine, application of clindamycin gel, calcium alginate or ABD pads, and nystatin powder to the peri-wound area. Review of treatment administration records showed multiple days on which the ordered daily wound treatments were not documented as completed. The ADON confirmed that these wound care treatments were not performed as ordered and that there was no documented reason for the missed treatments or additional supporting documentation.
Surveyors found that the facility did not implement care-planned fall-prevention interventions for two high-risk residents. One resident with severe cognitive impairment, gait abnormalities, and a history of multiple falls had a care plan requiring her walker to be kept within reach in her room, but during observation only her wheelchair was at bedside and no walker was accessible; a CNA familiar with her care needs was unaware she had a walker and confirmed it was not in reach. Another resident with hemiplegia, muscle weakness, and dependence for transfers had a care plan requiring provision of a reacher/grabber and encouragement to use it when items fell, yet she was observed in bed without the device in reach, later found stored on a distant nightstand; the resident confirmed it was not accessible, and an LPN verified that the reacher/grabber was a planned fall-prevention intervention that was not in place.
Surveyors observed an RN enter the room of a resident on transmission-based precautions for Covid-19 to administer morning medications wearing only an N-95 respirator and gloves, without a required gown, despite the facility’s Covid-19 policy mandating a respirator, gown, gloves, and eye protection for confirmed Covid-19 cases. The resident, who had multiple comorbidities including CHF, CKD, hypertensive heart disease, and morbid obesity, reported it was the tenth and final day of isolation following a positive Covid-19 test. A PPE cart was present outside the room, but the RN stated there were no gowns in it and admitted she did not check other carts, even though she knew a gown was required. The Droplet Precautions sign identifying the resident’s status was not prominently displayed, resting diagonally on a handrail and partially obscured by hallway equipment, and the medical record lacked a specific physician order detailing the need for and duration of Covid-19 TBP.
The facility failed to enforce its COVID-19 infection prevention and control policy during an outbreak affecting all residents. Despite posted instructions requiring N95 masks at all times, multiple night-shift staff, including LPNs and CNAs, were observed working without any masks, even while caring for residents with confirmed COVID-19. Some staff stated they were unsure of mask requirements or did not believe masks were effective. In addition, a CNA entered the room of a resident on droplet/contact precautions for COVID-19 wearing a gown, gloves, and an N95 mask but no eye protection, later stating she did not know eye protection was required, while an RN confirmed it was. Facility records showed numerous residents had recently tested positive for COVID-19, and the written policy required source control and full PPE (N95, gown, gloves, eye protection) for staff entering rooms of residents with suspected or confirmed infection, which was not consistently followed.
Three residents with severe cognitive impairment and dependent on staff for bathing did not receive scheduled showers on multiple occasions, as confirmed by care records and staff interviews. Staff reported that showers were missed during periods of inadequate staffing, with priority given to other essential care tasks. The DON confirmed that residents' shower preferences were documented and that the missed showers occurred as indicated in the records.
Two residents with significant medical conditions did not receive timely or accurate pressure ulcer care, including a nurse treating the wrong site and delays in initiating ordered treatments. Nursing staff also failed to document wound assessments on the correct dates, and treatments were not started promptly after physician orders, contrary to facility policy.
A resident with dementia and chronic respiratory failure was allegedly physically abused by a CNA during care. The incident was witnessed by another CNA, who delayed reporting it. The facility failed to notify law enforcement or the resident's family, and the Administrator did not substantiate the allegation due to insufficient evidence. This represents non-compliance with the facility's abuse prevention policy.
The facility failed to offer pneumococcal vaccinations to several residents, as revealed by a review of medical records and consent forms. The affected residents, who had various medical conditions, either did not have a record of receiving the vaccine or had no physician orders for it. The facility's consent process relied on residents or their families to request the vaccine, and there was no specific consent form for pneumococcal vaccination. The DON acknowledged the lack of proof that residents were asked about receiving the vaccine.
Failure to Assess and Escalate Care After Fall
Penalty
Summary
The facility failed to timely identify, assess, and obtain necessary medical intervention for a resident after an unwitnessed fall from bed. The resident had diagnoses including osteomyelitis, atrial fibrillation, cirrhosis of the liver, weakness, debility, and was receiving anticoagulant therapy. He was cognitively intact, dependent on staff for several activities of daily living, and at risk for falls. His care plan directed staff to monitor and document after falls and to report pain, bruising, mental status changes, and other concerns to the physician. After earlier falls in the facility, staff documented bruising to the resident’s right abdominal side, but the record did not show a thorough assessment of the bruising, measurements, or physician notification. The resident also had low hemoglobin and hematocrit values before the final fall. Following the unwitnessed fall from bed, the resident was noted to have slid onto the floor, denied hitting his head, and had initial vital signs that included low oxygen saturation. A skin assessment was not completed, and only one neuro check was documented. During the night after the fall, the resident developed hypotension and bradycardia, and the physician was notified with instructions to discontinue diltiazem and send the resident to the emergency room if distress developed. No additional assessment, increased monitoring, or further medical intervention was documented until the next morning, when the resident was found pale, with blood around his mouth, gurgling respirations, inability to clear secretions, agitation, hypotension, hypothermia, low oxygen saturation, and pinpoint nonreactive pupils. He was then transferred to the hospital, where imaging showed an acute C4 fracture, a large abdominal wall hematoma, and acute respiratory failure. He required blood transfusions and was later intubated and admitted to the ICU.
No Active Licensed Administrator Onsite
Penalty
Summary
The governing body failed to ensure the facility had uninterrupted administrative oversight by a licensed nursing home administrator with an active Ohio license after the previous administrator resigned. At the time of survey entrance, no licensed nursing home administrator was present in the facility. Corporate staff stated the previous administrator had resigned earlier that day, and the facility owner was licensed in Ohio but his license was inactive as of 04/01/26, which was confirmed by online licensure verification and by the Board of Executives of Long-Term Services and Supports (BELTSS). The Board also verified that the owner had been notified about the inactive license on 04/20/26 and had no evidence of attempts to reactivate it between that date and 06/29/26. During the investigation, corporate staff stated the facility did not have a full-time onsite DON and was using an interim DON who was out of state and reachable by phone. The previous administrator stated he resigned because of concerns including the owner’s direction to terminate the DON the prior week, leaving the facility without full-time onsite nursing oversight, and the use of a corporate clinical director in another state. The owner later stated the previous administrator had given notice and that the facility was trying to arrange interim coverage, but he did not provide evidence that measures were in place to ensure uninterrupted administrative services. Additional observations on 06/30/26 showed there was still no licensed nursing home administrator with an active Ohio license onsite to provide administrative oversight.
Failure to investigate injury of unknown origin after hematoma and C-4 fracture
Penalty
Summary
The facility failed to investigate an injury of unknown origin after Resident #160 was found to have an abdominal wall hematoma and a closed fracture of the left fourth cervical vertebrae. The resident had been admitted with diagnoses including osteomyelitis, atrial fibrillation, cirrhosis of the liver, and need for assistance with personal care. He was cognitively intact on the MDS, dependent on staff for toileting hygiene, personal hygiene, and bathing, and required substantial maximum assistance with transfers and bed mobility. Following a fall, an incident follow-up note documented bruising to the right side of the abdomen, but there was no documentation of the cause of the bruising, no comprehensive assessment with measurements or description of the bruise, no mention of physician notification, and no investigation started to determine whether the bruising was related to the fall. Medical Director progress notes later contained no mention of falls or bruising to the right abdomen. The resident was also receiving anticoagulant therapy and had physician orders to observe for bleeding, skin discoloration, changes in mental status, and vital signs, with progress notes and physician notification required. On 06/25/26, the resident was found pale, with blood around his mouth, gurgling respirations, soft garbled speech, agitation, hypotension, hypothermia, tachycardia, low oxygen saturation, and pinpoint non-reactive pupils, and he was transferred to the hospital. Hospital records showed abdominal wall hematoma, acute blood loss anemia, hemorrhagic disorder due to extrinsic circulating anticoagulants, acute respiratory failure with hypoxia, bilateral pleural effusions, and a closed displaced fracture of the C-4 vertebra. The DON confirmed that a thorough investigation for injuries of unknown origin had not been completed after the hospital identified the abdominal hematoma and C-4 fracture.
Incomplete fall assessment and monitoring after repeated resident falls
Penalty
Summary
The facility failed to develop and implement a comprehensive, individualized fall-prevention program for a resident admitted with osteomyelitis, need for assistance with personal care, atrial fibrillation, and cirrhosis of the liver. The resident’s initial fall risk evaluation identified low risk, but after the first fall the resident was found on the floor near the bathroom door with his walker beside him and stated he hit his head on the door. He was assessed, assisted back to bed, and educated to use the call light, and a bathroom-door reminder sign was placed. The record also documented bruising to the right side of the abdomen after the fall, but the follow-up note did not include measurements, a description, or the cause of the bruising. The resident fell again the next day when he slipped off the bed, and the only new intervention documented was placing the bed in the lowest position when occupied. No vital signs or skin assessment were documented after that fall. The care plan and interdisciplinary notes referenced monitoring, reporting bruising or mental status changes, and identifying causes of the falls, but the record did not show timely, updated interventions addressing the resident’s weakness, unsteady gait, poor balance, or delusions. Nursing documentation later noted the resident needed help with walking, transferring, and toileting more than usual, yet there was no evidence of new fall-risk or safety interventions being initiated at that time. The resident continued to have falls, including an unwitnessed fall in which he slid out of bed onto the floor. Vital signs were obtained and neuro checks were started, but only one neuro check was completed and no skin assessment was documented. The DON confirmed the fall investigations after the resident’s falls were not thorough or complete and lacked comprehensive skin assessments and vital sign monitoring, and also confirmed there should have been more detail documented about the second fall. The record further showed the resident had two falls and possible ataxia was questioned, but there was no documented treatment or follow-up related to that concern.
Therapy Services Not Provided as Ordered on Admission
Penalty
Summary
The facility failed to ensure specialized rehabilitative services were provided as ordered for a resident admitted with osteomyelitis, atrial fibrillation, cirrhosis of the liver, and need for assistance with personal care. Hospital discharge records showed the resident was to discharge to a skilled nursing facility with orders for physical and occupational therapy to evaluate and treat, along with activity orders to ambulate with assistance at least three times a day and remain out of bed to a chair all day. However, the resident’s physician orders for the month did not include physical or occupational therapy services, and the resident’s care plan identified significant dependence for activities of daily living, bed mobility, transfers, and ambulation due to muscle weakness and debility. Nursing documentation on 06/10/26 noted the resident required more than usual help with walking, transferring, and toileting and stated the resident was to be receiving therapy services with a goal to return home, yet another note the same morning stated the resident was not currently being treated by therapy. The resident’s sister stated the resident had lived at home alone before hospitalization and had been admitted for placement because he could not care for himself, and she voiced concern that therapy was supposed to be provided after admission but was never given. The Director of Rehab confirmed the resident did not receive therapy at any point during the stay, and Admissions stated she told therapy the resident did not need evaluation because therapy was not ordered or required, despite later confirming the referral information included instructions for PT and OT to evaluate and treat as needed.
Delayed Respiratory Assessment and Treatment
Penalty
Summary
The facility failed to ensure residents with acute respiratory changes and decline in condition received comprehensive assessment and timely treatment. For one resident with altered respiratory status and sleep apnea, the record showed no notes, vitals, or assessments documented overnight even though staff later reported oxygen saturations in the 70s and 80s, lethargy, and labored breathing. The day nurse completed an assessment only after report at the start of the next shift, found abnormal vital signs and bilateral rales, and the resident was then transferred to the hospital, where he was admitted with bilateral pulmonary embolisms and remained hospitalized for nine days. A second resident with COPD, CHF, pneumonia, COVID, and acute on chronic respiratory failure had continued low oxygen saturations over multiple days without timely intervention or provider notification. The record showed oxygen saturations as low as the 70s and 80% while oxygen was in place, but there was no evidence that the provider was notified at those times or that a comprehensive respiratory assessment was completed. The resident also had critically low hemoglobin and abnormal lab results, and the physician stated he was not made aware of the respiratory decline and would likely have sent the resident to the emergency department if he had known about the low oxygen levels along with the anemia. The resident was ultimately sent to the hospital and admitted with multifocal pneumonia, acute on chronic hypoxic respiratory failure, and acute on chronic symptomatic anemia. The report also identified additional care issues that did not rise to the level of harm. One resident’s right thigh skin tear was treated without cleansing the wound first as ordered. Other residents had skin impairments that were not identified and treated timely, and compression stockings used for peripheral edema were not applied as ordered. The report further noted that the facility’s investigation into the respiratory event for the first resident consisted only of a staff statement and a disciplinary form.
Failure to Administer Facility Resources and Oversight
Penalty
Summary
The facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently, affecting all 56 residents in the building. Survey findings showed multiple administrative and operational breakdowns involving unpaid bills, incomplete oversight of required background checks, and ineffective QAPI processes. The annual recertification and complaint survey began on 05/17/26, and the facility census was 56. Record review and interviews showed the facility had overdue financial obligations, including property taxes, a gas bill with a shut-off notice, and a bakery vendor account that remained unpaid beyond normal terms. A gas provider statement dated 05/14/26 showed $1,011.39 due immediately with shut-off scheduled for 06/01/26, and another amount of $672.88 due on 05/29/26. A bakery invoice dated 05/23/26 showed $1,975.03 owed dating back to 01/12/26, and the vendor stated the facility typically paid about 82 days overdue. The Administrator confirmed the gas bill was not paid until 05/26/26, and the local Treasurer’s office receipt showed property taxes were paid on 05/26/26 after the survey team requested evidence of payment. The survey also found the facility did not follow required hiring and background check processes. The personnel file for an Activity Assistant hired on 01/29/25 had no evidence that the State nurse aide registry had been checked for abuse findings at hire, and Human Resources staff confirmed this had not been done. Review of employee records showed 30 additional non-nurse, non-nursing assistant employees hired since November 2025 also had not been checked against the State nurse aide registry. In addition, an RN hired on 11/14/25 had signed a residency form indicating she had not lived in the state for the previous five years, but there was no evidence that the required FBI background check had been completed. The facility assessment dated 02/23/26 stated it would be shared with the QAPI committee at a TBD date, but there was no evidence it had been shared by the time of survey. Interviews with the Administrator and DON showed they did not feel QAPI was effective yet, had no current performance improvement plans in place, and had not identified current concerns related to change in condition, physician notification, ADLs, staff training and evaluations, infection control, financial solvency, or documentation. The Administrator also stated he did not have access to the facility policy and procedure manual until the evening before the interview. The Administrator and DON job descriptions identified responsibilities for policy review, background checks, budgeting, financial oversight, and nursing service oversight, but the survey findings showed those functions were not being carried out as described.
Failure to Complete Required Pre-Employment Background Checks
Penalty
Summary
The facility failed to complete required pre-employment background screening for multiple newly hired employees. Review of personnel files and staff interviews showed the State nurse aide registry was not checked for findings of abuse for 30 employees hired since November 2025 who were not nurses or nursing assistants, including activity staff, administrators, housekeepers, receptionists, dietary staff, cooks, and physical therapy assistants. Human Resources staff confirmed the registry had only been checked for nurses and nurse aides and that she was not aware it was required for other employees. The facility policy stated it would conduct employee background checks and would not knowingly employ individuals with findings of abuse, neglect, exploitation, misappropriation of property, or mistreatment, but the policy did not specifically address reference checks with previous or current employers. The facility also failed to complete an FBI background check for an RN who had not lived in the state for the previous five years, despite a signed consent form indicating that both state and FBI fingerprint checks were required. In addition, there was no evidence that any attempts had been made to check information from previous or current employers for 90 employees hired since November 2025, and Human Resources staff confirmed that reference checks were not completed for any of those employees. The report identified 56 residents residing in the facility as affected by these failures.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure RN coverage daily for eight consecutive hours and failed to maintain the required RN staffing pattern. Review of the facility assessment showed that staff needed for resident care included RNs and licensed nursing staff, with three nurses required on day shift and two at night. A review of the staffing schedule for 05/03/26 showed the DON was scheduled from 2:00 P.M. to 6:00 P.M. and was the only RN scheduled that day. Review of the Staffing Data Report dated 05/08/26 showed the facility had triggered excessively low weekend staffing and a one-star staffing rating for the first quarter of 2026. During interview on 05/26/26 at 9:15 A.M., the DON confirmed there was not an RN for eight consecutive hours on 05/02/26. The DON job description dated 01/08/26 stated the DON was responsible for ensuring a sufficient number of licensed practical and/or registered nurses for each tour of duty to maintain quality of care.
Missing Annual CNA Performance Evaluations
Penalty
Summary
The facility failed to ensure annual nurse aide performance reviews were completed. Review of personnel files showed CNA #125, hired on 10/12/23, had not received an annual performance evaluation, CNA #106, hired on 04/10/15, had not received an annual performance evaluation, and CNA #203, hired on 07/24/87, had not received an annual performance evaluation. Interview with HR #163 on 05/27/26 at 9:07 A.M. confirmed that CNA #106, #125, and #203 did not have annual evaluations completed on or within 30 days of their due dates. Review of the DON job description showed the DON was responsible for assisting HR in developing performance evaluation schedules, criteria, and annual reviews for the nursing service department.
Unsanitary Dry Food Storage Room
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in the dry storage room located in the kitchen. During observation while tray line was being monitored for the lunch meal, the dry food storage room door was found propped open even though it had a self-closing mechanism, with a lanyard strap tied around the door knob and a metal shelf inside the room. Loose uncooked pasta noodles and a large uncooked, unpeeled potato were found on the floor under a bottom rack of a metal storage shelf, and a rodent trap was also present on the floor in that area. The Dietary Manager confirmed the door should not have been propped open and acknowledged that leaving food products on the floor would not help with rodent problems in the area.
Inadequate QAPI and QA Program Oversight
Penalty
Summary
The facility failed to maintain an adequate quality assurance and program improvement program for 56 of 56 residents. Review of the facility assessment dated 02/23/26 showed the assessment was to be shared with the QAPI committee at a TBD date, and there was no evidence it had been shared with the committee by the time of the annual recertification survey that began on 05/17/26. The facility assessment also identified that the facility was licensed for 61 beds with a daily average census of 55-59 residents. The assessment stated that policies and procedures were to be evaluated with each regulatory update and with new technologies introduced to staff. During an interview on 05/27/26, the DON and Administrator stated the QA committee meets monthly and that quarterly meetings are used to identify trends and review MDS-related information including falls, wounds, behaviors, pharmacy, weights, infections, rehab, and ADL management. The Administrator stated previously identified trends included falls, showers, grievance reporting, medication errors, infection control, and training requirements, and that when a trend is identified a PIP is created with root cause analysis and a timeframe for improvement. At the time of the interview, there were no current PIPs in place, and the Administrator and DON stated they had not identified current concerns for change in condition, physician notification, ADLs, staff training and evaluations, infection control, or documentation. They also stated they did not feel QAPI was effective yet and described it as a work in progress.
Infection Control Program Not Implemented
Penalty
Summary
The facility failed to implement its infection prevention and control program for standard precautions, enhanced barrier precautions (EBP), and Legionella prevention. During observation of wound care for a resident with diabetes, hypertension, cerebral palsy, and bilateral heel deep tissue pressure ulcers, an LPN placed treatment supplies on the resident’s overbed table without a barrier and did not clean the table first. The LPN did not wear a gown even though the resident was on EBP, used a non-disposable tape measure to measure the wounds, touched the heels with the tape measure, and then placed the tape measure in her pocket and later on the treatment cart without cleaning it. The LPN also returned wound cleanser and gauze to the treatment cart after they had been placed on the bedside table without a barrier, and the box of gloves used during treatment was set back on the cart. For another resident with a suprapubic catheter and a skin tear on the right thigh, an LPN measured the wound with a non-disposable tape measure and cleaned the tape measure with an alcohol wipe afterward. During suprapubic catheter care, the same LPN dropped a multi-pack of gauze sponges on the floor and then placed them on top of the treatment cart. The LPN applied gloves but did not wear a gown despite the resident being on EBP. After removing soiled gloves, the LPN did not wash hands before putting on clean gloves. The DON confirmed staff should wear a gown for residents on EBP, should not place items on the cart after they have been dropped on the floor, and should wash hands after removing gloves and before putting on clean gloves. The facility’s Legionella water management procedure identified multiple water system components for monitoring and control, including hot and cold water outlets, the chiller, and random water sampling. However, review of maintenance records showed hot and cold water outlets were maintained monthly instead of weekly as required by the procedure, there was no evidence the chiller was serviced monthly by a contractor, and there was no evidence of random water sampling. The Maintenance Director stated he did not know whether the water had been sampled for Legionella and felt he needed training on the prevention procedures. The Administrator also stated he did not know whether sampling had been done or how often it should occur, and confirmed the outlet maintenance frequency did not match the procedure. A third resident on CPAP/BiPAP had the device observed laying directly on the nightstand, and the CPAP mask was also observed laying directly on the bedside table rather than being stored in a sanitary bag. These observations were made in the context of the facility’s infection control concerns and were included among the findings related to the failure to implement the infection prevention and control program.
Failure to Provide Required Annual CNA In-Service Education
Penalty
Summary
The facility failed to ensure that staff received a minimum of 12 hours of in-service education per year. Review of personnel files showed that CNA #125, hired on 10/12/23, had no evidence of at least 12 hours of annual in-service education. CNA #151, hired on 08/14/23, also had no evidence of completing the required annual in-services. CNA #132, hired on 09/16/21, likewise had no evidence of at least 12 hours of annual in-service education. During an interview on 05/27/26 at 9:07 A.M., HR #163 confirmed that CNA #125, #151, and #132 had no evidence of completing at least 12 hours of in-services annually. This deficiency affected 56 of 56 residents living in the facility.
Resident Trust Funds Not Accessible After Hours
Penalty
Summary
The facility failed to ensure residents had access to petty cash on an ongoing basis, including evenings and weekends, for the seven residents whose personal funds were managed by the facility. Review of resident personal funds records showed that the facility handled the personal funds for Residents #2, #6, #13, #25, #26, #27, and #43. Business Office Manager #186 stated that residents whose funds were handled by the facility were supposed to have access to petty cash at all times, and that business office staff were available only Monday through Friday from 8:00 A.M. to 4:30 P.M. She also stated that if a resident wanted money outside those hours, including weekends, there was a box behind the rehab desk containing petty cash, and the rehab nurse had the key to access it. However, LPN #164, who was working as the rehab charge nurse, stated she was not aware of any petty cash box at the rehab desk and had not been trained on it. She further stated she would not know how to get cash out for residents after hours when the business office was closed. The facility’s undated Resident Trust Fund policy stated that when a resident requires access to funds outside normal business office or banking hours, the charge nurse on duty is authorized to access the designated resident trust lock box containing limited petty cash funds.
Care Plans Not Reviewed and Revised by Interdisciplinary Team
Penalty
Summary
The facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team, including the resident, resident representative, and others knowledgeable about the resident’s needs, after comprehensive and quarterly assessments. This affected four residents in the sample. The deficiency was identified through record review, staff interviews, and resident interviews, and involved care conferences that were not held as expected or were held without documentation of participation by the full interdisciplinary team. For Resident #3, the record showed an admission for end stage renal disease with dialysis, diabetes, and hypertension, and an annual MDS documenting intact cognition. The resident stated he had not participated in a care plan meeting in the last six months and wanted one, noting his daughter had attended prior meetings. The last care conference summary in the record was from December 2025 and showed only the resident and social services were present, with no other interdisciplinary team members documented. The social worker confirmed there was no evidence of a care conference in March 2026 when the annual MDS was completed and stated there should have been one. For Resident #10, the record showed diagnoses including tremors, migraines, Schwannomatosis, bipolar disorder, parkinsonism, schizoaffective disorder, and normal pressure hydrocephalus, with MDS assessments showing cognitive impairment. The resident’s brother stated there had been no care conferences since admission and wanted to participate because he wanted to know what was being done about the resident’s declining mobility. The care conference summary from April 2026 documented only the resident and social services, with the brother invited but not participating, and no other interdisciplinary team members documented. For Resident #5, the record showed diagnoses including Alzheimer’s disease, anemia, and depression, with intact cognition on MDS. A care conference documented the resident, her son, and the social worker only, and the resident later stated she had not had a care conference yet. For Resident #9, the record showed diagnoses including malignant neoplasm of the prostate, malignant neoplasm of the rectum, and anemia, with a significant change MDS showing moderately impaired cognition. His care plan included use of Geri-sleeves for fragile skin, but observation showed he was not wearing them, and the RN stated he had not been wanting to wear them and the care plan had not been revised to reflect this non-compliance.
Unnecessary medications and incomplete pain and infection monitoring
Penalty
Summary
The facility failed to ensure that residents’ drug regimens were free from unnecessary drugs, including medications used without adequate indication for use. This affected four of five residents reviewed for unnecessary medications. The cited concerns involved prolonged antibiotic use without documented symptom review or infection surveillance, a steroid order that continued beyond the prescribed duration, and pain medications ordered without parameters to guide administration based on pain level. For one resident with acute and chronic respiratory failure, hypertension, anxiety disorder, morbid obesity, and status post pneumonia, prednisone 40 mg daily was ordered for seven days for cold symptoms, but the medication administration record showed it was given for 16 days. The DON confirmed the order was for seven days and stated a stop date had not been entered into the computer system, so the resident continued receiving the medication. The DON also stated the physician was contacted and an order was given to taper and discontinue the medication. Two residents received antibiotics after hospital treatment for suspected urinary tract infections, but the facility did not complete the Infection Control Surveillance form to determine whether the antibiotics were necessary. One resident had a urine culture showing 50,000-100,000 CFU/ml of Enterobacter cloacae and no signs or symptoms of infection documented after admission; the other had a urine culture showing 50,000 CFU/ml of Pseudomonas aeruginosa and no urinary symptoms documented in the facility. In addition, a resident with radiculopathy, polyneuropathy, and rheumatoid arthritis had orders for acetaminophen and oxycodone as needed for pain, but there were no parameters specifying which pain level should prompt use of either medication, and the DON confirmed the lack of parameters.
Incorrect Dessert Portion for CCD Residents
Penalty
Summary
The facility failed to ensure that residents receiving a carbohydrate controlled diet (CCD) were served the correct portion size of dessert during the lunch meal. During observation of the tray line, two residents identified as being on a CCD were served a full pre-packaged lemon bar, even though the specialty menu and spreadsheet indicated that residents on this diet were to receive half a serving of lemon bar. The meal tickets for these residents were reviewed during the tray line, and the dessert was included with the other meal items being assembled for delivery. The deficiency involved Resident #58 and Resident #65, and the facility identified 19 additional residents as receiving a CCD who could have been affected. Dietary Manager #142 confirmed that residents on a CCD were only supposed to receive half a serving of the lemon bar and acknowledged that the two residents had already been served a full serving. The report also notes that the facility's therapeutic diet policy required diets to be followed as ordered and that residents on therapeutic diets were not to receive extra or reduced portions unless approved by the attending physician in conjunction with the Clinical Dietitian.
Inaccurate resident documentation in skin, oxygen, and nail care records
Penalty
Summary
The facility failed to ensure medical record documentation was completed accurately to reflect residents’ status. Record review, observations, and staff interviews showed that documentation for four residents did not match what was observed or confirmed at the bedside. The report identified inaccurate charting related to skin assessments, oxygen tubing changes, and nail care documentation. For one resident admitted with multiple rib fractures and muscle weakness, weekly skin assessments documented bruising at first and then later documented no bruising, even though the resident was observed with a large amount of bruising to both upper extremities and the resident stated staff were not monitoring it. An LPN confirmed the bruising was still present and had been there since admission, and the DON confirmed the assessments from several dates did not include the bruising and were inaccurate. For another resident with Alzheimer’s disease and anemia, skin assessments alternated between documenting bruising and documenting no bruising, while observation showed scattered bruising to the right hand and forearm; the resident stated the bruises were from the hospital, and the DON confirmed several assessments were inaccurate. For a resident with COPD, CKD, diabetes, and bipolar disorder, the oxygen tubing and humidifier bottle were observed dated earlier than the dates documented on the oxygen administration record, and staff confirmed the tubing and setup had been charted as changed multiple times when they had not been. For another resident with Parkinson’s disease, hypertension, and anxiety disorder, the resident was observed with long fingernails and dark substance under the nails, stated the nails needed to be cut, and an LPN documented that the nails had been trimmed and filed even though she later confirmed she had not done so. The ADON also confirmed the nails did not appear to have been trimmed as documented.
Fall prevention interventions not implemented and resident transported to appointment without needed staff assistance
Penalty
Summary
The facility failed to ensure fall prevention interventions were implemented as documented for a resident with severely impaired cognition, dependence on staff for transfers, and a history of falls. Resident #44’s care plan identified fall risk interventions including Dycem in the recliner to prevent sliding and the use of appropriate footwear when out of bed. During observation, the resident was found sitting in a wheelchair without Dycem in place, and staff searched the room but did not find any Dycem. The nurse stated the resident would need Dycem applied to the seat as outlined in the care plan. The facility also failed to ensure that a resident who required staff assistance for transfers was accompanied by knowledgeable staff to an outside appointment. Resident #21 had diagnoses including pericardial effusion and cardiac tamponade, severely impaired cognition, was dependent on staff for transfers, and required total assistance for toileting transfers. The resident was transported to an eye appointment with only a driver from the facility. At the appointment, the resident was described as wheelchair bound, hard of understanding, anxious, and unable to explain why she was there. She repeatedly stated she needed to use the bathroom and could not do so independently. Office staff assisted the resident to and from the restroom and noted she was completely dead weight and had to be lifted onto the toilet. The provider stated the resident’s exam could not be completed because she did not have an aide or caretaker with her, and the facility was notified that the appointment should be rescheduled when someone could accompany her. Facility staff interviewed after the event stated they were unsure why no one accompanied the resident, and the DON acknowledged the resident required a mechanical lift and someone should have gone with her.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure a resident receiving an antidepressant was fully informed about the risks and benefits of the medication before it was started, and there was no documented informed consent from the resident’s legal guardian. Resident #44 was admitted with diagnoses including unspecified dementia with mood disturbance, depression, and anxiety disorder. Her significant change MDS showed no communication issues and moderately impaired cognition. Her record identified an attorney as her legal guardian. Her active orders included Remeron 7.5 mg by mouth at bedtime for dementia, along with Zoloft, scheduled Ativan, and PRN Ativan for anxiety/agitation related to depression. Review of the resident’s psychotropic medication consent forms showed informed consent for Ativan was obtained from the resident’s daughter, and a consent form for Zoloft was signed by the resident, although the form was not signed by the resident to show informed consent was obtained. The medical record did not contain evidence that informed consent was obtained from the resident’s legal guardian for Remeron after it was initiated. The DON confirmed there was no evidence of informed consent from the legal guardian for Remeron before it was started. The facility policy required informed consent before initiating psychotropic medications, except in emergency situations, and stated the discussion and consent were to be documented in the medical record.
Resident Funds Not Properly Accounted For
Penalty
Summary
The facility failed to maintain a full and complete accounting of a resident’s personal funds entrusted to it. Resident #25 was admitted with diagnoses including psychosis, paranoid personality disorder, delusional disorder, and Alzheimer’s disease, and a MDS assessment showed severe cognitive impairment. Financial records showed the facility handled the resident’s personal money, and a Resident Statement Landscape showed that $970.00 was deducted from the resident’s account for personal needs items, leaving a balance of $1000.44. The Business Office Manager stated there were no receipts for any items purchased with the $970.00 and explained the money had been intended for a television and other personal items for the resident by her family. She stated the money was not used, was never actually taken out of the account, and should have been credited back to the resident’s personal account but had not been. The resident’s daughter stated she had been told the facility had to cut a check for the money, did not know how $970.00 was determined, and was later told there was no money in the resident’s account.
Failure to Notify Provider of Significant Respiratory Changes
Penalty
Summary
The facility failed to ensure the resident’s medical provider was notified when two residents had significant changes in condition. One resident, admitted with pneumonia, acute posthemorrhagic anemia, COPD, CHF, and acute on chronic respiratory failure, had documented oxygen saturations in the low 70s and 80s on multiple nursing notes. Staff increased oxygen to 6 lpm, provided respiratory treatments, and monitored the resident, but there was no evidence the physician was contacted about the low oxygen saturations. The physician later stated he should have been notified any time oxygen saturation was in the 70s and that he was not aware of the resident’s respiratory struggles. The second resident, admitted with diagnoses including other pericardial effusion and cardiac tamponade, had altered respiratory status and sleep apnea with CPAP use in the care plan. During the night shift, the resident’s oxygen saturation reportedly remained in the 70s to 80s and the resident was lethargic. The night nurse did not document an assessment or progress note, and the incoming nurse was told the resident had low oxygen all night but had not been sent out or reported to the doctor. When the resident was assessed in the morning, vitals were abnormal, lung sounds revealed rales bilaterally, and the physician was notified and ordered transfer to the emergency room. Interviews confirmed the communication failures. The DON stated the first resident was not sent out or called to the doctor because staff tried to address the concerns in-house first, and she was not aware of the earlier note showing oxygen in the low 70s. The PA and physician stated abnormal oxygen saturations, especially in the 70s, required provider notification and a full assessment including vital signs and lung sounds. The facility policy stated it shall promptly notify the resident, attending physician, and representative of changes in the resident’s medical or mental condition and/or status.
Failure to Provide Required Medicare Coverage Notices
Penalty
Summary
The facility failed to ensure proper Medicare beneficiary notices were given when skilled services were ending for three residents reviewed for beneficiary notices. Resident #1, admitted with diagnoses including other lack of coordination, muscle weakness, and COPD, had a skilled stay that began on 11/12/25 and a last covered day of 12/12/25, but a Notice of Medicare Non Coverage (NOMNC) was not issued because the discharge plan was to go home. Resident #4, admitted with diagnoses including CHF, muscle weakness, and lack of coordination, had skilled services that began on 10/29/25 and ended on 12/02/25, and a NOMNC was also not issued for the same reason that the discharge plan was to go home. Resident #69, admitted with diagnoses including cerebral ischemia, muscle weakness, and lack of coordination, had a care plan showing a discharge plan to remain in the facility for long term care. The resident's skilled stay began on 11/06/25 and ended on 12/19/25, and the facility initiated discharge from Medicare Part A services before benefit days were exhausted. A NOMNC was provided, but an advanced beneficiary notice (ABN) was not. The NOMNC was dated 12/19/25 and was given on 12/17/25, 48 hours in advance. During interview, the Business Office Manager stated NOMNCs were not completed for the two residents going home because she was not aware they had to be completed when residents were cut from Medicare coverage, and she stated she had received no training on NOMNCs or ABNs.
Failure to Provide Written Bed-Hold Notice at Hospital Transfer
Penalty
Summary
The facility failed to ensure that the resident or the resident representative received written notice, at the time of transfer for hospitalization, specifying the duration of the bed-hold policy. Resident #62 was admitted on 02/09/26 with diagnoses including cerebral infarction with hemiplegia, diabetes, rheumatoid arthritis, and hypertension. A MDS assessment completed on 02/15/26 showed a brief interview for mental status score of 15, indicating intact cognition. Nursing progress notes documented that on 03/04/26 staff spoke with the resident and her husband about discharge planning and possible long-term placement, and later that day the resident was transferred to the hospital for stroke-like symptoms including left facial drooping and slurred speech. The physician was present and ordered stat baby aspirin while waiting for the squad, and the resident did not return to the facility. Record review found no evidence that the resident or her representative was provided written notice of the bed-hold policy at the time of transfer to the hospital. The Business Office Manager confirmed on interview that there was no evidence written notice of the bed-hold policy had been provided to the resident or her representative at the time of transfer, and stated she had only realized about a week earlier that the facility was not providing this notice upon transfer. The facility policy titled "readmission to the Facility" stated that at the time of transfer for hospitalization or therapeutic leave, the facility will provide the resident or resident representative written notice specifying the duration of the bed-hold policy and the opportunity to pay the bed-hold if allowed by the State Plan.
Inaccurate MDS Coding for Medications and Corrective Lenses
Penalty
Summary
The facility failed to ensure Minimum Data Set (MDS) assessments were completed accurately for three residents in the areas of medications received during the assessment period and vision/corrective lenses. For one resident with adult-onset diabetes mellitus, the annual MDS coded injections and insulin as having been received on all seven days of the assessment period, even though the resident’s physician’s order was for weekly Mounjaro and there was no order for insulin. The medication administration record showed only the weekly Mounjaro injection, and the MDS nurse acknowledged that Mounjaro is not insulin and that the assessment was coded incorrectly. For another resident with unspecified dementia and an infrarenal abdominal aortic aneurysm without rupture, the significant change MDS coded the resident as having received an anticoagulant during the seven-day assessment period. The physician’s order and MAR showed the resident received Plavix 75 mg by mouth each morning, which is an antiplatelet medication, and there was no evidence of an anticoagulant such as Eliquis or Coumadin being administered. The MDS nurse confirmed the assessment was not coded accurately and acknowledged Plavix should not have been coded as an anticoagulant. For a third resident with acute and chronic respiratory failure, schizoaffective disorder, hypertension, and anxiety disorder, the admission and quarterly MDS assessments indicated vision was adequate with no corrective lenses. However, nursing notes documented the resident’s son requested an eye doctor appointment for replacement glasses, and the resident stated she wears glasses but did not have any because they were left at a prior facility. The MDS nurse stated she relied on staff input about whether residents wear glasses and confirmed the MDS was inaccurate if the resident wears glasses.
PASARR Assessments Not Updated for Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure Pre-Admission Screening and Resident Review (PASARR) assessments were accurate and updated to reflect residents’ mental health diagnoses. This affected three of four residents reviewed for PASARRs. The deficiency involved Resident #40, Resident #53, and Resident #6, whose records showed mental health diagnoses that were not fully or accurately reflected on their PASARR documentation. Resident #40 was admitted with diagnoses including major depression and anxiety disorders, and a psychotic disorder was later added to the record. A PASARR completed earlier did not indicate any mental health diagnoses for this resident, even though the care plan later listed mood deficits related to family deaths, psychotic disorder, depression, anxiety, insomnia, and Parkinson’s disease. Resident #53 was admitted with bipolar disorder, and the care plan addressed mood stabilizer therapy related to bipolar disorder, but the PASARR listed other psychotic disorder and left the mood disorder field blank. The Admissions Director stated she did not know bipolar disorder should have been listed as a mood disorder. Resident #6’s record showed diagnoses of paranoid personality disorder, delusional disorder, generalized anxiety disorder, and major depressive disorder, with paranoid personality disorder and delusional disorder present on the diagnosis list since 04/29/23. However, the PASARR Identification Screen completed on 05/10/26 did not mark personality disorder or delusional disorder as known diagnoses, and the resulting notice stated the resident had no indications of serious mental illness or developmental disability, so no Level II referral was made. During interview, the Admissions Director confirmed the PASARR was not completed accurately because those diagnoses were missed and stated she had been working to update other residents’ PASARRs after the issue was brought to attention.
Care plans not developed and implemented for edema and fall prevention
Penalty
Summary
The facility failed to ensure a resident with known edema to both lower extremities had a care plan developed to address the edema. The resident had diagnoses including Alzheimer's disease, dementia with behavioral disturbances, neurocognitive disorder with Lewy Bodies, hypertension, muscle weakness, and abnormalities of gait and mobility. Her annual MDS showed severely impaired cognition, limited ROM in both lower extremities, and she was dependent on staff for dressing and required two staff if combative. Her active care plans addressed self-care deficits, but did not address the edema in her bilateral lower extremities. The resident had physician orders to elevate both lower extremities when in bed and to wear compression stockings when out of bed, both originating on 05/14/26. During observations on 05/17/26 and 05/18/26, she was seen up in her wheelchair with swollen lower extremities, her legs in a dependent position, and no compression stockings in place. Staff interviews confirmed the resident had been observed without the stockings and that the edema care plan had not been initiated, which meant the order for compression stockings was not included on the Kardex used by aides to direct care. The facility also failed to implement a fall-risk care plan for another resident. That resident had diagnoses including muscle weakness, abnormalities of gait and mobility, lack of coordination, need for assistance with personal care, hypertension, and unspecified dementia with mood disturbance. Her MDS showed moderately impaired cognition, limited ROM in all extremities, wheelchair use, substantial to maximum assist with transfers, and two falls since the last assessment. Although her care plan included interventions for fall risk, observations showed she was up in her reclining wheelchair without Dycem in place as planned and later wearing socks that were not non-skid, despite the care plan calling for appropriate footwear when out of bed.
Failure to Provide Required Hygiene Assistance
Penalty
Summary
The facility failed to ensure residents who required assistance with hygiene services received showers, facial hair removal, and nail care. The deficiency involved three residents out of five reviewed for ADLs. The report states that the facility census was 56 and that the issue was identified through record review, observations, interviews, and policy review. Resident #30 had diagnoses including dementia and depression, with care plan interventions for shower assistance twice weekly or per resident preference and dependent personal hygiene assistance. Her MDS showed severely impaired cognition and dependence on staff for personal hygiene. During observation and interview, she was found with multiple long gray hairs on her chin, and her daughter stated she had brought tweezers and asked activities staff to help clean up her chin hair, but no one had yet. The AD later stated the daughter had provided tweezers about a week earlier and that she had not completed the task because she was afraid of bruising the resident; she later plucked the chin hairs and the resident reported feeling much better. Resident #40 had diagnoses including Parkinson's disease and hemiplegia/hemiparesis following cerebral infarction, with a care plan calling for showers twice weekly or per resident preference and maximum assistance for showers. Her MDS indicated mildly impaired cognition and need for maximum assistance with showers. Shower records showed she was scheduled for showers on Sunday and Wednesday but did not receive them on two scheduled dates, and she told staff she was not getting her showers. Resident #13 had diagnoses including Parkinson's disease, hypertension, and anxiety disorder, and his MDS showed intact cognition but dependence for personal hygiene, dressing, and showers. He had an order for weekly nail trimming and filing with skin checks, yet observations showed white facial hair, long fingernails with dark substance under them, and he stated it had been several days since he had been shaved and that his nails needed cutting. The record also showed a shower on 05/14/26, while staff later confirmed he was not documented as receiving a scheduled shower on 05/17/26 and an LPN admitted she did not trim his nails even though she documented that she had done so.
Failure to Ensure Access to Vision Services
Penalty
Summary
The facility failed to ensure residents received proper treatment and assistive devices to maintain vision abilities by assisting with making appointments and/or arranging transportation to and from practitioner offices. Resident #7 was admitted with diagnoses including acute and chronic respiratory failure, schizoaffective disorder, hypertension, and anxiety disorder. Her MDS assessments indicated vision was adequate and cognition was intact. She had agreed to receive vision services on admission, and her son later requested an eye doctor appointment so she could get replacement glasses. However, the resident reported she wore glasses but did not have any because they were left at her prior facility, and she had not seen an eye doctor since admission. Staff confirmed the facility’s mobile vision provider had no set schedule, had last been at the facility months earlier, and no local eye doctor appointment had been arranged for her. Resident #13 was admitted with diagnoses including Parkinson’s disease, diabetes, anxiety disorder, and hypertension. An in-house vision consult documented dry eyes in both eyes, interest in glasses, cataract and poor corneal surface limiting reading, and a recommendation for artificial tears three times daily with a return visit in 1-3 months for cornea evaluation. There was no evidence the resident received the recommended eye drops or was seen again by the eye doctor. The resident stated he had been told he needed eye drops but had not gotten any, and staff confirmed the eye doctor had not returned to the facility since the consult and the resident had not been seen again as recommended.
Failure to Provide Ordered Oxygen Therapy and Maintain Respiratory Equipment
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for two residents who required oxygen therapy. Resident #56, who had diagnoses including COPD, CKD, diabetes, and bipolar disorder, had a physician order for weekly oxygen tubing and setup changes. Although the oxygen administration record documented multiple weekly changes, observation showed the oxygen tubing was dated 04/02/26 and the humidifier bottle was dated 03/26/26. An LPN confirmed the dates on the equipment and stated the tubing was supposed to be changed weekly, while the ADON confirmed the record showed six documented changes when the tubing had not actually been changed. Two LPNs acknowledged documenting tubing and setup changes on several dates when the equipment was not changed, and one stated there was no excuse for why it was not done. Resident #21, who had diagnoses including pericardial effusion and hypothyroidism and severe cognitive impairment, had an order for oxygen at 3 liters per minute via nasal cannula continuously. During observation, the resident was sitting in a wheelchair with the nasal cannula in place, but the oxygen concentrator was completely off. The resident stated she was having a hard time breathing. A CNA confirmed the oxygen was off and turned the concentrator on, returning it to 3 liters per minute.
Pharmacy Recommendations Not Timely Addressed
Penalty
Summary
The facility failed to ensure that pharmacy recommendations generated from monthly medication regimen reviews were addressed and/or responded to in a timely manner by the attending physician for two residents reviewed for unnecessary medications. The report states that a licensed pharmacist completed monthly medication regimen reviews and identified irregularities, but the related recommendations were not consistently acted upon or documented as responded to by the physician. For one resident with COPD, generalized anxiety disorder, major depressive disorder, paranoid personality disorder, and delusional disorder, the pharmacist recommended physician review of Valium and Buspar and consideration of a gradual dose reduction after noting the resident had been on both medications for an extended period. The report states there was no evidence of physician response until the same recommendation was repeated months later. The pharmacist also recommended that nursing add instructions for the resident to rinse the mouth with water and spit after using Advair to reduce the risk of oral thrush, but there was no evidence that this nursing recommendation was followed up on, and the active Advair order did not include those special instructions. For another resident with psychosis, paranoid personality disorder, delusional disorder, major depressive disorder, Alzheimer’s disease, and PTSD, the pharmacist repeatedly identified an irregularity involving Wellbutrin SR and recommended changing it to Wellbutrin XL. The physician documented responses on some occasions, but the ordered medication remained Wellbutrin SR 150 mg daily in the morning, and the report states there was no evidence that one recommendation was responded to and that other physician responses did not address the pharmacist’s identified irregularity. The DON confirmed the delayed or absent responses and that the recommended change had not been implemented.
Failure to Obtain and Review Ordered Lab Results
Penalty
Summary
The facility failed to ensure ordered lab results were obtained and reviewed for a resident with low hemoglobin. The resident was admitted with diagnoses including pneumonia due to mycoplasma pneumoniae and acute posthemorrhagic anemia, and also had COPD, CHF, and acute on chronic respiratory failure requiring continuous oxygen therapy. During the stay, the resident had repeated low hemoglobin results, including critical values, and the physician ordered additional testing to evaluate the cause of the anemia, including CBC with retic count, iron studies, and occult blood testing. A nursing note documented that CBC, retic, iron, and iron binding capacity were drawn and sent to a local hospital with a facility driver, and the facility was awaiting results. However, the physician later stated he did not know what happened to those lab results and needed them to determine the cause of the low hemoglobin. The DON later stated she would attempt to locate the labs and occult stools. When the ordered labs were eventually received by the facility months later, they showed low iron, low TIBC, elevated retic count, low hematocrit, low RBCs, and a critically low hemoglobin of 6.7. The ordered occult stool testing was also not completed or provided. Nursing notes documented multiple shifts in which the resident did not have a bowel movement, and one note stated the equipment was not available to obtain the sample. The administrator confirmed the labs ordered for the resident were not received or reviewed by the facility until much later, and the occult stools were not provided.
Failure to Monitor Antibiotic Use
Penalty
Summary
The facility failed to implement its antibiotic stewardship program to ensure appropriate antibiotic use for three residents reviewed for infection control concerns. The record review, staff interview, policy review, and infection surveillance reports showed that the facility did not complete the Infection Control Surveillance form for residents who were prescribed antibiotics, and the results of cultures and clinical findings were not reviewed with the physician to determine whether antibiotics remained necessary. For one resident, the hospital diagnosed a urinary tract infection and started Cipro after the resident was taken to the hospital for weakness, agitation, hallucinations, and difficulty urinating. The urine culture showed 50,000-100,000 CFU/ml of Enterobacter cloacae, and after admission to the facility the Cipro continued for 18 doses. Nursing documentation on 04/08/26 stated the resident had no signs or symptoms of infection. The ADON confirmed the Infection Control Surveillance form was not completed and stated the urine culture results and lack of symptoms were not discussed with the physician to determine whether the antibiotic should continue. For another resident, the hospital admission was for confusion, urinary frequency, and lower abdominal pain, with a diagnosis of acute metabolic encephalopathy likely secondary to infection and a urine culture showing 50,000 CFU/ml of Pseudomonas aeruginosa. After admission to the facility, the resident received ceftriaxone IV for three days, and the Infection Surveillance Report listed a urinary tract infection with dysuria and altered mental status. Nursing notes documented no urinary symptoms, and the ADON confirmed the Infection Control Surveillance form was not completed and that the culture results and lack of symptoms were not discussed with the physician. For a third resident, the Infection Surveillance Report documented a urinary tract infection with burning on urination, dysuria, and E-coli, and the resident received Bactrim DS for seven days, but there was no evidence that an Infection Control Surveillance form was completed to determine whether the antibiotic was necessary and appropriate.
Failure to Offer and Document Flu and Pneumonia Vaccines
Penalty
Summary
The facility failed to provide education for and offer the influenza and pneumonia vaccines for Resident #6. The resident was admitted on 01/13/26 with diagnoses including acute and chronic respiratory failure, morbid obesity, hypertension, and schizoaffective disorder. Record review showed no evidence that the resident had been educated about or offered either vaccine, and there was no evidence that the resident had previously received them. During interview on 05/18/26 at 9:35 A.M., the Assistant Director of Nursing stated Resident #6 should have been offered the influenza and pneumonia vaccines on admission and could find no evidence that this occurred. Review of the facility policy for influenza vaccine stated that between October 1st and March 31st each year, the vaccine shall be offered unless medically contraindicated or already received, and that education about benefits and potential side effects shall be documented in the medical record. The pneumococcal vaccine policy stated that prior to or upon admission, residents will be assessed for eligibility and, when indicated, offered the vaccine within 30 days of admission unless medically contraindicated or already vaccinated, with education documented in the medical record.
Failure to Educate and Offer COVID-19 Vaccine
Penalty
Summary
The facility failed to provide education and then offer the COVID-19 vaccine to a resident on admission. Record review for Resident #6 showed an admission date of 01/13/26 and diagnoses including acute and chronic respiratory failure, morbid obesity, hypertension, and schizoaffective disorder. The record contained no evidence that the resident was educated about or offered the COVID-19 vaccine, and there was no evidence the resident had previously received the vaccine. During interview, the Assistant DON stated the resident should have been offered the COVID-19 vaccine on admission and could find no evidence that this occurred. The facility policy stated the COVID-19 vaccine shall be offered to residents unless medically contraindicated or already immunized, and that education on benefits and potential side effects must be provided and documented in the medical record.
Significant Medication Error and Delayed Response After Wrong Medications Given
Penalty
Summary
The deficiency involves a failure to ensure that a resident was free from significant medication errors when an agency LPN did not follow proper medication administration procedures. The LPN prepared and administered evening/bedtime medications for two roommates at the same time, in a dark room, by popping both residents’ pills into separate cups labeled with their names. The LPN later admitted that she prepared both residents’ medications together and that the room was dark when she administered the medications. One resident, who was not ordered any benzodiazepines or opioid pain medications, was instead given medications that were ordered for his roommate, including Xanax 2 mg PO, Percocet (Oxycodone/Acetaminophen) 10–325 mg PO, and Gabapentin 800 mg PO. The resident who received the wrong medications had a history that included dementia with Lewy Bodies, neurocognitive disorder, mood disorder, major depressive disorder, anxiety disorder, CHF, hypertension, cirrhosis, muscle weakness, difficulty walking, and insomnia. His active orders included medications such as Abilify, Aspirin, Atorvastatin, Vitamin D, Plavix, Aricept, Fluoxetine, Lactulose, Magnesium Oxide, Melatonin, Remeron, Potassium Chloride, Sennosides, and Tamsulosin, with PRN orders for Acetaminophen, artificial tears, Mucinex, and Zofran. He had no orders for benzodiazepines or opioids. On the evening in question, the LPN documented administering his scheduled evening/bedtime medications around 8:44 P.M. and noted that he complained of being tired after a room change earlier that day. Shortly thereafter, his roommate complained to a CNA that his pain medications did not feel like they had worked, stating he could usually tell within 10 minutes when they took effect, suggesting concern that he had not received his usual medications. The facility also failed to timely identify and correlate the reported medication mix-up with the resident’s subsequent change in condition. Around 8:53 P.M., the LPN found the resident lethargic but responsive to touch and able to follow simple commands, with vital signs within acceptable ranges. The resident’s wife reported that he had not awakened during her visit. Despite the roommate’s report that he believed the medications had been mixed up and the LPN’s own acknowledgment that both residents’ medications had been prepared together, the LPN did not notify a physician of a possible medication error or seek medical guidance at that time. Throughout the night, the resident remained lethargic, and staff noted that something seemed “off,” but no provider was contacted until approximately 1:15 A.M., when the resident was found unresponsive, hypotensive, and bradycardic. EMS was then called, and the resident was transferred to the hospital with an altered mental status and unresponsiveness. Hospital evaluation, including a urine drug screen, showed the presence of benzodiazepines and oxycodone, which matched medications ordered for the roommate and not for the resident, confirming that a significant medication error had occurred and contributed to the resident’s serious deterioration in condition. Additional documentation from EMS and the hospital further described the resident’s condition following the error. EMS records indicated that the resident was unresponsive with pinpoint pupils, hypotension, bradycardia, and a Glasgow Coma Scale score of seven, and he received multiple doses of Narcan and Atropine en route. The ED provider note documented hypotension, bradycardia, poor responsiveness, and initial miotic pupils with partial response to Narcan, and the clinical impression included acute encephalopathy and unresponsiveness. The hospital history and physical described acute hypoxic respiratory failure and multifocal pneumonia, with progressive respiratory decline requiring endotracheal intubation and ICU admission. These findings, together with the positive urine drug screen for benzodiazepines and oxycodone in a resident without orders for those medications, were included in the facility’s investigation file as evidence of the significant medication error and its impact on the resident’s condition. The facility’s internal investigation gathered statements from the involved LPN, another LPN who assessed the resident, and a CNA. The agency LPN confirmed that she had prepared both roommates’ medications at the same time, in the dark, and that the roommate later complained that his medications did not feel effective. The second LPN reported that the resident’s condition appeared abnormal and that she eventually insisted he be sent out when he no longer responded as before. The CNA reported that the resident initially seemed at his baseline but later became more lethargic and took a “drastic turn” after his wife left. The DON acknowledged that the incident was possibly medication-related and that the resident’s transfer to the hospital for unresponsiveness was logged as an incident. Collectively, these actions and inactions—improper preparation and administration of medications, failure to promptly recognize and act on the reported medication mix-up, and delayed notification of a physician despite progressive lethargy—constituted the deficiency in ensuring the resident was free from significant medication errors.
Removal Plan
- The Vice President of Clinical Services created a performance improvement plan (PIP), presented it to the Director of Nursing (DON), and the DON assigned the Assistant Director of Nursing (ADON) to assist with medication audits designed to address medication pass performance criteria.
- The DON began an investigation for a possible medication error requiring a resident to be sent to the hospital.
- The DON interviewed the nurse involved and obtained the nurse’s statement of the incident.
- The DON interviewed the nurse working the night of the event and obtained the nurse’s statement.
- The DON interviewed the CNA who worked with the resident the night of the event.
- The DON interviewed the resident’s roommate to obtain a statement.
- The facility provided education on proper medication administration and the five rights of medication administration.
- The DON initiated an in-service on safe medication administration techniques and change of condition with nurses currently on shift regarding the possible medication error.
- The facility implemented a plan for the DON/designee to educate nurses on changes of condition and the five rights of medication administration followed by medication administration audits.
- The facility completed education for all current full-time licensed nurses and implemented a plan for new and agency nurses to be educated upon hire/scheduling by unit managers.
- The facility continued the process for an agency nurse resource guide binder to be available for agency staff to review.
- The DON/ADON began auditing changes in condition per the established schedule, with results reviewed through QAPI and issues addressed as needed.
- The DON/ADON began medication audits per the established schedule, including audits of resident identification/picture identification availability, with results reviewed through QAPI and issues addressed as needed.
- The DON conducted interviews with nurses who had worked prior to the incident/event.
- The ADON completed skin checks and health assessments on residents with low BIMS scores to identify changes in condition or possible medication adverse effects.
- The Vice President of Clinical Services and DON reviewed current policies and procedures for medication administration and change in condition.
- The physician assessed the roommate resident for possible medication adverse effects and reviewed medications for the affected resident.
- The DON reviewed the agency staff process and provided report forms to nursing staff at the beginning of shift to inform nurses how residents take their medication, and identified additions needed to the process including five rights and change in condition policy/education.
- Social Services conducted resident interviews regarding life satisfaction, abuse/neglect, and comfort reporting concerns.
- The DON completed a one-on-one in-service with the nurse involved on safe medication administration and change in resident conditions.
- The DON initiated an in-service for nursing staff on when to notify the DON regarding accidents/incidents, significant changes, medication errors, and emergencies, and implemented education upon hire for new nurses.
- The facility placed the nurse involved on the Do Not Return list.
- The facility implemented a requirement for all residents to have a picture in their chart and completed an immediate audit to verify compliance.
- The physician reviewed medications for the affected resident upon return from the hospital.
- The provider reviewed and approved all medications and documents for the affected resident.
- Social Services interviewed residents to identify concerns about receiving other residents’ medications.
- The facility implemented a plan to discuss the incident at the next QAPI meeting and to review audit results through QAPI with issues addressed as needed.
Failure to Notify State Agency of Administrator Changes
Penalty
Summary
The facility failed to notify the state survey agency of changes in administrative personnel, specifically changes in the Administrator position, affecting all 59 residents in the facility. Review of the Enhanced Information Dissemination and Collection (EIDC) website showed that neither the current Administrator nor the interim Administrator who served from November 2025 through January 2026 were listed as required. In an interview, the current Administrator confirmed that the facility had not informed the state survey agency of these changes in administrators, including the current Administrator. This deficiency was identified as an incidental finding of non-compliance during the investigation of Complaint Number 2735791. No additional resident-specific clinical information, medical history, or condition at the time of the deficiency was provided in the report.
Failure to Ensure Required Training for CNAs
Penalty
Summary
The facility failed to maintain an effective training program for staff, affecting all 59 residents in the facility. Record review of personnel files showed that one CNA hired on 12/19/25 did not have documented training in compliance and ethics, the quality assurance program, effective communication, or behavioral health. Another CNA hired on 10/08/25 did not have documented training in compliance and ethics, the quality assurance program, or behavioral health. During an interview on 03/04/26 at 3:04 P.M., the HR staff member confirmed that the required training had not been completed for these CNAs. This deficiency was identified as an incidental finding of non-compliance during the investigation of Complaint Number 2735791.
Failure to Recognize and Report Change in Condition Related to Suspected Medication Error
Penalty
Summary
The deficiency involves the facility’s failure to timely identify and report a significant change in condition for a cognitively intact resident, and to properly correlate that change to a suspected medication error. The resident had multiple diagnoses including dementia with Lewy Bodies, mood and anxiety disorders, CHF, hypertension, cirrhosis, and insomnia, but his MDS showed he was cognitively intact, had no communication issues, and was not ordered any benzodiazepines or opioids. His active orders included antidepressants, antipsychotic adjunct therapy, dementia medication, cardiac and GI medications, sleep aids, and bowel regimen, with PRN orders limited to acetaminophen, artificial tears, Mucinex, and Zofran. He did not have any orders for Xanax, oxycodone, or other narcotic pain medications. On the evening in question, an agency LPN prepared bedtime medications for the resident and his roommate at the same time, popping both residents’ pills into separate labeled cups at the medication cart. She crushed the cognitively intact resident’s pills in pudding and later gave the roommate’s pills whole, acknowledging that the room was dark when she administered the roommate’s medications. The roommate later reported that he believed he had received his roommate’s medications and that his own usual large gabapentin pill and the bitter-tasting oxycodone were missing from what he was given. He stated he did not experience his usual pain relief within 10–15 minutes and complained to staff that he had not received his correct medications. He also reported telling staff that his roommate had been given his medications and that this was why the roommate became unresponsive, and he stated that no one from the facility assessed him or investigated his report of a medication mix-up. After the agency LPN administered the bedtime medications, the resident complained of being tired following a room change and was assisted to bed. Around 8:53 p.m., the resident’s wife arrived and reported that he had not awakened during her visit. The LPN found him lethargic but able to follow commands, with vital signs within normal limits, and attributed his condition to fatigue from the move. Throughout the night, the LPN and another LPN noted that “something seemed off,” but they continued to attribute his lethargy to the room change and sleepiness. The resident’s condition progressively worsened; by approximately 1:15 a.m. he was more lethargic, then unresponsive to verbal and painful stimuli, with hypotension and borderline oxygen saturation. Only at that point was the on-call physician notified and EMS summoned. EMS and hospital records documented hypotension, bradycardia, unresponsiveness, pinpoint pupils, administration of Narcan and Atropine, and a urine drug screen positive for benzodiazepines and oxycodone—medications not ordered for the resident but ordered for his roommate. Despite these findings and the roommate’s contemporaneous statements, the DON reported she did not substantiate a medication error and did not clearly link the resident’s change in condition to a medication mix-up, reflecting a failure to promptly recognize, correlate, and report the suspected medication error and associated change in condition to the physician. Hospital documentation further described the resident as presenting with acute encephalopathy, acute hypoxic respiratory failure, shock, and unresponsiveness with pinpoint pupils and low blood pressure and heart rate. The ED and ICU notes referenced multiple doses of Narcan, a positive urine drug screen for benzodiazepines and oxycodone, and family and roommate concerns that the resident had received his roommate’s medications, including opioids and gabapentin. Subsequent hospital records from a tertiary facility noted that the encephalopathy was likely multifactorial on a background of Lewy Body dementia, with possible contributions from polypharmacy and anoxic brain injury in the setting of prolonged downtime and suspected receipt of the roommate’s opioids and gabapentin, though this could not be definitively confirmed. Within the facility, however, the change in condition was initially attributed to fatigue from a room move, the resident was allowed to remain in a progressively worsening state for several hours before EMS was called, and the facility did not substantiate or clearly document a medication error despite objective toxicology findings and consistent reports from the roommate and family. The facility’s internal investigation collected staff statements, MARs for both residents, controlled drug records, and hospital records. The agency LPN acknowledged that she prepared both residents’ medications at the same time and that it was possible she could have popped pills into the wrong cup or grabbed the wrong cup when crushing medications, though she denied intentionally giving the wrong medications. Another LPN recalled the roommate saying that the agency nurse had given the lethargic resident his pills, and that EMS administered Narcan due to pinpoint pupils. The DON confirmed that the resident’s urine drug screen was positive for benzodiazepines and oxycodone, and that the roommate was ordered Xanax and oxycodone at bedtime, but she stated she could not be certain the resident did not receive these drugs from another source and therefore did not substantiate a medication error. This sequence of events demonstrates that the resident’s significant change in condition was not promptly recognized as potentially medication-related, was not timely reported to the physician when first observed, and was not adequately correlated with the suspected medication error despite contemporaneous reports and objective toxicology findings.
Failure to Report Allegation of Misappropriation of Resident Property
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of misappropriation of resident property to the state as required by regulation and facility policy. Resident #10 was admitted with diagnoses including muscle weakness and hypertension, and her care plan and MDS documented intact cognition with no behaviors or history of making false allegations. A grievance report documented that the resident’s son had brought five lottery tickets to the resident; when he returned, the resident reported that one ticket, which she stated was a $250 winner, was missing while the other four tickets remained present but were not winners. According to the grievance documentation and interviews, the resident’s son searched the room, including dressers, drawers, and the trashcan, but could not locate the winning ticket. The social worker then assisted in searching the room without success. Resident #10 confirmed that her son had brought her four or five scratch-off tickets, that one was a $250 winner, and that she later noticed the winning ticket was missing after leaving the room for an activity and returning. She stated she did not throw the ticket away, did not see anyone else throw it away, and did not witness another resident or staff member take it, but believed someone must have taken it. Multiple staff members, including CNAs, RNs, agency nurses, and the ADON, were interviewed; several recalled seeing lottery tickets on the resident’s bedside table on various days, but none could confirm the number of tickets or what happened to the winning ticket. Interviews with facility leadership established that the situation was recognized as a potential misappropriation. The social worker stated that allegations of abuse or misappropriation would be reported to the state by the Administrator or DON. The Administrator acknowledged that a missing lottery ticket worth $250 constituted an allegation of misappropriation that should have been reported to the state and stated that such allegations should be reported immediately, but confirmed he did not report it and was unsure of his responsibility. The DON stated that allegations of misappropriation are to be reported to the state immediately upon suspicion or discovery, but confirmed she had not reported the allegation and had not been informed of the situation until later in the week. Review of the facility’s Abuse Investigation and Reporting policy showed that all reports of misappropriation must be promptly reported to appropriate agencies, with allegations reported within two hours, which did not occur in this case.
Failure to Provide Scheduled Showers and ADL Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide scheduled showers and personal care to dependent residents who required assistance with activities of daily living (ADLs). One resident with dementia, muscle weakness, diabetes, and impaired mobility had a care plan dated 08/27/25 indicating a need for assistance with self-care, ADLs, and mobility, with a goal to remain clean, dry, dressed, groomed, and free of odors. Interventions included dependent shower assistance by one helper, and an MDS dated 11/18/25 showed the resident required maximum assistance for bathing. The shower schedule showed this resident was to receive showers on Mondays and Fridays on dayshift, but shower records revealed missed showers on 02/20/26 and 02/27/26. Another resident with hypertension and cancer had a care plan dated 08/15/25 indicating dependence on staff for bathing/showering due to pain, limited mobility, limited range of motion, and weakness, with a goal to maintain current ADL function. An MDS showed this resident was dependent on staff for bathing and had refused care on four to six days during the review period. The shower schedule indicated showers on Tuesday and Friday dayshift, but shower records showed missed showers on 12/26/25 and 12/30/25. A third resident with hypertension, osteoarthritis, impaired mobility, weakness, cognitive deficits, and pain had a care plan dated 10/13/25 requiring assistance with self-care, ADLs, and mobility, including assistance as needed with showers twice weekly or per preference and partial assist with showers. The MDS indicated moderate assistance was needed for bathing/showering, and the shower schedule listed Tuesday and Friday nightshift. Shower records showed this resident did not receive showers on 10/21/25, 11/06/25, 11/13/25, 11/25/25, and 11/28/25. In an interview on 03/04/26 at 1:10 P.M., the ADON confirmed these residents were not provided scheduled showers and that there was no other documentation to show the showers were given.
Failure to Complete Ordered Daily Wound Care Treatments
Penalty
Summary
The facility failed to ensure that ordered non-pressure wound care treatments were completed as prescribed for one resident. The resident was admitted with type II diabetes and hidradenitis suppurativa, and an MDS assessment documented moisture associated skin damage (MASD). A care plan identified the resident as being at risk for skin impairment due to weakness, cognitive deficit, incontinence, impaired mobility, thin and fragile skin, falls, and autoimmune disease, with goals and interventions that included keeping the skin clean and dry, using lotion on dry but not broken skin, monitoring and documenting skin injuries, and following facility protocols for treatment. An order dated 11/18/25 directed daily wound care including cleansing with chlorhexidine wash, applying clindamycin gel to the wound, covering with an ABD pad, and applying nystatin powder to the peri-wound area; this order remained in effect until 12/19/25. Record review of the treatment administration record for 12/2025 showed that this daily wound care was not completed on 12/11/25, 12/12/25, 12/16/25, and 12/18/25. A subsequent order dated 12/19/25 revised the daily treatment to include cleansing with chlorhexidine wash, applying clindamycin gel, applying calcium alginate, covering with an ABD pad, and applying nystatin powder to the peri-wound. The treatment administration record for 12/2025 showed missed treatments on 12/21/25, 12/25/25, 12/30/25, and 12/31/25, and the record for 01/2026 showed missed treatments on 01/03/26, 01/04/26, and 01/05/26. In an interview, the ADON confirmed that these treatments were not completed as ordered and stated there was no reason they should not have been completed and no additional documentation explaining the omissions. This deficiency was investigated under Complaint Number 2722441.
Failure to Implement Care-Planned Fall-Prevention Interventions for High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement fall-prevention interventions as outlined in residents’ care plans for residents identified as high fall risks. For one resident with multiple diagnoses including osteoporosis, gait abnormalities, cognitive impairment, and a history of multiple falls, the fall risk assessment identified her as high risk and her care plan required that her walker be kept within reach when she was in her room. During observation, the resident was lying in bed with her wheelchair at the bedside, but no walker was within reach as required by her fall-prevention care plan. A CNA who had been working at the facility for about four months reported being familiar with this resident, acknowledged that the resident was a fall risk with a history of falls, and stated that the resident was supposed to wear non-skid socks or shoes when ambulating and primarily used a wheelchair. However, the CNA was not aware that the resident had a walker and confirmed, upon returning to the room, that no walker was kept within the resident’s reach despite this being an active intervention in the resident’s fall-risk care plan. For a second resident with multiple conditions including hemiplegia, muscle weakness, reduced mobility, and total incontinence, the fall risk assessment also identified her as high risk for falls, and her care plan required that she be provided with a reacher/grabber and encouraged to use it, particularly if she dropped items on the floor. Observation found this resident in bed with an air mattress, perimeter overlay, assist bars, and call light within reach, but without a reacher/grabber in reach as specified in her care plan. The resident stated she had a reacher/grabber “around there somewhere” but confirmed it was not within reach, and a reacher/grabber was later observed stored on a nightstand in an area of the room not accessible to her. An LPN, new to the facility, confirmed that the reacher/grabber was part of the resident’s fall-prevention interventions and that it was not within the resident’s reach at the time of observation. The facility’s fall policies required identification and implementation of interventions based on resident-specific risks, but the required interventions were not in place for these residents at the time of surveyor observations.
Failure to Ensure Appropriate PPE Use for Resident on Covid-19 Transmission-Based Precautions
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate use of personal protective equipment (PPE) for a resident on transmission-based precautions (TBP) for Covid-19. During a medication pass on the North hall, an RN entered the room of Resident #30, who verbally reported it was her tenth and final day of isolation for a positive Covid-19 test, wearing only an N-95 particulate respirator and gloves. The RN did not don a gown before entering, despite the facility’s Covid-19 policy requiring a NIOSH-approved N-95 or higher respirator, gown, gloves, and eye protection for healthcare providers entering the room of a patient with suspected or confirmed Covid-19 infection. Observation after the medication pass showed a PPE cart outside the resident’s room and a Droplet Precautions sign that was not prominently displayed, as it was resting diagonally on the handrail, partially obscured by equipment stored in the hallway. Record review showed Resident #30 was admitted on an earlier date with diagnoses including congestive heart failure, chronic kidney disease, hypertensive heart disease, and morbid obesity. Nursing progress notes documented that on a prior date the resident was tested for Covid-19 due to headache, chills without fever, and sore throat, and the test was positive. However, the active physician’s orders did not include a specific order for TBP for Covid-19 or the duration of isolation, only an open-ended order allowing Covid-19 testing as needed. In an interview, the RN confirmed she knew the resident was in isolation for Covid-19, acknowledged that a gown was required PPE for entering the room, and stated she did not wear a gown because none were available in the PPE cart and she did not check other carts. She also acknowledged that the Droplet Precautions sign was not clearly visible or posted on the door where it would be easily seen when the door was closed.
Failure to Enforce COVID-19 Source Control and PPE Requirements During Outbreak
Penalty
Summary
The deficiency involves the facility’s failure to maintain and implement its infection prevention and control program, including required COVID-19 precautions, during an active outbreak that affected all residents. Surveyors observed a sign at the facility entrance stating that staff and visitors were required to wear N95 masks at all times due to a current COVID-19 outbreak. Despite this, four of five night-shift staff members, including two LPNs and two CNAs, were observed inside the facility without any masks. One LPN acknowledged she had a resident on her unit with COVID-19 and confirmed staff were supposed to wear masks at all times. Another CNA stated she was unsure whether staff were required to wear masks at all times and reported working on the LTC unit. A second LPN, who also had a resident with COVID-19 on his unit, stated he did not believe masks worked, was not aware staff were to wear masks, and said he would only wear a regular mask, not an N95, when entering a COVID-positive resident’s room. Another CNA reported being unclear about mask use outside resident rooms and stated that staff had become more relaxed about mask use at night after several residents had COVID-19. Further observations showed improper use of personal protective equipment (PPE) for residents on isolation for COVID-19. A CNA delivering a breakfast tray to a resident on droplet/contact precautions for COVID-19 donned a gown, gloves, and an N95 mask but did not wear eye protection while providing care and handling items in the room. Upon exiting, she removed her gown and gloves, performed hand hygiene, and applied a new N95 mask, later stating she was new and did not know eye protection was required for entering the room of a resident with COVID-19. An RN confirmed that staff were required to wear eye protection when entering such rooms. Record review showed that one resident had tested positive for COVID-19 and was placed on isolation, and another resident later tested positive and was placed on droplet/contact isolation. Facility infection tracking logs documented that 18 residents had tested positive for COVID-19 over a defined period, with all but one remaining in the facility. The facility’s written COVID-19 policy required source control (mask use) for individuals in areas experiencing a SARS-CoV-2 outbreak and specified that staff entering rooms of residents with suspected or confirmed COVID-19 must use an N95 mask, gown, gloves, and eye protection, which was not consistently followed in practice.
Failure to Provide Showers per Resident Preferences Due to Staffing Shortages
Penalty
Summary
The facility failed to ensure that residents received showers according to their preferred schedules, as documented in their care plans. Three residents with severe cognitive impairment and dependent on staff for bathing did not receive showers on multiple scheduled days. Medical records and care plans indicated that these residents were to receive showers twice a week, with specific days assigned for each individual. Shower records revealed that the scheduled showers were missed on several occasions for each resident. Interviews with CNAs, LPNs, and RNs confirmed that showers were not completed when there were staffing challenges. Staff reported that, during periods of inadequate staffing, priority was given to other essential care tasks such as turning, changing, and assisting residents with eating, resulting in showers being omitted. The Acting DON confirmed that residents' shower preferences were obtained on admission and that the missed showers were accurately reflected in the records. Family members of one resident expressed concern about the resident's hygiene, noting a decline in cleanliness and the importance of showering to the resident. The deficiency was identified during an investigation under specific complaint numbers.
Failure to Provide Timely and Accurate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate and timely pressure ulcer care for two residents, resulting in deficiencies in wound management and prevention. For one resident with a history of congestive heart failure, respiratory failure, diabetes, and stage four kidney disease, a physician's order was in place to treat a pressure ulcer on the left heel. However, during wound care, a registered nurse mistakenly treated the right heel, which no longer had a pressure ulcer, instead of the left heel as ordered. The nurse confirmed the error after it was pointed out, and the facility's policy required adherence to physician orders for wound treatment. Another resident, admitted after hip replacement surgery and with stage three kidney disease and hypertension, was identified as being at risk for skin breakdown. Initial skin assessments were inaccurately dated, and the resident developed pressure ulcers on the right upper buttock and coccyx, which later merged into a larger wound. Treatment for these ulcers was not initiated until several days after the wounds were first noted, despite physician orders being obtained. Additionally, deep tissue pressure injuries were identified on both heels, but treatment was delayed by a day after the injuries were discovered and orders were received. Interviews with nursing staff and the Director of Nursing confirmed that documentation was not completed on the correct dates and that treatments were not started promptly as required by facility policy. The facility's Skin Integrity Management Policy specified that treatment plans should be established and implemented for residents with pressure ulcers, but these procedures were not consistently followed for the affected residents.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to ensure timely and appropriate reporting of an allegation of physical abuse involving a resident with chronic respiratory failure, dementia with psychotic disturbance, and psychosis. The incident occurred when two CNAs were providing care to the resident, who became combative. One CNA reportedly responded to the resident's attempt to bite by pushing and smacking the resident's head. This incident was witnessed by the other CNA, who did not report it immediately. The abuse was not reported to the local law enforcement agency or the resident's family, and the facility's Administrator unsubstantiated the allegation due to a lack of evidence. The facility's policy requires immediate reporting of abuse allegations to a supervisor, with subsequent notifications to the physician, resident's family, Ombudsman, and local law enforcement. However, the report indicates a delay in reporting the incident, as the witnessing CNA did not report it until several hours later, and the Administrator did not notify the necessary parties. The deficiency was identified during the investigation of a complaint, highlighting non-compliance with the facility's abuse prevention policy.
Failure to Offer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to offer pneumococcal immunizations to residents, as evidenced by the review of medical records, vaccination consent forms, and staff interviews. This deficiency affected four out of five residents sampled for immunization review. The residents involved had various medical conditions, including heart disease, diabetes, dementia, renal disease, and respiratory failure. The immunization records for these residents showed either no record of receiving a pneumococcal vaccine or an unknown type of vaccine administered years prior. Additionally, there were no physician orders for the pneumococcal vaccine for these residents. The facility's Vaccine Administration Record (VAR)/Informed Consent form allowed residents or their responsible parties to indicate their wish to receive vaccinations, including COVID-19, influenza, and others. However, the forms for the affected residents did not indicate a request for the pneumococcal vaccine. An interview with the Director of Nursing (DON) revealed that there was no specific consent form for the pneumococcal vaccine, and the facility relied on residents or their families to write in their request for this vaccine. The DON acknowledged that there was no proof that the affected residents were asked about receiving the pneumococcal vaccine, highlighting a gap in the facility's vaccination consent process.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Athens
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Laurels Of Athens, The | 3.1 mi | ★★★★★ | 17 | 1 |
| Hickory Creek Of Athens | 4.2 mi | ★★★★★ | 0 | 0 |
| Arbors At Pomeroy | 15.5 mi | ★★★★★ | 7 | 0 |
| Arcadia Valley Skilled Nursing And Rehabilitation | 17.4 mi | ★★★★★ | 20 | 0 |
| Maple Hills Skilled Nursing & Rehabilitation | 19.2 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.