Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Kirtland Woods Of Journey during CMS and state inspections, most recent first.
Failure to employ a qualified full-time social worker: The facility, licensed for 180 beds, had no LSW after the prior LSW left, and the DON and Regional Nurse confirmed that department heads were covering social work duties. An off-site social worker provided only guidance and did not complete or sign any facility work, while the Facility Assessment identified the need for a full-time social worker and the job description required oversight of medically related social services.
The facility failed to notify residents or their responsible parties when personal fund accounts exceeded the Medicaid resource limit. Four residents reviewed had balances above the $2,000 limit, and there was no documentation that spend-down notices were sent. The BOM acknowledged the high balances, stated no staff were assigned to prepare notices, and said the facility lacked a process to help residents manage excess funds.
A resident’s room was not kept clean when a stained window curtain remained unaddressed despite repeated requests, and staff confirmed it was visibly soiled. In the memory care dining and common areas, surveyors observed sticky residue on a table, food and drink spills on the floor, stained chairs, a frayed and taped carpet with dark stains, and a damaged table with loose trim and tennis balls on the legs while a resident was seated nearby.
Missed Routine Care Plan Conferences: The facility failed to conduct routine care plan conferences for multiple residents, with no documented conferences for several months in some cases. A resident with intact cognition, residents with moderate to severe cognitive impairment, and residents dependent on staff for ADLs, transfers, toileting, and continence care all had outdated care conferences despite ongoing care needs. The DON and RCN verified the facility lacked LSW coverage for social work duties, and the facility policy required the interdisciplinary team to review and revise the comprehensive care plan after each comprehensive and quarterly MDS assessment.
Failure to Provide Required Social Services Oversight: The facility had no LSW for more than five months, and staff without social work qualifications were informally trying to cover social services tasks without oversight. As a result, several residents missed care conferences and resident/representative participation in care planning was absent or delayed, including a resident with intact cognition, residents with dementia, and a resident with COPD, depression, dysphagia, and fall risk. The lack of social services oversight also led to no notifications when resident personal fund accounts exceeded Medicaid limits.
Failure to feed a resident in a dignified manner. A resident with dementia, dysphasia, malnutrition, and dependence for eating was observed in the dining room being fed by an LPN and later a CNA while both staff stood over him. Facility guidance for assisting with meals stated staff should be seated next to the resident and not stand behind or over the resident, and the resident rights policy required respectful, dignified care.
A resident with severe cognitive impairment, dementia, and agitation was verbally abused during hands-on care when a CNA used inappropriate and unprofessional language. Staff later reported that an audio recording existed and had been shared, and the facility’s investigation substantiated the verbal abuse after reviewing the recording and staff statements.
A resident with a right ankle/foot wound, chronic osteomyelitis, and cellulitis did not receive dressing changes as ordered. The resident said the dressing had not been changed in over a week and denied refusing care, yet the TAR showed refusals were documented and an LPN later confirmed the dressing changes were not being done daily as ordered. The DON verified staff were not following the provider’s wound care order and were signing off treatments as completed when they had not been performed.
A resident with PTSD and multiple chronic conditions had a care plan that noted trauma history and a goal to identify coping mechanisms, but no individualized triggers were documented. The resident reported triggers including certain TV shows, sudden loud noises, and being startled when someone entered the room quietly, and said reciting The Lord's Prayer helped as a coping mechanism. The DON confirmed the triggers and coping mechanisms had not been identified.
The facility failed to manage biohazardous materials and handle linen properly, risking infection spread. Observations showed soiled items on floors, dirty fans in the laundry area, and improper transport of clean clothes. Staff confirmed these issues, indicating non-compliance with infection control protocols.
The facility failed to maintain a safe, sanitary, and homelike environment, affecting numerous residents. Observations revealed issues such as sticky floors, unsecured toilet paper holders, and low water levels in toilets with soiled paper. Shared bedrooms and bathrooms had missing handles, protruding screws, and sticky floors. Additional deficiencies included missing window coverings, broken toilet paper holders, and missing baseboards. Bathrooms had dried feces on various surfaces, and some areas had rusted and peeling toilet risers. Maintenance staff confirmed these findings, indicating a lack of timely repairs and cleaning.
The facility did not provide dementia management training for three newly hired STNAs, potentially affecting all 103 residents. The facility's assessment required such training due to the acceptance of residents with neurological and psychiatric disorders, but the training was not completed as confirmed by the HR Director.
The facility failed to store refrigerated medications properly and allowed food items in medication carts. Observations revealed snack items in medication carts and insulin stored without a thermometer in a refrigerator. Additionally, the memory care unit's refrigerator was at a freezing temperature, below the recommended range for insulin and Tuberculin. The facility's policy requires proper storage temperatures, which were not maintained.
The facility failed to provide private closet space for 46 residents, resulting in shared closets without separation for clothing. This issue was confirmed during a facility tour and interview with the MD, affecting numerous resident pairs across the facility.
A facility failed to prevent resident-to-resident abuse involving two residents. One resident with Alzheimer's and dementia exhibited aggressive behavior despite being on multiple medications. The resident was observed hitting another resident, leading to an investigation that confirmed the incident. Staff interviews revealed that the aggressive resident was known to be restless and fidgety, and the incident occurred during a shift with many agency staff.
A facility failed to update a resident's care plan regarding contact lens use. Despite the resident's severe cognitive impairment and a recommendation from an ophthalmologist to avoid contact lenses, the care plan continued to include outdated interventions related to contact lens care. The resident's family agreed to switch to eyeglasses, but the care plan was not revised to reflect this change, as confirmed by the DON and a Regional Resource Nurse.
Two residents received incorrect meal trays due to a mix-up, affecting their dietary needs. One resident on a cardiac diet received a tray meant for another resident, while the second resident, who required a mechanical soft diet, consumed the wrong meal. Both residents expressed dissatisfaction, and a STAT chest x-ray was ordered for one to rule out aspiration.
The facility failed to document fall interventions for a resident with a history of falls and did not maintain accessible vaccination records for two other residents. A resident's care plan indicated a discontinued fall intervention, but the physician order was not updated. Additionally, two residents had incomplete immunization records, with tuberculosis and influenza vaccination statuses not properly recorded.
A resident's bathroom privacy was compromised as the facility used a curtain instead of a door, leaving gaps that allowed visibility from the hallway. The Maintenance Director confirmed the issue during a facility tour.
The facility failed to ensure a clean and homelike environment, affecting all 110 residents. Observations revealed open windows allowing hot air and insects, with torn screens and dirty light fixtures. Interviews confirmed uncertainty about window cleaning responsibilities and issues with soiled mechanical devices. The facility's housekeeping checklist lacked guidance on window cleaning, contributing to continued noncompliance.
A resident with multiple medical conditions was found unable to reach their call light, which was wrapped around the side rail and dangling on the ground. This oversight left the resident unable to request assistance for personal care needs, as confirmed by staff interviews.
A resident with multiple medical conditions, including hemiplegia and diabetes, expressed a preference to be up in her chair before lunch and back in bed by 3:00 P.M. However, staff often did not accommodate this preference, leaving her in the chair through the evening. On the day of observation, the resident was found in bed wearing a stained tee-shirt and an incontinence brief, and her lunch was brought to her room while she was still in bed. A State tested Nurse Aide was unaware of the resident's preferences, as she had not worked that hall in several weeks.
The facility failed to ensure a comfortable ambient temperature, as open windows allowed hot air to enter, affecting a resident who appeared restless due to the heat. Observations confirmed broken window controls and gaps in louvers, with room temperatures reaching 82.9°F. The National Weather Service reported high temperatures during this period.
A resident with severe cognitive impairment and a history of using contact lenses developed conjunctivitis due to the facility's failure to provide comprehensive and individualized eye care. Despite known risks and instructions from an eye physician, the resident continued to use contact lenses without proper management, leading to actual harm.
The facility failed to provide adequate assistance and supervision to prevent falls for two residents. One resident sustained a shoulder fracture due to insufficient staff assistance, and another resident was found on the floor multiple times due to improper bed positioning and lack of a floor mat.
The facility failed to complete annual performance evaluations for nurse aides as required, potentially affecting all 120 residents. Personnel files for three STNAs hired in March and April 2023 showed no evidence of annual performance evaluations. This was confirmed by the HR Business Partner during an interview.
The facility failed to properly store injectable pharmaceuticals by not dating opened containers and not maintaining clean medication storage refrigerators. An undated insulin pen was found in a medication cart for a resident with diabetes, and an undated vial of Tuberculin was found in the Central medication room refrigerator. Both medication room refrigerators had significant ice overgrowth.
The facility failed to serve meals at palatable temperatures, affecting several residents. Observations showed significant drops in food temperatures from the kitchen to the point of service, and multiple residents expressed dissatisfaction with the cold meals.
The facility failed to maintain a clean and sanitary kitchen and nursing unit refrigerators, affecting all residents. Observations included dirty walls, drawers, and dish room, as well as unclean nursing unit refrigerators. The Dietary Manager and a dietary assistant verified these findings, which were not in accordance with the facility's sanitization policy.
The facility failed to complete TB testing for a resident with multiple serious health conditions and did not accurately complete TB testing for five new employees, as required by facility policy and CDC guidelines.
The facility failed to maintain essential laundry equipment, with one washing machine and one dryer being non-functional for extended periods. This caused delays in the turnaround time for residents' clothing, potentially affecting all 120 residents. The issues were confirmed by the Housekeeping Manager and Maintenance Director, who noted difficulties in obtaining parts and indecision about repairs or replacement.
The facility failed to ensure a clean, sanitary, and homelike environment, affecting all 120 residents. Issues included an improperly taped window causing discomfort, persistent urine odor traced to a non-compliant resident's mattress, absence of a closet door, crumbling doorway, water stains, dried bowel movements, worn floor tiles, and a non-functioning paper towel dispenser. Staff acknowledged the issues but did not always take immediate action.
The facility failed to ensure handrails were in good repair, potentially affecting all residents. During an observation, a missing portion of the handrail was noted across from the 300-hall dining/activity area and next to the area where puzzles were kept. The Maintenance Assistant verified the observation and stated he did not know how long it had been that way but would get it fixed.
The facility failed to complete the required 12 hours of annual training for nurse aides, potentially affecting all 120 residents. A review of personnel files for two STNAs revealed no evidence of training. An interview with the HR Business Partner confirmed these findings. The facility policy stated that nurse aides should be competent in necessary skills and techniques.
The facility failed to ensure Resident Fund Authorizations were witnessed, affecting six residents. The Business Office Manager confirmed that the authorization forms had not been witnessed as required.
The facility failed to offer COVID-19 education and vaccination opportunities to five staff members, including an STNA, a cook, two LPNs, and an RN. The immunization status for these staff members was listed as past due, and there was no evidence of education or booster offers. The DON confirmed the lack of information regarding COVID-19 education and vaccination offers.
The facility failed to ensure accurate assessments for multiple residents, including incorrect coding of hospice services, discharge destinations, oral health status, and alarm use. These discrepancies were confirmed through interviews and record reviews, highlighting significant deficiencies in the facility's assessment processes.
The facility failed to provide baseline care plan summaries within 48 hours of admission for four residents, despite having a policy requiring it. The MDS Director confirmed that while the care plans were created, they were not provided to the residents or their responsible parties.
The facility failed to serve a resident finger food items as per physician's orders, resulting in the resident being served inappropriate food items on multiple occasions. Staff confirmed the discrepancies, indicating a failure to adhere to the prescribed dietary requirements.
The facility failed to assess two residents for influenza or pneumonia immunization status upon admission, despite having policies in place that require such assessments. Both residents had tuberculosis testing but lacked information on their immunization status for influenza and pneumonia.
The facility failed to create comprehensive care plans for three residents, neglecting to address PTSD, oral/dental status, and eye care related to contact lenses. This resulted in unaddressed medical needs and complications.
The facility failed to revise the care plan for a resident in a timely manner. Despite the discontinuation of a restorative program due to the resident's inability to participate, the care plan remained unchanged for over a month. This oversight was confirmed by the MDS Director.
The facility failed to provide activities consistently according to the care plan and preferences for a resident with dementia and other conditions. Despite the resident's interest in music, animals, group activities, and religious services, the resident was often found sitting at the nurses' station without engaging in these activities. Staff interviews and observations confirmed systemic issues in ensuring the resident's participation in preferred activities.
The facility failed to implement its abuse prevention policy by not completing job reference checks and timely state nurse aide registry (NAR) checks for new employees. This deficiency was confirmed through a review of personnel files and an interview with the HRBP, potentially affecting all 120 residents.
Failure to Employ a Qualified Full-Time Social Worker
Penalty
Summary
The facility failed to employ a qualified full-time licensed social worker as required in a facility licensed for 180 beds. During interviews on 04/28/26, the DON and Regional Nurse confirmed that no LSW had been employed since 11/05/25, after the departure of Former LSW #571. The DON stated that department heads had been performing social work duties and that she had contacted a Social Worker at another facility for guidance, but that off-site Social Worker did not complete or sign any work for the facility. The personnel record showed Former LSW #571’s last day worked was 11/05/25, and the updated Facility Assessment dated 01/05/26 recognized the need for a full-time Social Worker as part of the interdisciplinary team to address resident care needs. The Social Services Director job description stated the role was responsible for overseeing the Social Services Department and ensuring medically related social services were provided in accordance with State and Federal regulations.
Failure to Notify Residents of Excess Personal Fund Balances
Penalty
Summary
The facility failed to notify residents or their responsible parties when resident personal fund accounts reached within $200 of the Medicaid resource limit, as required by regulation. Record review showed that four of six residents reviewed for personal funds had balances above the $2,000 Medicaid resource limit, including balances of $20,702.70, $6,007.89, $24,237.64, and $4,280.00, and there was no documentation that the residents or responsible parties were notified of the need to spend down the funds. During interview, the Business Office Manager acknowledged awareness of the high balances and stated the facility did not have a social worker to prepare and send spend-down letters, no other staff were assigned to this task, no spend-down notifications were issued, and the facility lacked a process to assist residents in managing excess funds.
Dirty Room and Poorly Maintained Memory Care Areas
Penalty
Summary
The facility failed to provide a clean, safe, sanitary, and homelike environment when Resident #36’s room was not maintained in a clean condition. During an interview, the resident reported that the window curtain in his room was dirty and said he had asked staff multiple times to clean it without any action being taken. He stated the curtain had already been soiled when he moved into the room about four months earlier. Observation of the room confirmed a left window curtain panel with large reddish-brown stains on its underside, and a later observation showed the same stains remained. A CNA acknowledged the curtain was soiled, and the Maintenance Director confirmed it was visibly soiled and said anyone cleaning the room should have noticed it. The Daily Housekeeping Checklist required windowsills to be cleaned daily, and the facility’s Environmental Quality and Resident Rights policies required staff to report and maintain furnishings and the environment in a clean condition. The memory care dining and common areas were also observed in poor condition. In the dining room, one table had a clear sticky substance on it, the floor beneath another table had a red juice stain and multiple brown spillage spots, and a damp washcloth on the floor revealed additional brown spillage when moved. A CNA verified these findings and stated housekeeping was responsible for cleaning the dining room after meals, while the UM/LPN reported housekeeping services were inconsistent and unit staff sometimes had to clean the area. In the common area, the carpet had frayed edges secured with blue tape and several large dark stains. In the dining room, four stained chairs were observed along the wall, and a wooden table was found in significant disrepair with loose and hanging trim, a missing section of upper trim, and tennis balls attached to three legs while a resident was seated at the table awaiting lunch.
Missed Routine Care Plan Conferences
Penalty
Summary
The facility failed to ensure routine care plan conferences were conducted for six sampled residents, and the comprehensive care plan was not being reviewed and revised by the interdisciplinary team after quarterly or comprehensive MDS assessments as required by facility policy. Record review showed that the last care conferences for Residents #13, #14, #22, #32, #49, and #11 occurred months before the survey, with no subsequent conferences documented after July 2025, July 2025, April 2025, April 2025, February 2025, and April 2025, respectively. Resident #13 had diagnoses including osteoarthritis, skin cancers, anxiety disorder, major depressive disorder, dementia, protein-calorie malnutrition, and dysphagia. The resident’s quarterly MDS showed intact cognition with a BIMS of 15/15, but the resident still required assistance and cueing with hygiene, toileting, showers, and transfer to a wheelchair, and was frequently incontinent of bowel and bladder. The resident stated on interview that no care conferences had occurred at the facility since July 2025. Resident #14 had diagnoses including endometrial cancer, type 2 diabetes, major depressive disorder, anxiety, protein-calorie malnutrition, obesity, a left fibula fracture, and cerebral infarction. The resident’s quarterly MDS showed moderate cognitive impairment with a BIMS of 12/15 and dependence on staff for hygiene, toileting, showers, and wheelchair transfers, with frequent bowel and bladder incontinence. Resident #22, Resident #32, and Resident #49 each had severe cognitive impairment on MDS, were dependent on staff for all ADLs and mobility needs, and were always incontinent of bowel and bladder. Resident #11 had COPD, CHF, atrial fibrillation, generalized weakness, and malignant neoplasms, and was dependent for toileting and required maximal assistance for showers, dressing, and transfers. The DON and Corporate RCN verified the facility did not have a LSW or designee with LSW oversight since November 2025, the former LSW’s last day worked was 11/05/25, and care conferences had been missed for long-stay residents. The facility policy titled Comprehensive Care Plans stated the care plan would be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.
Failure to Provide Required Social Services Oversight
Penalty
Summary
The facility failed to provide medically related social services necessary for residents to attain or maintain their highest practicable physical, mental, and psychosocial well-being because it had no Licensed Social Worker (LSW) providing or overseeing required social services for more than five months. During an interview, the DON and Regional Nurse confirmed the facility had not employed an LSW since 11/05/25, and no LSW had completed, overseen, or signed social services documentation, assessments, or care conferences since that time. Department heads were informally attempting to perform social services tasks without training, qualifications, or LSW oversight, and an off-site Social Worker at another facility was only contacted for advice and did not perform or sign any work for this facility. This resulted in missed care conferences and lack of resident and representative involvement in care planning for multiple residents. Resident #13, who had intact cognition and dependence on staff for ADLs, had not had a care conference since 07/02/25; Resident #14, with moderate cognitive impairment, last had a care conference on 07/28/25; Resident #22, with dementia and total dependence for ADLs, last had a care conference on 04/16/25; Resident #32, with dementia, COPD, depression, dysphagia, and fall risk, last had a care conference on 04/08/25; Resident #49, with dementia and multiple chronic conditions, last had a care conference on 02/13/25; and Resident #11, with multiple chronic conditions and intact cognition, had not had a care conference in approximately a year. Resident #49's daughter stated she had not participated in a care conference in over a year despite requesting them. The absence of a Social Worker also led to failure to notify residents or representatives when personal fund accounts exceeded Medicaid limits, including residents with balances of $20,702.70, $6,007.89, $24,237.64, and $4,280.00, and the BOM confirmed no spend-down notifications were issued and no process existed to assist residents in managing excess funds.
Failure to Feed Resident in a Dignified Manner
Penalty
Summary
The facility failed to ensure a resident was fed in a dignified manner. Resident #19 was admitted on 01/12/23 with diagnoses including unspecified dementia, unspecified protein calorie malnutrition, Alzheimer's disease, dysphasia, and need for assistance with personal care. The resident's quarterly MDS indicated a severe cognitive deficit, that he was rarely understood, and that he was dependent on staff for eating. The care plan also identified that he required assistance with ADLs and was dependent on staff for eating. During observation, Resident #19 was seen in the East dining room seated in his wheelchair while being fed by an LPN and later by a CNA, with both staff members standing over him while assisting with meals. The LPN and the Executive Director verified the first observation, and the RN verified the second observation. The facility's undated Validation Checklist-Assisting Resident with Meals stated staff should be courteous, seated next to the resident, not standing behind or over the resident, and primarily conversing with the resident during the meal. The facility policy titled Resident Rights stated residents have the right to be treated with respect and dignity and to receive services with reasonable accommodation of needs and preferences.
Verbal Abuse Toward Resident With Dementia During Care
Penalty
Summary
Staff failed to prevent verbal abuse toward Resident #6, a resident with senile degeneration of the brain, vascular dementia with agitation, severe cognitive impairment, and frequent physical behavioral symptoms. The resident was admitted to a secured memory care unit and required assistance with all activities of daily living because of impaired cognition and resistance to care. The care plan documented the resident’s need for redirection, environmental changes, diversion, toileting, limit-setting, and reapproaching as needed during care. The facility became aware of an allegation that a care team member yelled at the resident during hands-on care after staff reported that an audio recording existed and had been shared among employees. An investigation was initiated, including resident and staff interviews and skin assessments. Two staff members independently reported that the recording depicted a CNA using inappropriate language toward Resident #6 during care, and the recording was later obtained and reviewed by administration. The facility investigation determined that a verbal altercation occurred during resident care involving inappropriate and unprofessional language toward Resident #6. The CNA involved was identified after a delay, removed from resident care, and later terminated. The DON and ED verified that the substantiated incident involved verbal abuse.
Physician-Ordered Wound Dressing Changes Not Followed
Penalty
Summary
The facility failed to ensure physician orders were followed for Resident #35’s right ankle/foot surgical wound. The resident was admitted with diagnoses including a non-displaced fracture of the right fibula/ankle, chronic osteomyelitis of the right ankle and foot, and cellulitis of the right lower limb. The resident was cognitively intact with a BIMS score of 15/15 and required assistance with lower body ADLs, hygiene, transferring, and mobility. The physician’s order dated 04/07/26 directed staff to cleanse the wound with wound cleanser, apply betadine-moistened gauze to the incisions, and wrap with Ace wrap every day. Resident #35 stated she had not received a dressing change to the right foot in over a week and said her provider told her the dressing changes should occur daily; she also stated she had never refused any dressing changes. However, the TAR showed dressing changes were signed off as refused on 04/22/26, 04/25/26, and 04/26/26. During wound care observation, the wound had crusted serosanguinous drainage adhered to the gauze wrap, and the LPN performed the dressing change at that time. The LPN confirmed the dressing changes were not being performed daily and stated she had signed off multiple dressing changes in the EMR as completed even though they were not performed as ordered. The DON confirmed staff were not following the provider’s order and that nursing staff were signing off dressing changes as completed when they were not being done.
Failure to Document Trauma Triggers and Coping Mechanisms
Penalty
Summary
The facility failed to identify and document individualized trauma triggers and coping mechanisms for a resident with post-traumatic stress disorder (PTSD). Resident #3 was admitted with diagnoses including chronic obstructive pulmonary disease, type II diabetes, hypertension, congestive heart failure, non-rheumatic aorta insufficiency, and PTSD, and the care plan identified the resident as a trauma survivor related to military service with a goal that coping mechanisms would be identified. Although the interventions included identifying triggers related to past trauma, none were documented in the care plan. The quarterly MDS showed the resident was moderately cognitively impaired and required maximal assistance for toileting and transfers and moderate assistance for dressing. During interview, the resident identified triggers such as certain television shows, sudden loud noises like the fire alarm, and being startled when someone entered the room quietly, and reported reciting The Lord's Prayer as a coping mechanism. The DON confirmed that triggers and coping mechanisms had not been identified for the resident.
Inadequate Infection Control in Linen and Biohazard Management
Penalty
Summary
The facility failed to properly manage biohazardous materials and handle clean and soiled linen, which could potentially spread infection among residents. Observations revealed a feces-soiled pillowcase on the bathroom floor shared by four residents, and soiled linens placed on the laundry room floor due to a non-functioning washer. Additionally, dirty fans were found in the clean laundry area, blowing air toward clean linens, which could contaminate them. Interviews with staff confirmed these findings, indicating a lack of adherence to infection control protocols. Further observations showed a laundry worker delivering clean clothes without a proper covering, using a thin sheet that inadequately protected the clothes from contamination. In another instance, soiled linen was found on a resident's bathroom floor, and biohazardous red bags containing soiled linen and a disposable gown were improperly stored in a shared bathroom. The facility's policy on handling soiled laundry and bedding was not followed, as it required protection of clean linen from dust and soiling during transport and storage.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and homelike environment, affecting 48 residents and potentially impacting all 103 residents. Observations revealed numerous issues, including sticky floors, unsecured toilet paper holders, and low water levels in toilets with soiled paper. Shared bedrooms and bathrooms had missing handles, protruding screws, and sticky floors. Interviews with staff confirmed these findings, indicating a lack of proper maintenance and cleanliness. Further observations highlighted additional deficiencies, such as missing window coverings, broken toilet paper holders, and missing baseboards in the memory care unit. Residents complained about bright lights at night due to the lack of window coverings. The facility's administrator acknowledged that repairs were planned but had been delayed since May 2024. Housekeeping staff confirmed the presence of broken toilet paper holders and the placement of toilet paper rolls in inappropriate locations. Additional issues included missing or malfunctioning closet doors, exposed screws, and broken light fixtures. Bathrooms had dried feces on various surfaces, and some areas had rusted and peeling toilet risers. The laundry room contained a blanket stuffed between dryers, covered in lint and debris, which was placed there due to concerns about critters. Maintenance staff confirmed these findings, indicating a lack of timely repairs and cleaning, contributing to an unsafe and unsanitary environment.
Lack of Dementia Management Training for Nurse Aides
Penalty
Summary
The facility failed to provide dementia management training for three State Tested Nursing Assistants (STNAs) after their hire, which had the potential to affect all 103 residents residing in the facility. The personnel files for STNA #485, #496, and #503, who were hired on 06/12/24, 06/26/24, and 07/10/24 respectively, showed no evidence of completed dementia management training. An interview with the Human Resource Director confirmed that the required training was not provided to these STNAs. The facility's assessment, effective from January 2024 through December 2024, indicated that the facility accepted residents with neurological and psychiatric mood disorders and provided special treatments for behavioral health needs, cognitive loss, and dementia. The assessment required that staff, including nurse aides, receive dementia management training, which was not fulfilled in these cases.
Improper Storage of Medications and Food in Medication Carts
Penalty
Summary
The facility failed to properly store refrigerated medications and ensure that food items were not stored inside medication carts. During an observation, it was found that the east long medication cart contained snack-sized packages of cookies, and the central medication cart contained snack-sized containers of applesauce and pudding. Additionally, the central medication room refrigerator lacked a thermometer and contained insulin pens and vials for two residents. The Unit Manager verified these findings during the observation. Further observations revealed that the memory care unit medication room refrigerator had a freezing point temperature of 32 degrees Fahrenheit, which is below the recommended storage temperature for insulin and Tuberculin. The refrigerator contained insulin pens for two residents and vials of Tuberculin used for residents and staff. The temperature log for the refrigerator showed daily checks with a maintained temperature of 35 degrees Fahrenheit, except for one day when no temperature check was recorded. The FDA guidelines recommend storing insulin and Tuberculin at 36 to 46 degrees Fahrenheit, and they should not be frozen. The facility's policy on medication storage, revised in November 2020, requires drugs and biologicals to be stored under proper temperatures.
Deficiency in Private Closet Space for Residents
Penalty
Summary
The facility failed to provide private closet space separate from roommates' clothing for 46 residents out of 103 rooms reviewed. During a facility tour, it was observed that several pairs of residents were sharing a single closet without separation for their clothing. This deficiency was confirmed through observations and an interview with the Maintenance Director. The affected residents were identified by room numbers, indicating a widespread issue across the facility.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident abuse, affecting two residents. Resident #104, who had diagnoses including Alzheimer's disease and dementia with agitation, was admitted for a respite stay. The resident exhibited severely impaired cognition and various behavioral symptoms, including physical and verbal aggression. Despite being on multiple medications for behavior management, Resident #104 continued to display agitation and restlessness, frequently wandering into other residents' rooms and touching them. The facility's care plan included interventions such as medication administration, redirection, and monitoring, but these measures were ineffective in preventing the resident's aggressive behavior. On the night of the incident, Resident #104 was observed being physically aggressive towards Resident #41, hitting her in her room. Staff intervened, but Resident #104 became combative, striking staff with a dry erase board and attempting to cover Resident #41's head with a pillow. Although Resident #41 was assessed and found to have a small red mark under her eye, she did not exhibit signs of distress or recall the incident. The facility's investigation confirmed the occurrence of the incident, and Resident #104 was sent to the hospital for evaluation. Interviews with staff revealed that Resident #104 was known to be restless and fidgety, often touching everything and everyone around him. The incident occurred during a shift with a high number of agency staff, which may have contributed to the lack of effective intervention. Despite previous reports of increased agitation and restlessness, the facility did not implement adequate measures to prevent the resident's aggressive behavior, resulting in the deficiency.
Failure to Update Care Plan for Resident's Contact Lens Use
Penalty
Summary
The facility failed to adequately update the care plan for a resident regarding the use of contact lenses. The resident, who had severe cognitive impairment and a history of rejecting care, was initially prescribed to have contact lenses removed every evening. However, this order was discontinued, and the resident's contact lens was eventually removed by an eye doctor. Despite the recommendation from the ophthalmologist to avoid using contact lenses and the family's agreement to switch to eyeglasses, the care plan was not updated to reflect these changes. The care plan still included interventions related to contact lens care, such as documenting refusals, family assistance with placement and cleaning, and other maintenance instructions, even though the resident was no longer wearing contact lenses. The Director of Nursing and Regional Resource Nurse confirmed that the care plan goals had changed, but the care plan itself did not reflect the updated care approach. This oversight affected the resident's care and was identified during a review of the facility's care plan revision process.
Dietary Errors Affect Two Residents
Penalty
Summary
The facility failed to provide food in the correct form to two residents, which had the potential to affect all 48 residents on the 300 unit. Resident #10, who was cognitively intact and on a cardiac diet with regular texture and thin liquids, received the wrong diet tray at lunchtime. The resident complained about not receiving her lunch tray and was later given Resident #11's tray, which included items not suitable for her cardiac diet. Despite the error, Resident #10 did not experience any issues consuming the meal, but she expressed dissatisfaction with the utensils and the meal content. Resident #11, who was cognitively impaired and on a mechanical soft texture diet with specific adaptive equipment, received and consumed the wrong diet tray intended for Resident #10. The resident's tray was supposed to include pureed corn and a grilled cheese sandwich, but instead, it contained a hamburger and other items not aligned with his dietary needs. The resident consumed most of the meal without issues but complained about the missing grilled cheese. A STAT chest x-ray was ordered to rule out aspiration, and the guardian was notified of the incident.
Documentation Failures in Fall Interventions and Immunization Records
Penalty
Summary
The facility failed to accurately document fall interventions for a resident and maintain accessible vaccination records for two other residents. For Resident #62, who had a history of muscle weakness and repeated falls, a physician order required a floor mat to be placed at the left bedside. However, during an observation, it was noted that the mat was not present, and the nursing assistant confirmed it was not listed on the Kardex. The care plan indicated that the intervention was discontinued, but the physician order was not updated to reflect this change, leading to a discrepancy in the resident's care documentation. For Residents #97 and #102, the facility did not maintain complete and accessible immunization records. Resident #97's records showed incomplete documentation of tuberculosis testing and refusal of the Pneumococcal vaccine, with the second step of the tuberculosis test recorded in different places. Resident #102's records lacked information on the influenza immunization status, although the facility had located the information but failed to enter it correctly. These documentation lapses affected the accuracy and accessibility of the residents' medical records.
Inadequate Bathroom Privacy Due to Curtain
Penalty
Summary
The facility failed to provide adequate privacy for a resident's bathroom by using a curtain instead of a door. During a facility tour, it was observed that the bathroom entrance of a resident's room was covered with a full-length curtain on a rod, which extended two to three inches away from the wall. This setup left a wide gap on both sides of the curtain, allowing visibility into the bathroom from the hallway when the bedroom door was open. The Maintenance Director confirmed these findings during the observation.
Facility Fails to Maintain Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean, sanitary, and homelike environment, affecting all 110 residents. Observations on the East wing revealed open windows allowing hot air and insects to enter, with grayish-black spots on window seals, tears in screens, and dead insects on windowsills. Light fixtures contained dark spots resembling insects, and the common sitting area had windows with detached or torn screens, dead insects, dust, debris, and black and gray spots around the seals. A thick yellow substance was splashed and dried on the walls near a table and trash can. Interviews with Housekeeper #398 confirmed the presence of hot air, broken blinds, greasy substances, and dead insects, with uncertainty about who was responsible for window cleaning. The window near room [ROOM NUMBER] had gaps between glass louvers, allowing insects and outside temperatures to affect the hallway. STNA #397 verified the heat and insects near the window, and Shower Room C had a foul odor, hair, lint, and standing water with black flecks. Maintenance Director #357 confirmed these issues, including broken window controls, torn screens, and dirty light covers. Two sit-to-stand mechanical devices in the East-2 wing were soiled, with missing handle grips and caked-on substances. RN #326 confirmed the need for cleaning, stating it should occur on night shifts or after use with residents in isolation. Interviews with STNAs #359 and #353 confirmed night staff were responsible for cleaning equipment. The facility's housekeeping checklist did not address window cleaning, contributing to the continued noncompliance noted in a previous survey.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that call lights were within reach for residents, specifically affecting one resident. This resident, who had multiple medical conditions including visual hallucinations, hemiplegia, and diabetes, was admitted with a care plan that required assistance with incontinence care and ensuring the call light was accessible when in bed. During an observation, the resident was found in bed with a call light wrapped around the bottom of the side rail and dangling on the ground, making it unreachable. The resident expressed discomfort and the inability to call for assistance since early morning, highlighting the lack of adherence to the care plan. Interviews with staff confirmed the deficiency. A registered nurse acknowledged that the call light was not within reach and took steps to rectify the situation by providing the resident with the call light. A state-tested nurse aide admitted to being unaware of the resident's needs and confirmed the improper placement of the call light. This oversight resulted in the resident being unable to request necessary assistance, such as adjusting the air conditioner, changing incontinence briefs, and receiving help to get into a chair before lunch.
Failure to Honor Resident's Choice for Daily Routine
Penalty
Summary
The facility failed to honor the choices of Resident #86, who was one of five residents reviewed for choices. Resident #86 had a medical history that included visual hallucinations, hemiplegia, type two diabetes mellitus, asthma, and other conditions, and required maximal assistance for transfers and was dependent for toileting and bathing. The resident expressed a preference to be up in her chair before lunch and back in bed by 3:00 P.M., but staff often did not accommodate this preference, leaving her in the chair through the evening due to being busy or handing her off to the next shift. On the day of observation, Resident #86 was found in bed wearing a stained tee-shirt and an incontinence brief, and her lunch was brought to her room while she was still in bed. It was observed that a State tested Nurse Aide (STNA) was unaware of Resident #86's preferences and had not been informed of them, as she had not worked that hall in several weeks. The facility's policy on Resident Rights, revised in February 2021, stated that residents had the right to self-determination and a dignified existence, which was not upheld in this instance.
Facility Fails to Maintain Safe Ambient Temperature
Penalty
Summary
The facility failed to maintain a comfortable and safe ambient temperature for its residents, as evidenced by observations and interviews conducted on the East wing. On multiple occasions, windows were found open, allowing hot air to enter the building. Housekeeper #398 confirmed that the windows had screens that were loose and torn, and the glass louvers had gaps between them, which allowed hot air to flow into the facility. The knob to control the louvers was also broken, exacerbating the issue. Maintenance Director #357 acknowledged that several windows were open on hot days and confirmed the broken control knob and gaps between the louvers. Resident #73 was directly affected by this deficiency. Observations revealed that the resident appeared restless and was trying to remove her clothing due to the uncomfortable heat in her room. The window above her bed was open, and hot air was blowing into the room, which registered an ambient temperature of 82.9 degrees Fahrenheit. The Maintenance Director confirmed the room temperature was inappropriate and noted the absence of a window air conditioner. The National Weather Service reported high temperatures and heat indices during this period, further highlighting the facility's failure to provide a safe and comfortable environment for its residents.
Failure to Provide Adequate Eye Care
Penalty
Summary
The facility failed to provide comprehensive, individualized, and sufficient eye care for Resident #104, who was admitted with severe cognitive impairment and a history of using contact lenses. Despite the resident's known refusal to remove contact lenses for regular washing, the care plan did not include any focus on eye care or the management of contact lenses. This oversight led to the resident developing conjunctivitis, requiring antibiotic treatment due to the lack of routine eye care. The medical record review revealed that Resident #104 had a contact lens in the right eye since admission, which was not removed until an eye physician's visit on 12/04/23. Despite instructions from the eye physician to prevent the resident from wearing contact lenses, the resident continued to use them, and staff failed to document or follow up on this issue adequately. The resident's care plan was not updated to reflect the risks associated with contact lens use, and there was no evidence of ongoing education for the resident or family regarding these risks. Interviews with staff and family members indicated that attempts to remove the contact lens were unsuccessful, and there was a lack of communication and documentation regarding the resident's eye condition. The resident's right eye became red, swollen, and painful, leading to a diagnosis of acute conjunctivitis. The facility's failure to provide appropriate eye care and follow-up resulted in actual harm to the resident, highlighting significant deficiencies in the management of the resident's eye care needs.
Failure to Prevent Falls and Implement Fall Interventions
Penalty
Summary
The facility failed to provide adequate assistance, supervision, and assistive devices to prevent falls for two residents. Resident #57, who was moderately cognitively impaired and required two staff members for bed mobility, sustained a fall and a right shoulder fracture when only one staff member was providing care. The staff member did not follow the Kardex instructions, which indicated that two staff members were required for bed mobility. The resident's care plan had been updated to reflect the increased risk of injury due to osteoporosis, but the intervention was not followed, leading to the fall and subsequent injury. Resident #101, who had impaired cognition and was at risk for falls, was found kneeling on the floor next to the bed after attempting to pick up a dropped pill. Despite the care plan and Kardex indicating that the bed should be kept in the lowest position and a floor mat should be placed next to the bed, multiple observations revealed that these interventions were not consistently implemented. The resident's bed was often found in a high position, and the floor mat was not in place, increasing the risk of falls. The facility's policy on falls and accidents aimed to provide an environment free from accident hazards and to ensure supervision and assistive devices were used to prevent avoidable accidents. However, the facility failed to consistently implement these interventions, resulting in actual harm to Resident #57 and potential harm to Resident #101. The lack of adherence to the care plans and Kardex instructions contributed to the deficiencies observed during the survey.
Failure to Complete Annual Nurse Aide Performance Evaluations
Penalty
Summary
The facility failed to complete annual performance evaluations for nurse aides as required, potentially affecting all 120 residents. Personnel files for three State Tested Nursing Assistants (STNAs) hired in March and April 2023 showed no evidence of annual performance evaluations. This was confirmed by the Human Resource Business Partner during an interview. The facility's policy on staff competency, dated December 31, 2023, mandates that nurse aides must be competent in skills and techniques necessary to care for residents' needs.
Improper Storage and Labeling of Injectable Pharmaceuticals
Penalty
Summary
The facility failed to properly store injectable pharmaceuticals by not dating opened containers and not maintaining clean medication storage refrigerators. This was observed in two of four medication rooms and one of six medication carts, affecting one resident and potentially impacting all 120 residents in the facility. Specifically, an opened and undated insulin pen (Humalog KwikPen) was found in a medication cart for a resident with diabetes mellitus type II, and an opened and undated vial of Tuberculin purified protein derivative (Tubersol) was found in the Central medication room refrigerator. Both the [NAME] and Central medication room refrigerators had significant ice overgrowth due to lack of defrosting. The Director of Nursing (DON) confirmed these findings during the observation. The facility's policy on medication storage, revised in November 2020, mandates that nursing staff maintain medication storage and preparation areas in a clean, safe, and sanitary manner, and that discontinued, outdated, or deteriorated drugs or biologicals be returned to the dispensing pharmacy or destroyed. The deficiency was investigated under Master Complaint Number OH00153331.
Failure to Serve Meals at Palatable Temperatures
Penalty
Summary
The facility failed to ensure meals were served at palatable temperatures, affecting four residents and potentially all residents receiving food from the kitchen. Resident interviews revealed complaints about the food being served cold. Observations showed that the food temperatures were significantly lower when served compared to when they were taken from the steam table. For instance, the barbeque beef riblet temperature dropped from 188 degrees Fahrenheit to 97 degrees Fahrenheit, and the baked beans from 160 degrees Fahrenheit to 75 degrees Fahrenheit. The Dietary Manager verified the low temperatures and confirmed that the food was not to her liking. Multiple residents expressed dissatisfaction with the temperature of their meals, stating that the food was not hot when received.
Failure to Maintain Clean and Sanitary Kitchen and Refrigerators
Penalty
Summary
The facility failed to ensure a clean and sanitary kitchen and nursing unit refrigerators, which had the potential to affect all residents. During an initial tour of the kitchen, several deficiencies were observed, including an opened bulk bag of panko sitting on the floor, dirty walls with dried food splatter, and dirty drawers containing serving utensils. The dish room had a malodorous smell with gnats flying around a bucket with dirty rags, and various food crumbs and debris were found underneath the dish machine. The Dietary Manager verified these findings and mentioned that the odor was related to a plumbing issue for which a plumber had been called. Further observations revealed that the nursing unit refrigerators were also not maintained in a clean and sanitary manner. The freezer in one unit had a moderate amount of frozen spillage, while another refrigerator had dried spillage and food debris on the shelves. The memory care unit's refrigerator was missing a grill and contained various trash and debris, including an empty juice cup and food crumbs. Additionally, a dietary assistant was observed using a napkin to wipe off spillage from a pan and table, which was not in accordance with sanitary practices. The facility's policy on sanitization, revised in November 2022, stated that the food service area should be maintained in a clean and sanitary manner, which was not adhered to in these instances.
Failure to Complete TB Testing for Resident and New Employees
Penalty
Summary
The facility failed to complete admission testing for tuberculosis (TB) for Resident #419, who was admitted with multiple serious health conditions including stroke, atrial fibrillation, congestive heart failure, chronic kidney disease, heart disease, dementia, multiple myeloma, and diabetes. Despite the facility's policy requiring TB screening for all new admissions, there was no documented evidence of TB testing for Resident #419. The Director of Nursing confirmed the absence of TB testing documentation and provided a CT scan from the hospital that noted lung nodules without specifying their type. Additionally, the facility did not accurately complete TB testing for five new employees, including the Maintenance Director, two LPNs, the Human Resource Business Partner, and the Assistant Director of Nursing. The personnel files either lacked evidence of TB screening or showed incomplete two-step TB testing, with the second step not read within the required 48-to-72-hour timeframe. The facility's policy and CDC guidelines mandate TB screening and testing for all new hires, but these procedures were not followed, as confirmed by the Human Resource Business Partner.
Failure to Maintain Essential Laundry Equipment
Penalty
Summary
The facility failed to ensure that essential laundry equipment, specifically washers and dryers, were in good repair, potentially affecting all 120 residents. Observations revealed that one of three washing machines and one of four dryers were not operational. The non-functional washing machine, dedicated to residents' clothing, had been down for about seven months, causing delays in the turnaround time for residents' clothing from an eight-hour shift to 24 hours or longer. The Housekeeping Manager confirmed the issues and noted that parts for the old washing machine were obsolete, and there had been discussions about replacing it, but no further action had been taken. Additionally, one dryer had been down off and on, and another dryer had not been hooked up for a long time. The Maintenance Director corroborated the Housekeeping Manager's statements, adding that corporate had initially wanted to repair the washing machine, but the cost was nearly the same as replacing it. The Maintenance Director was unsure about the current status of the payment for the repairs or replacement. The last administrator had seemingly decided to replace the washing machine, but no further steps had been taken. The contractor had also indicated that continuing to repair the old machines would be difficult due to the unavailability of parts. This deficiency was investigated under Master Complaint Number OH00153331 and Complaint Number OH00153001.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to ensure a clean, sanitary, and homelike environment, affecting all 120 residents. Resident #59 reported a breeze from an improperly taped window, causing discomfort at night. Observations confirmed the plastic covering was not securely taped. Additionally, there was a persistent odor of urine near the 100-hall nursing station, which was traced to Resident #6's room. The resident was non-compliant with incontinence care, and the odor was believed to be coming from the mattress, which had not been reported to management. Resident #43 also reported the absence of a closet door, which was confirmed during the observation. Further observations revealed multiple maintenance and cleanliness issues throughout the facility. The beauty shop doorway was crumbling, and there were water stains on ceiling tiles near the 300-hall dining/activity area. Resident #66's bathroom had dried bowel movement on the toilet riser, and Resident #72's room had corroded wooden drawers and smeared bowel movement in the bathroom. Resident #67's room had worn floor tiles and a dirty bathroom. The paper towel dispenser in Resident #7's room was not functioning, and a room under construction was found in disrepair with various items scattered on the floor. Interviews with staff confirmed these observations, with housekeeping and maintenance staff acknowledging the issues but not always taking immediate action. Housekeeping procedures for daily cleaning were reviewed, but the facility failed to maintain a clean and homelike environment as required. The deficiency was investigated under multiple complaint numbers, highlighting the widespread nature of the issues within the facility.
Handrails in Disrepair
Penalty
Summary
The facility failed to ensure handrails were in good repair, which had the potential to affect all residents. During an observation on 04/25/24 at 11:13 A.M., a missing portion of the handrail was noted across from the 300-hall dining/activity area and next to the area where puzzles were kept. The Maintenance Assistant (MA) verified the observation and stated he did not know how long it had been that way but would get it fixed. This deficiency was investigated under Master Complaint Number OH00153331 and Complaint Number OH00153001.
Failure to Complete Required Annual Training for Nurse Aides
Penalty
Summary
The facility failed to complete the required 12 hours of annual training for nurse aides, which had the potential to affect all 120 residents residing in the facility. A review of the personnel files for two State tested Nursing Assistants (STNAs) revealed that neither had completed any training toward the required minimum of 12 hours annually. One STNA was hired on 03/14/23, and the other on 04/25/23, with no evidence of training documented for either. An interview with the Human Resource Business Partner confirmed these findings. The facility policy titled Staff Competency, dated 12/31/23, stated that the facility would ensure nurse aides were competent in skills and techniques necessary to care for residents' needs. This deficiency was investigated under Complaint Number OH00153001.
Failure to Witness Resident Fund Authorizations
Penalty
Summary
The facility did not ensure Resident Fund Authorizations were witnessed, affecting six residents. A review of the authorization forms for these residents revealed that none had been witnessed as required. During an interview, the Business Office Manager confirmed that the facility had not had the Resident Fund Account authorization forms witnessed.
Failure to Provide COVID-19 Education and Vaccination Opportunities to Staff
Penalty
Summary
The facility failed to offer COVID-19 education and vaccination opportunities to five staff members, including a State Tested Nursing Assistant (STNA), a cook, two Licensed Practical Nurses (LPNs), and a Registered Nurse (RN). The review revealed that there was no evidence of education being provided or the vaccine being offered to these staff members, particularly when booster doses became available. The immunization status for these staff members was listed as past due, indicating a lapse in the facility's compliance with COVID-19 vaccination protocols. Specifically, the STNA's immunization dates were recorded, but there was no evidence of education or booster offers. The cook, hired in March 2023, had no information regarding education or vaccination offers. One LPN had an immunization date but no evidence of further education or booster offers, while another LPN had no evidence of education or booster offers despite being immunized. The RN, hired in January 2024, also had no evidence of education or vaccination offers upon hire. The Director of Nursing confirmed the lack of information regarding COVID-19 education and vaccination offers for these employees.
Inaccurate Resident Assessments
Penalty
Summary
The facility failed to ensure accurate assessments for multiple residents, as evidenced by discrepancies in the Minimum Data Set (MDS) 3.0 assessments. For instance, Resident #62, who was admitted with diagnoses including dementia and Alzheimer's disease, was incorrectly coded in the MDS assessment as not receiving hospice services despite being on hospice care. This error was confirmed by the MDS Director during an interview. Similarly, Resident #114's discharge MDS assessment was inaccurately coded as a discharge to a short-term general hospital, whereas the resident had actually moved out of state to live with a friend. This mistake was also acknowledged by the MDS Director upon review. Additionally, Resident #37's oral health evaluation was inaccurately documented, failing to note the resident's missing upper dentures, which were reported lost by the resident and confirmed through interviews with staff and the resident herself. The MDS Director admitted that the oral evaluation was not accurately assessed. Furthermore, the facility incorrectly coded the use of alarms for multiple residents in the memory care unit. The MDS assessments for these residents indicated daily use of alarms, but there was no evidence in the medical records to support this. The MDS Coordinators verified that the coding was based on the presence of alarmed entrance and exit doors in the memory care unit, which is not in accordance with the MDS 3.0 Resident Assessment Instrument User's Manual guidelines. This widespread inaccuracy in resident assessments highlights significant deficiencies in the facility's assessment processes.
Failure to Provide Baseline Care Plan Summaries
Penalty
Summary
The facility failed to provide residents with a summary of their baseline care plan within 48 hours of admission, affecting four residents out of 32 reviewed. Resident #105, admitted with multiple severe diagnoses including dementia with severe agitation and congestive heart failure, did not receive a summary of his baseline care plan within the required timeframe. The Minimum Data Set (MDS) Director confirmed that the baseline care plan was entered into the electronic record but not provided to the resident or his responsible party. Similar deficiencies were found for Resident #114, who was admitted with conditions such as hypotension and epilepsy, and was discharged to the hospital without receiving a summary of the baseline care plan. The MDS Director acknowledged the omission in both cases. Additionally, Resident #418, admitted with dementia and high blood pressure, and Resident #419, admitted with a stroke and chronic kidney disease, also did not receive their baseline care plan summaries within 48 hours of admission. The MDS Director confirmed that while the baseline care plans were created, they were not provided to the residents or their responsible parties. The facility's policy, last revised in March 2022, mandates that a baseline care plan be developed within 48 hours of admission and that a written summary be provided to the resident or their responsible party, which was not adhered to in these cases.
Failure to Provide Finger Food Diet as Ordered
Penalty
Summary
The facility failed to ensure that Resident #70 was served finger food items as per the physician's orders. Resident #70, who had diagnoses including dementia, schizoaffective disorder, and alcohol-induced persisting dementia, was observed on multiple occasions being served food items that did not meet the finger food diet requirements. For instance, on 04/23/24, Resident #70 was served strawberries in a liquid, which spilled down his hand and arm as he attempted to eat them. Additionally, on 04/24/24, Resident #70 was served baked beans instead of the prescribed frozen green beans for the finger food diet. Further, on 04/29/24, Resident #70 was found with a strip of bacon and a white food substance resembling hot cereal in his wheelchair, indicating he had been served oatmeal instead of finger food cereal as required by his diet plan. Interviews with staff, including a State Tested Nurse Aide (STNA) and the Dietary Manager (DM), confirmed that the food items served did not comply with the finger food diet. The DM acknowledged that the strawberries should have been drained and that the hot cereal should have been replaced with finger food cereal options like Cheerios or flakes. These observations and interviews highlight the facility's failure to adhere to the prescribed dietary requirements for Resident #70, potentially impacting his nutritional intake and overall well-being.
Failure to Assess Immunization Status Upon Admission
Penalty
Summary
The facility failed to assess residents for influenza or pneumonia immunization status upon admission, affecting two residents out of 17 reviewed for new admission. Resident #104, admitted with multiple diagnoses including high blood pressure, stroke, dementia, and chronic obstructive pulmonary disease, was found to have no information on influenza or pneumonia immunization status despite having tuberculosis testing upon admission. The Director of Nursing (DON) confirmed the lack of immunization information for Resident #104. Similarly, Resident #105, admitted with diagnoses such as dementia with severe agitation, chronic obstructive pulmonary disease, atrial fibrillation, and diabetes, also had no information on influenza or pneumonia immunization status, although tuberculosis testing was conducted upon admission. The DON confirmed the absence of immunization information for Resident #105. The facility's policies on influenza and pneumococcal vaccines, last revised in March 2022, were reviewed and indicated that all residents should be encouraged to receive these vaccines unless contraindicated, but these policies were not followed in these cases.
Failure to Formulate Comprehensive Care Plans
Penalty
Summary
The facility failed to formulate comprehensive care plans to include all necessary goals of care for three residents. Resident #21, who had multiple diagnoses including PTSD, did not have a care plan addressing PTSD. The MDS Director confirmed that no care plan was initiated for this diagnosis despite the resident having an intact cognition and PTSD listed as a diagnosis in the Admission MDS assessment. Resident #37, who required assistance with personal care and had protein-calorie malnutrition, congestive heart failure, and type II diabetes mellitus, also lacked a care plan for her oral/dental status. Despite having missing teeth and losing her upper dentures, which she reported to the staff, no care plan was initiated to address these issues. The MDS Director verified that the oral evaluation was incomplete and did not reflect the resident's actual dental condition. Resident #104, diagnosed with dementia with psychotic disturbance, aphasia, and other conditions, did not have a care plan focusing on eye care or the care of contact lenses. The resident had a history of refusing to remove contact lenses, which led to complications. Despite multiple progress notes and family concerns about the resident's eye condition, no care plan was initiated to address the risks associated with the use of contact lenses. The MDS Directors confirmed that no care planning was completed for eye care until after surveyor intervention.
Failure to Revise Care Plan in a Timely Manner
Penalty
Summary
The facility failed to revise the care plan for a resident in a timely manner. Resident #62, who was admitted with diagnoses including dementia with behaviors, Alzheimer's disease, high blood pressure, legal blindness, schizophrenia, and a stroke, was admitted to hospice services for vascular dementia with cerebral vascular disease. The resident was severely cognitively impaired, rarely understood, and demonstrated physical and verbal behaviors towards others. She was dependent on staff for all care. On 03/12/24, her restorative program for upper and lower range of motion exercises was discontinued due to her inability to actively participate in the program. However, the care plan for the restorative program remained unchanged as of 04/22/24 when the survey process began, despite the program being discontinued over a month earlier. This oversight was confirmed by the MDS Director during an interview on 04/24/24 at 11:21 A.M.
Failure to Provide Consistent Activities According to Care Plan
Penalty
Summary
The facility failed to ensure that activities were provided consistently according to the care plan and resident preferences for Resident #70. Resident #70, who had diagnoses including dementia with behavioral disturbance, schizoaffective disorder, anxiety disorder, muscle weakness, and schizophrenia, had a care plan that emphasized the importance of activities such as listening to music, being around animals, participating in group activities, going outside for fresh air, and attending religious services. Despite these preferences, the activity logs for April 2024 revealed that Resident #70 did not attend any church services or music-related activities, which were important to him as per his care plan and MDS assessment. Observations confirmed that Resident #70 was often found sitting at the nurses' station without engaging in any activities that matched his preferences. Interviews with staff and the Activity Director (AD) indicated that there were systemic issues in ensuring Resident #70's participation in activities. The AD mentioned that she often did not receive assistance from other staff to take residents to activities and that Resident #70 was frequently kept at the nurses' station. The AD also confirmed that there was no TV or music playing at the nurses' station, which further limited Resident #70's engagement in preferred activities. Additionally, the AD noted that the live entertainment scheduled for 04/29/24 was moved to an earlier time, and Resident #70 did not attend because he was likely in bed at that time. The facility's policy on activity programs, which aims to meet the interests and support the physical, mental, and psychosocial well-being of each resident, was not adhered to in the case of Resident #70. The deficiency was identified under Complaint Numbers OH00153001, highlighting the facility's failure to provide activities consistently according to the care plan and resident preferences, thereby affecting the resident's overall well-being and quality of life.
Failure to Implement Abuse Prevention Policy
Penalty
Summary
The facility failed to implement its policy and procedure for the prevention of abuse by not completing job reference checks and documenting timely state nurse aide registry (NAR) checks for new employees. This deficiency was identified through a review of personnel files for multiple staff members, including State Tested Nursing Assistants (STNAs), a receptionist, a registered nurse (RN), a maintenance director (MD), a director of nursing (DON), a unit manager licensed practical nurse (LPN), a human resource business partner (HRBP), and an assistant director of nursing (ADON). In each case, there was either no evidence of completed job reference checks or the NAR checks were not dated, indicating they may not have been conducted in a timely manner. The HRBP confirmed these findings during an interview, verifying the accuracy of the documentation review. The facility's policy, titled 'Freedom from Abuse and Neglect Policy,' mandates pre-employment screening, including reference checks and registry checks, to prevent the hiring of individuals with a history of abuse or neglect. However, the facility did not adhere to this policy, potentially affecting all 120 residents residing in the facility.
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What surveyors actually found near you
We read the 661 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Kirtland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mentor Hills Post Acute | 2.5 mi | ★★★★★ | 0 | 0 |
| Mentor Ridge Health And Rehabilitation | 2.9 mi | ★★★★★ | 6 | 0 |
| Willoughby Post Acute | 3.6 mi | ★★★★★ | 2 | 0 |
| Ohio Living Breckenridge Village | 3.8 mi | ★★★★★ | 1 | 0 |
| Altercare Of Mayfield Village, Inc | 5.4 mi | ★★★★★ | 1 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.