Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Luxe Rehabilitation And Care Center during CMS and state inspections, most recent first.
A resident who was dependent on two staff and required a mechanical sling lift for all transfers was manually moved from bed to wheelchair by two CNAs without the lift while an LPN briefly left the room. During the transfer, the resident's leg became trapped under the wheelchair, but the event was not promptly reported to nursing or medical providers. The resident later developed ongoing pain and swelling, was found to have multiple fractures after an X-ray and ER evaluation, declined, was transferred to hospice, and died from complications of the injuries.
Uncomfortable Resident Room Temperatures: The facility failed to keep resident room temperatures at a comfortable level for 25 residents. During survey observations, two AC units were out, room temperatures ranged from 68 to 80.4 degrees, and several residents said their rooms were too hot or too warm. Staff confirmed the AC problem had been ongoing for weeks, while temperature logs showed hallway readings but no room temperatures were recorded by Maintenance.
A resident with dementia, severe cognitive impairment, and extensive assistance needs was observed being assisted from her room in a shower chair while wearing a nightgown that exposed her lower body in the hallway in front of other residents. The CNA confirmed the exposure and said she was going to cover the resident with a sheet. The facility’s dignity policy requires residents to be cared for in a manner that protects bodily privacy during personal care.
The facility failed to maintain proper hot water and a homelike room environment for multiple residents. Staff reported that hot water to resident rooms on one secured memory care unit had been turned off because of a leak, while another secured unit had lukewarm sink water with temps measured in the low 70s and a blown element/popped fuse identified as the cause. Surveyors also observed a resident room with deep black gouges in the tile floor and another resident bathroom sink where hot water barely trickled.
Incomplete and inaccurate resident assessments: The facility did not complete several MDS assessments within required timeframes for multiple residents, and it failed to accurately assess a resident’s pressure ulcers on admission. In another case, a resident with PTSD had trauma-informed care screening marked no despite PTSD being an active dx on the MDS and confirmed on admission. The MDS Coordinator, DON, and Social Services all verified the record discrepancies.
Failure to Provide Resident-Centered Activities on Memory Care Units: Residents on two secured memory care units were observed without scheduled activities occurring, despite calendars listing chats, lunch and tunes, exercise, snack and chat, bible study, and karaoke. Staff stated the 10:00 A.M. chats were done by unit aides, some scheduled activities were not completed, and the memory care calendars repeated the same four activities daily. One resident with dementia had documented interests in reading, religion, animals, fresh air, bingo, and clergy visits, but his record showed mostly current events and room visits with no evidence of activities matching his preferences.
The facility failed to implement ordered pressure ulcer care for multiple residents. One resident’s heel wound treatments were delayed after new heel ulcers were identified, while other residents with pressure ulcer risk or active wounds were observed on air or low air loss mattresses set to incorrect weight settings. Staff also observed a resident with stage III and unstageable ulcers lying without off-loading, and records showed wound descriptions and ordered interventions were not consistently carried out as documented.
Unsafe food handling and improper food storage were observed in the kitchen and snack fridge. An Dietary Manager handled pureed food with gloved hands after touching multiple surfaces, used a spoon placed on a bare table, and scraped food from a blender container in a manner confirmed by the manager as not following hand hygiene and barrier practices. The steam table water pans had heavy mineral buildup, and the snack refrigerator contained unlabeled or undated resident food items, including applesauce and spaghetti, along with spilled residue on the shelves.
A resident with severe cognitive impairment and multiple chronic conditions was admitted with an indwelling urinary catheter for urinary obstruction and cystocele with prolapse. On two separate occasions, the resident removed the catheter; each time the physician was notified, first resulting in reinsertion and later in an order to leave the catheter out and monitor. However, there was no documentation that the resident’s POA was notified of either the catheter removal incidents or the decision to discontinue the catheter, despite facility policy requiring timely notification of the physician and resident representative for significant changes in condition. The Administrator confirmed that the POA had not been notified.
Failure to Honor Bathing Preferences: A resident with CKD, PTSD, paraplegia, ESRD, schizophrenia, depression, and other conditions had a documented preference for morning showers and no cognitive deficit, but bath records showed repeated bed baths instead of scheduled showers. The resident stated he preferred showers but was given bed baths because he was bed bound and required two-person assistance, and a CNA reported staffing shortages on the hallway sometimes prevented showers from being provided.
Failure to Provide Privacy During Wound Care: A resident with dementia and two pressure ulcers received ordered wound care with the window blind open, facing another wing and within view of other residents' windows. The RN verified privacy was not provided. Facility policy states residents have the right to privacy and confidentiality.
Failure to Notify State LTC Ombudsman of Resident Transfers and Discharges: The facility did not notify the State LTC Ombudsman of transfers/discharges for two residents. One resident with alcoholic cirrhosis, hepatic encephalopathy, and malnutrition was transferred to the hospital and did not return, and another resident with DM, pancreatitis, cancer of the glottis, CHF, and acute/chronic respiratory failure was sent to the hospital after a physician visit and later transferred to another NF. The HR Director said she believed she was emailing the monthly list to the Ombudsman, but it was actually being sent to the State legal department.
A resident with dementia and severely impaired cognition had admission skin assessments and an MDS that did not accurately reflect the number of pressure wounds present on admission. The DON confirmed the resident was admitted with one coccyx pressure wound, but the MDS showed two wounds present on admission while also documenting additional heel pressure wounds that were not present on admission.
Inaccurate PASARR documentation was identified for a resident with cerebral infarction, HTN, and PTSD. The record showed additional diagnoses of major depressive disorder and generalized anxiety were added, but the most recent PASARR did not list generalized anxiety or PTSD, and the Social Services Director verified the omission.
Delayed PASARR Screening: A resident with PTSD, cerebral infarction, and HTN was admitted to the facility, but the PASARR screening was not completed within the required 30-day timeframe. The SS Director verified the screening was completed late.
A resident admitted after a fall with a head bleed and shoulder fracture had ongoing pain, confusion, and repeated yelling out in discomfort, but the facility did not develop a baseline pain care plan. Staff documented pain complaints and gave scheduled Tylenol, while a lidocaine patch was ordered but not documented as given until later; the resident remained in obvious distress, required an opioid order, and was ultimately sent to the hospital for evaluation.
A resident with CVA, HTN, PTSD, major depressive disorder, and generalized anxiety had a care plan that did not address anxiety, depression, or PTSD. The MDS validated these diagnoses, and the SSD confirmed the care plan omission.
A resident with chronic constipation, back pain treated with narcotic analgesics, and repeated bowel issues had multiple laxative and bowel protocol orders, plus abdominal x-rays showing fecal loading. Nursing notes documented manual stool removal, abdominal pain/distention, and ongoing constipation, yet the care plan did not include constipation or any related interventions.
A resident with severe cognitive impairment and multiple diagnoses, including CVA, CKD stage 4, DM, and dementia, had a PRN clonidine order for hypertension to be given when BP was greater than 140. The MAR showed the resident did not receive clonidine during the month reviewed, even though repeated BP readings were above the ordered parameter. An LPN confirmed the readings indicated the medication should have been given, and facility policy required medications to be administered in accordance with physician orders.
A resident with a suprapubic catheter and multiple chronic conditions, including urinary retention and bladder neck obstruction, was observed with the catheter drainage bag hanging above the bladder on the bed enabler bar. An RN verified the bag was positioned above the bladder, contrary to facility catheter care policy requiring the drainage bag to remain lower than the bladder at all times to prevent backflow.
Failure to address significant weight loss and nutrition monitoring. Three residents with dementia, dysphagia, chronic disease, and other nutritional risks had documented significant weight loss, but weights were not consistently rechecked, the RD was not always notified, meal intake was not reliably documented, and an ordered supplement was not provided on one resident’s tray. Staff and leadership confirmed missing re-weighs, missing intake documentation, and gaps in follow-through on nutrition monitoring.
A resident with COPD, emphysema, respiratory failure, pleural effusion, and OSA was observed wearing oxygen at 3 L via nasal cannula continuously, but the chart did not contain an active physician or practitioner order for supplemental oxygen. The resident stated oxygen was needed continuously, and an LPN confirmed the order was missing even though facility policy required verifying a physician order before oxygen administration.
A resident with recent traumatic injuries, including a shoulder fracture and subarachnoid hemorrhage, had ongoing pain that was not properly recognized or documented by staff. Pain checks were charted as 0 despite repeated reports and observations of shoulder, back, neck, and sacral pain, moaning, yelling out, and refusal to eat or stay up. Tylenol was given, a lidocaine patch was ordered but not documented as administered, and the resident was later sent to the hospital for uncontrolled pain.
Failure to Complete Ordered Medication Monitoring Labs: Two residents did not have ordered lab monitoring completed. One resident receiving simvastatin had a lipid panel completed but no LFT results despite a pharmacy review and physician order for monitoring. Another resident receiving glargine insulin had a quarterly Hgb A1C ordered, but there was no evidence of any A1C after the last documented result. The DON confirmed the missing lab work.
Two residents experienced deficiencies in medical record documentation, including missing entries for wound care treatments and conflicting information about the type, location, and origin of pressure ulcers and MASD. Staff interviews confirmed that treatments were performed but not documented, and that care plans and wound assessments contained errors and contradictions regarding wound status.
Two nurses failed to don required PPE and perform proper hand hygiene while providing tracheostomy and PEG tube care to a resident on enhanced barrier precautions for invasive devices. Despite clear signage and available PPE, both entered the room and performed high-contact care without gowns or masks, and removed gloves without hand hygiene before touching supplies or leaving the room. Facility policy required these infection control measures, but they were not followed during the observed care.
The facility did not pay its food supply vendor on time, resulting in a missed food delivery and the need to alter menus until service resumed after payment. Staff interviews and records showed a significant outstanding balance, and the business office manager could not provide invoices or payment details. This deficiency impacted all residents.
A resident with intact cognition and a history of seizures reported feeling mistreated, but the facility did not conduct a thorough investigation as required. Although a skin check was performed and no injuries were found, there was no evidence that follow-up questions were asked to determine the specifics of the alleged mistreatment, and required interviews were not completed.
A resident with severe cognitive impairment and a history of schizophrenia was transferred to another SNF after a single elopement incident, but the facility failed to document the necessity of the transfer, why the resident's needs could not be met, or involve the legal guardian in the decision. The transfer was made to a facility far from the guardian, with no evidence of attempts to find a closer option or documentation of how the new facility would better meet the resident's needs.
A resident with severe cognitive impairment was transferred to another facility after an elopement incident, but the required written notice, including the reason for transfer, effective date, location, appeal rights, and Ombudsman contact information, was not provided to the resident's legal guardian. Facility staff confirmed that the transfer was facility-initiated and that proper documentation and notification were not completed as required by policy.
The facility did not ensure that required fall prevention interventions were in place for a resident with cognitive impairment and failed to provide adequate supervision and documentation when another resident with severe cognitive impairment eloped from the building. Staff were unaware of the procedures related to exit door security during fire panel alarms, and key safety interventions were not implemented as outlined in care plans and facility policy.
A resident with complex medical needs was found to have soiled bedrail padding and a wheelchair with visible stains and smears. An LPN and the DON confirmed the equipment was dirty and required cleaning, contrary to facility policy requiring a clean and sanitary environment.
A resident's responsible party was not included in the development or review of the resident's baseline care plan, as required. Medical records and staff interviews confirmed that neither the resident nor their POA participated in the initial care planning process, and no documentation or signatures were obtained to show their involvement.
A resident with dementia and a history of falls sustained a laceration after a fall, but the facility failed to promptly notify the correct Power of Attorney (POA) as required by policy, instead informing the resident's daughter. The appropriate representative was not notified until the following day, resulting in non-compliance with notification requirements.
Surveyors observed that the facility's medication error rate was 11.9%, exceeding the acceptable threshold. Errors included an LPN administering a chewable Aspirin tablet whole, another LPN giving a chewable Phenytoin tablet whole, and the same LPN crushing or opening delayed release and extended release medications before administration. These actions did not follow proper medication administration protocols as outlined in facility policy.
An LPN did not perform hand hygiene after checking a resident's blood pressure and before preparing medication for another resident. The LPN also handled dropped medication and removed pills from a medication cup with bare hands, contrary to facility policy prohibiting direct contact with medications to prevent contamination.
The facility failed to conduct federal background checks for new hires who had not lived in the state for five years and did not have a policy in place for such checks. Additionally, a resident reported feeling intimidated and verbally abused by staff, but the facility did not conduct a thorough investigation or report the incident to the state. The alleged perpetrators continued to work during the investigation, contrary to policy.
The facility failed to provide sufficient and adequately trained staff for food and nutrition services, affecting nearly all residents. Meal delivery was inconsistent, with breakfast and supper often served late. The Dietary Manager, also serving as Activity Director, confirmed operational challenges due to only one kitchen being used. Staff interviews revealed inadequate training and short-staffing, while residents reported dissatisfaction with late and cold meals. The Dietician confirmed insufficient staffing and cold test trays, and the Administrator acknowledged multiple resident complaints.
The facility failed to serve meals at regular times and according to resident preferences, affecting 137 residents. Breakfast and supper services were inconsistent, with meals served late and often cold. Staff shortages, equipment issues, and the use of only one kitchen contributed to the delays. Residents frequently complained about the late and cold meals, and the facility had not determined resident meal time preferences.
The facility did not employ a full-time, qualified social worker, affecting 139 residents. The Social Service Director had a degree in business administration, not in social work or a human services field. The last licensed social worker left in December 2024, and interviews confirmed the absence of a licensed social worker during the survey.
The facility failed to schedule activities for memory care residents, affecting all 21 residents in the unit and one outside of it. Observations showed no activities on weekends and delays during scheduled times due to staff being occupied with meal duties. Interviews confirmed activities were often late or not conducted as planned, causing frustration for residents.
A facility failed to provide adequate care for a resident with complex medical conditions, including heart failure and diabetes. The resident's blood pressure and blood sugar levels were not consistently monitored or reported to a physician, and vital signs were carried over from previous days without new measurements. The facility lacked a policy on vital sign monitoring, and the resident's condition was not adequately addressed, leading to a deficiency finding.
The facility failed to ensure safe smoking practices and did not assess residents for safe smoking, as required by their policy. Observations showed residents smoked on non-designated areas and disposed of cigarette butts unsafely. Interviews confirmed the lack of adherence to the smoking policy, which required residents to smoke off property. Additionally, smoking assessments were not conducted for residents with significant medical histories, as confirmed by the DON.
The facility failed to follow prescribed menus and serving sizes, affecting 11 residents. Staff used food packaging to determine serving sizes, leading to inconsistencies. Residents on various diets received incorrect portions, and some did not receive required food items. The dietary manager and dietician were unaware of the lack of printed menus with serving sizes, contributing to the oversight.
The facility failed to ensure meals were palatable and served at appropriate temperatures, affecting several residents. Observations showed that breakfast trays were not fully distributed until 45 minutes after delivery, resulting in cold food. Interviews with residents and staff confirmed frequent complaints about cold meals, and a test tray confirmed food temperatures were below required standards. The facility's policy on food temperatures was not adhered to, and the issue was investigated under specific complaint numbers.
A resident with severely impaired cognition and on a pureed diet due to food pocketing received regular texture pineapple during lunch service, contrary to dietary orders. An LPN confirmed the error and removed the pineapple, but the resident later received another bowl of regular texture pineapple, possibly from another resident. The resident did not eat any food during the observation.
The facility failed to notify representatives of significant changes in two residents' conditions. One resident, with a complex medical history, was not reported to family about declining vital signs before passing away. Another resident's POA was not informed about changes in swallowing ability and diet modification. The facility's policy on notifying representatives was not followed.
A resident with multiple health conditions reported feeling intimidated and verbally abused by staff, which was not reported to the state survey agency as required. The facility's policy mandates immediate notification of abuse allegations, but this was not followed, and the resident was not interviewed about the incident.
A facility failed to thoroughly investigate an abuse allegation involving a resident who felt intimidated and verbally abused by three staff members, including two CNAs and an LPN. The resident reported that the abuse stopped after being moved to a different room. The facility did not document interviews with the resident or other potential witnesses, and the alleged perpetrators continued to work during the investigation. The facility's policy required immediate removal of accused staff, but this was not followed, resulting in a deficiency.
The facility failed to ensure medications were available for two residents as per physician orders. A resident's Vitamin D2 was unavailable during administration, and another resident's Mucinex DM ER and fexofenadine were also not available. The DON and ADON confirmed the unavailability of these medications, which were supposed to be provided by the pharmacy or as stock medications.
Unsafe Transfer of a Non-Ambulatory Resident
Penalty
Summary
The facility failed to ensure a resident who was dependent on two staff members and required a mechanical sling lift for all transfers was transferred safely and according to the plan of care. The resident had diagnoses including dementia, Parkinson's disease, reduced mobility, osteoarthritis, chronic obstructive pulmonary disease, and an unstageable sacral pressure ulcer. Her care plan and physician orders both directed that all transfers be completed with a mechanical sling lift and two assists because she was unable to bear weight. On the evening of the incident, the resident was being moved from bed to wheelchair when an LPN exited the room and two CNAs manually transferred her without using the mechanical sling lift. During the transfer, the resident's right leg became positioned under the wheelchair, and staff later reported that the leg was gently repositioned. The event was not reported to additional staff or medical providers at the time. The resident later had continued complaints of pain, swelling, and warmth in the lower extremities, and change-in-condition evaluations documented new or worsening pain and edema. An X-ray was eventually obtained and showed a right femur fracture. The resident was sent to the emergency room, where additional fractures were identified, including a fracture to the right shin and a left tibial plateau fracture. Hospital records noted that she was not a surgical candidate. Following the fractures, the resident declined, was transferred to inpatient hospice, and later died due to complications from multiple fractures. Interviews with staff and family described that the resident had ongoing leg pain and swelling before the fracture was identified, and staff acknowledged that the resident should have been transferred with the mechanical lift.
Uncomfortable Resident Room Temperatures
Penalty
Summary
The facility failed to ensure temperatures in resident rooms and common areas were maintained at a comfortable level for 25 residents out of a census of 142. During an observation with the Maintenance Director, two air conditioning units were reported to be out and had been out for a couple of weeks, with repair planned in the next few days. Room temperatures observed during the survey ranged from 68 degrees to 80.4 degrees, and rooms at 80 degrees did not have window AC units. Daily temperature logs from 06/01/26 to 06/11/26 showed hallway temperatures from 71 degrees to 78 degrees, but no room temperatures were taken by Maintenance. Maintenance logs from April 2026 through June 2026 showed no concerns with the air conditioning. Residents interviewed during room temperature checks stated their rooms were too hot or too warm, including residents whose rooms measured between 72.7 degrees and 80.4 degrees. Several residents reported using fans, opening windows, or going into the hallway to cool off, and one resident stated the air was broken. Staff interviews confirmed the air conditioning had been an ongoing issue, had gone out the prior year as well, and had been broken for a few weeks. The facility policy titled Homelike Environment stated residents are to be provided a safe, clean, comfortable and homelike environment with comfortable and safe temperatures between 71 degrees Fahrenheit and 81 degrees Fahrenheit.
Resident dignity not maintained during personal care
Penalty
Summary
The facility failed to maintain Resident #15’s dignity during assistance with personal care. Resident #15 was admitted with diagnoses including dementia, need for assistance with personal care, reduced mobility, epilepsy, and anxiety disorder, and the most recent MDS showed a BIMS score of 0 with substantial/maximal assistance needed for showering/bathing, personal hygiene, and transfers. During observation, the resident was being assisted out of her room in a shower chair by CNA #172 while wearing a nightgown that exposed her body from the waist down in the hallway in front of other residents. CNA #172 confirmed the resident’s hips and lower body were exposed and stated she was going to cover the resident with a sheet because her lower body was exposed. The facility policy on dignity states residents shall be cared for in a manner that promotes well-being, self-worth, and privacy, including bodily privacy during personal care and treatment.
Hot Water and Room Condition Deficiencies
Penalty
Summary
The facility failed to maintain safe, comfortable hot water temperatures and a homelike environment for residents on the 200 unit, the 300 unit, and in two individual resident rooms. On the 200 unit, staff reported that the hot water tank serving resident rooms had been turned off because of a leak, and the Environmental and Safety Director stated this had been in place for about two weeks while the facility tried to locate a plumbing company with special equipment to identify the leak through the concrete floor. Observation confirmed there was no hot water being delivered to resident rooms on that hall, which was a secured memory care unit housing 13 residents. On the 300 unit, observations in resident bathrooms showed the sink water felt cool, and testing found temperatures of 71 degrees and 73.4 degrees in two resident rooms. The Environmental and Safety Director stated the resident-room hot water should be between 105 and 120 degrees and later identified a blown element and popped fuse as the cause of no hot water in the resident rooms. The shower room on that hall had a separate hot water tank, and after adjustment the shower water measured 101 degrees. A nursing assistant also reported that the water on that hall had been only lukewarm the prior week. This affected 16 residents living on the secured memory care unit. Additional findings included a resident room with multiple deep black gouges and cuts in the tile flooring that were not cleanable and were observed to require replacement of the flooring. In another room, a cognitively intact resident with quadriplegia, depression, and anxiety had a bathroom sink where hot water barely trickled from the faucet, and the Environmental and Safety Director confirmed the hot water did not work properly. These observations showed room conditions and water service issues affecting resident living areas and bathrooms.
Incomplete and inaccurate resident assessments
Penalty
Summary
The facility failed to complete required MDS assessments within the required timeframes for four residents. Resident #7 had an admission date of 05/30/25 and a re-entry date of 02/11/26, with diagnoses including cerebral infarction, anxiety disorder, chronic kidney disease stage four, major depressive disorder, diabetes, and dementia; the admission MDS was not completed until 03/02/26. Resident #15 was admitted on 09/02/25 with diagnoses including alcohol abuse, cannabis dependence, and hypertension, and the quarterly MDS was not completed until 03/02/26. Resident #60 was admitted on 12/19/25 and re-entered on 01/17/26 with diagnoses including end stage renal disease, diabetes, and hypertension; the admission MDS was not completed until 01/12/26. Former Resident #147 was admitted on 11/02/25 and discharged on 02/28/26 with diagnoses including paraplegia, depression, and hypertension, and the quarterly MDS was not completed until 01/23/26. The CMS LTC Facility Resident Assessment Instrument 3.0 User’s Manual states quarterly assessments must be completed no later than 14 days after the ARD, and admission assessments must be completed by the end of day 14, counting the admission date as day 1. The facility policy titled MDS Completion and Submission Timeframes stated assessment and submission timeframes are based on the current requirements in the Resident Assessment Instrument Manual. During interview, the MDS Coordinator confirmed the assessments for Residents #7, #15, #60, and #147 were not completed until the dates identified in the record review. The facility also failed to ensure the initial wound assessment was accurate for Resident #157 and failed to ensure the comprehensive assessment was accurate for Resident #8. Resident #157 was admitted with a stage III pressure ulcer to the sacrum measuring 11 cm by 0.5 cm by 0.1 cm and an unstageable pressure ulcer to the left gluteal fold measuring 0.5 cm by 1.0 cm, but the admission assessment did not comprehensively assess the wounds, including the condition of the wound, type of dressing, and wound description. The DON verified the wounds were not comprehensively assessed on admission. Resident #8 had diagnoses including cerebral infarction, hypertension, and PTSD, but the Trauma Informed Care Assessment marked the PTSD screen as no on multiple assessments even though the MDS listed PTSD as an active diagnosis; Social Services confirmed the resident had a PTSD diagnosis upon admission.
Failure to Provide Resident-Centered Activities on Memory Care Units
Penalty
Summary
The facility failed to provide activities that met the interests and needs of residents on the secured memory care units on the 200 and 300 halls of the [NAME] Wing. Surveyors observed that scheduled activities were not occurring as listed on the activity calendars, including chats, lunch and tunes, exercise, snack and chat, bible study, and karaoke. On multiple observations, residents were seen sitting in lounges, dining rooms, hallways, or in bed with no organized activity in progress, while staff were either absent from the area, sitting idle, or engaged in other tasks. On the 200 hall memory care unit, 13 residents resided there, including residents with dementia and other cognitive impairment. The activity calendar listed chats at 10:00 A.M., but no activity was observed at that time. Later observations also showed no activity during scheduled snack and chat, bible study, and karaoke times. A nursing assistant stated there was no activity schedule or plan for the unit and that activity aides were supposed to provide the activities. The activity director confirmed that the memory care calendar repeated the same four activities every day in March, that the 10:00 A.M. chats were done by unit aides rather than activities staff, and that no one completed the 11:00 A.M. lunch and tunes activity on the day observed. On the 300 hall memory care unit, 16 residents resided there, including Resident #29, who had vascular dementia, cerebral infarction, severe cognitive impairment on MDS, and required set-up assistance only with eating. His activity interview form documented interests in reading, religion/bible study, reminiscing, TV/radio, movies/videos, cooking/food, sports, bingo, clergy visits, animals, fresh air, and religious activities. Despite this, his activity participation record showed only current events and room visits for 23 of 30 days, with no evidence of activities matching his preferences. Observations showed no activity during scheduled chats, snack and chat, or bible study times, and staff interviews confirmed that the scheduled activities were not consistently being carried out. The facility policy stated that activity programs are designed to meet each resident’s interests and support physical, mental, and psychosocial well-being, and that activities should be based on each resident’s assessment and preferences.
Failure to Implement Ordered Pressure Ulcer Care and Mattress Settings
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and to implement ordered skin and wound interventions for multiple residents. Review of the medical record for Resident #11 showed admission with a coccyx pressure wound and later identification of pressure wounds to both heels. Although treatment orders were obtained for the heel wounds, the orders were not implemented in the medical record until two days later. The resident also had a BIMS score of 0 out of 15, indicating severely impaired cognition, and was documented as independent for bed mobility with no upper or lower extremity impairment. Resident #57 had an order for an air mattress for pressure relief, a care plan identifying risk for skin integrity problems, and a Braden score of 12. During observation, the resident’s air mattress was set to the wrong weight setting while the resident weighed 85.9 pounds, and staff stated hospice provided and maintained the mattress. Resident #138 also had a low air loss mattress order and a care plan identifying pressure ulcer risk related to immobility, quadriplegia, and incontinence. Observation showed the mattress was set to alternate and 600 to 1,000 pounds while the resident weighed 216.1 pounds, and staff verified the setting was incorrect. Resident #157 was admitted with a stage III sacral pressure ulcer and an unstageable ulcer to the left gluteal fold, with a Braden score of 16. The admission assessment did not include a description of either wound. On observation, the resident was positioned on her back with no off-loading to the wounds, and the low air loss mattress was set to firm rather than the appropriate weight range for the resident’s 132.8-pound weight. Resident #108 had an order for a low air loss mattress and a care plan calling for adjustment based on weight, but observation showed the mattress was set to 318 pounds, which staff confirmed was not correct for the resident’s weight. The facility policy stated nurses would ensure orders, interventions, and treatments for skin and wounds were implemented as ordered.
Unsafe Food Handling and Improper Food Storage
Penalty
Summary
Food was not stored, prepared, and served in accordance with professional standards in the [NAME] Wing kitchen and snack refrigerator. During observation of the Dietary Manager preparing pureed lunch items, she placed gloves on after hand hygiene, tore breadsticks into smaller pieces, left the prep area to obtain a measuring spoon, scraped food from the blender container with a spoon, and used her gloved hand to remove bread from the spoon. She later completed hand hygiene and put on new gloves, then handled multiple bowls of salad, uncovered them, and used her gloved hands to scrape the salad into the blender. She also used a spoon that had been placed on a bare metal table to scrape pureed salad from the blender container. The Dietary Manager confirmed she had touched multiple surfaces without repeating hand hygiene and acknowledged the spoon should have been placed on a barrier before use. The steam table in the [NAME] kitchen had four empty water pans with a heavy buildup of tan limescale or mineral deposits. The Dietary Manager confirmed the buildup and stated the pans needed to be cleaned with a de-[NAME] obtained from maintenance. In the snack refrigerator at the nurses station on [NAME] Wing, an unlabeled plastic container of applesauce dated 01/04/26 had no use-by or expiration date, and a plastic bowl of spaghetti labeled with a room number for Resident #153 was not dated. The refrigerator also had a sticky substance spilled on the shelves, and the LPN confirmed the items were not dated to determine when they should be used by. The facility policy stated food brought by family or visitors and left for later consumption must be labeled and stored in a clearly distinguishable manner, and perishable foods must be discarded on or before the use-by date.
Failure to Notify Resident Representative of Catheter Removal and Discontinuation
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s power of attorney (POA) of significant changes in the resident’s condition related to an indwelling urinary catheter. The resident was admitted with multiple diagnoses including anemia, cystocele with prolapse, osteoarthritis, diabetes mellitus, chronic kidney disease, dementia, urinary tract infection, uterovaginal prolapse, spinal stenosis, osteoporosis, Alzheimer’s disease, and adult failure to thrive. On admission, the resident was alert and oriented only to name and had an indwelling urinary catheter for urinary obstruction and cystocele with prolapse. Assessments documented that the resident had a severe cognitive deficit, required substantial to maximal assistance with toileting, had an indwelling urinary catheter, and was frequently incontinent of bowel. On one occasion, a progress note documented that the resident removed her indwelling urinary catheter and stated, “I didn’t want this in me anymore.” The physician was notified and a new catheter was reinserted, but there was no documentation that the POA was notified of this event. On a later date, another progress note documented that the resident again removed her indwelling urinary catheter; the physician was notified and ordered that the catheter be left out and the resident monitored. The medical record again contained no evidence that the POA was notified of the discontinuation of the catheter. In an interview, the Administrator confirmed that the POA had not been notified of either the resident’s removal of the catheter or the physician’s order to leave it out, despite a facility policy requiring timely notification of the physician and resident representative for significant changes in condition.
Failure to Honor Bathing Preferences
Penalty
Summary
The facility failed to honor Resident #108’s bathing preferences by providing bed baths instead of the resident’s preferred showers. The resident was admitted on 08/23/23 and readmitted on 03/02/26 with diagnoses including chronic kidney disease, PTSD, paraplegia, urinary retention, diabetes mellitus, mild intellectual disabilities, chronic pain, ESRD, paranoid schizophrenia, major depressive disorder, spinal stenosis, need for assistance with personal care, and COPD. The care plan dated 12/18/24 stated the resident required assistance with showering and was to be showered weekly per facility protocol, and the admission assessment dated 11/19/25 documented a preference for morning showers. The MDS indicated the resident had no cognitive deficit and that choosing between a tub bath, shower, bed bath, or sponge bath was very important to the resident. Bathing records showed that in January 2026 the resident had nine scheduled shower opportunities, but received showers only on 01/03/26, 01/20/26, and 01/24/26, with bed baths on the remaining scheduled dates. In February 2026, the resident had eight scheduled shower opportunities and received bed baths on all scheduled shower dates. In March 2026, the resident had seven scheduled shower opportunities to date and received bed baths on all scheduled shower dates. During interviews, the resident stated he preferred showers but was given bed baths because he was bed bound and required two-person assistance. A CNA stated residents on the hallway were scheduled for showers twice weekly, that only one CNA was staffed for the hallway, and that residents needing two staff members had longer waits and at times did not receive showers because of staffing shortages. An LPN later verified the resident was given a bed bath instead of the preferred shower.
Failure to Provide Privacy During Wound Care
Penalty
Summary
Privacy was not provided during wound care for one resident with multiple pressure ulcers. The resident was admitted with diagnoses including dementia, anxiety disorder, abnormal weight loss, urinary tract infection, fracture of the lower leg, and senile degeneration of the brain. The admission assessment and baseline care plan documented a stage III pressure ulcer to the sacrum measuring 11 cm by 0.5 cm by 0.1 cm and an unstageable pressure ulcer to the left gluteal fold measuring 0.5 cm by 1.0 cm, with no description of either wound. The care plan identified impaired skin integrity related to the sacral and left gluteal wounds, and physician orders included wound cleansing and dressing instructions, barrier cream after incontinence episodes, enhanced barrier precautions, and a low air loss mattress. During observation of the RN providing the ordered wound care, the resident was treated with the window blind open, facing another wing of the facility and within view of other residents' windows with open blinds. The RN verified that privacy was not provided during the wound care. The facility policy on Resident Rights states that residents have the right to privacy and confidentiality.
Failure to Notify State LTC Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility failed to provide notice to the office of the State long-term care Ombudsman for resident transfers or discharges, affecting two of three closed records reviewed. For Resident #146, the record showed an admission on 02/17/26 with diagnoses including alcoholic cirrhosis, peptic ulcer, hepatic encephalopathy, and protein/calorie malnutrition. The resident was at the facility for two days before being transferred to the hospital and did not return to the facility because the family requested the resident go to a different facility. An email dated 03/03/26 from the Human Resources Director listed Resident #146 on the February transfers and discharges notice, but it was sent to the State legal department, and there was no evidence the Ombudsman office was notified. For Resident #144, the record showed an admission on 01/13/26 with diagnoses including diabetes, alcohol induced pancreatitis, malignant neoplasm of the glottis, congestive heart failure, and acute and chronic respiratory failure. The resident went out to a physician appointment on 01/30/26 and was sent to the hospital from the physician's office for further evaluation, did not return to the facility, remained in the hospital until 03/02/26, and was then transferred to another nursing facility. The facility provided a January 2026 list of residents who were transferred or discharged, and Resident #144 was on the list, but there was no evidence the list was provided to the State long-term care Ombudsman. The Human Resources Director stated she thought she was sending the monthly list to the Ombudsman office but had been emailing the State legal department instead since at least August 2025.
Inaccurate Admission Pressure Wound Assessment
Penalty
Summary
The facility failed to ensure resident assessments accurately reflected the number of pressure wounds present upon admission. Medical record review for one resident showed an admission date of 12/19/2025 and diagnoses including generalized anxiety, dementia, and a wedge compression fracture of the thoracic vertebra. The resident’s quarterly MDS 3.0 assessment showed a BIMS score of 00 out of 15, indicating severely impaired cognition for daily decision-making abilities, and documented three stage III pressure ulcers, with two of those ulcers identified as present upon admission. Skin observation assessments documented a pressure wound on the coccyx measuring 5 cm by 7 cm with depth unable to be determined, and another assessment identified a coccyx pressure wound as present upon admission. The same assessment also documented a left heel pressure wound measuring 3 cm by 3 cm by 0.1 cm and a right heel pressure wound measuring 3.5 cm by 3 cm by 0.1 cm, both noted as not present upon admission. During interview, the DON stated that the floor nurse is responsible for completing admission nursing assessments, including whole body and skin assessments, within 24 hours of admission, and confirmed the resident was admitted with one pressure wound to the coccyx, not two as reflected in the MDS.
Inaccurate PASARR Documentation
Penalty
Summary
The facility failed to ensure pre-admission screening and resident review (PASARR) was completed accurately for one resident reviewed for PASARR. Resident #8 was admitted with diagnoses including cerebral infarction due to occlusion or stenosis of a small artery, hypertension, and PTSD. The medical record showed that major depressive disorder and generalized anxiety were added by the nurse practitioner on 01/22/26, but the most recent PASARR documentation dated 01/26/26 did not list generalized anxiety or PTSD for the resident. Social Services Director #366 verified during interview that the PASARR was missing additional diagnoses.
Delayed PASARR Screening
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed timely for one resident. Resident #8 was admitted to the facility with diagnoses including cerebral infarction due to occlusion or stenosis of a small artery, hypertension, and post-traumatic stress disorder (PTSD). Medical record review showed the resident had PTSD upon admission, but the PASARR was not completed until 10/31/25. Social Services Director #366 verified that the PASARR was not completed within the required 30-day timeframe from admission to the facility.
No Baseline Pain Care Plan for Resident With Ongoing Uncontrolled Pain
Penalty
Summary
The facility failed to develop a baseline care plan that included the instructions needed to provide effective and person-centered care for pain for one resident. The resident was admitted after a hospital stay following a fall and had diagnoses including osteoporosis, chronic kidney disease, hypertension, depression, and anxiety disorder. Hospital records showed an acute traumatic subarachnoid hemorrhage and an acute traumatic glenoid fracture, and the discharge summary noted the resident was stable, eating a regular diet, and receiving oral pain medication, including Tylenol 1000 mg three times daily. On admission, the physician ordered pain monitoring every shift and recording pain on a 0-10 scale, but the record did not contain a pain care plan. After admission, the resident continued to have pain issues. The resident was found on the floor in her room, reported mild left shoulder pain, and later had a lidocaine patch ordered as needed. The resident’s daughter reported the resident was sleeping more, more confused, and more delirious toward evening after the fall at the facility, and stated the resident had not been like that in the hospital. The daughter also stated the resident had chronic back pain and was having more pain than before. During interview and observation, the resident was seen fidgeting in bed, refusing breakfast while complaining of back pain, and later moaning in pain in the recliner with no staff response. Staff documented ongoing pain complaints, but the notes did not include a 0-10 pain score in several entries. The resident received scheduled Tylenol, but the lidocaine patch ordered earlier was not documented as administered until later, and pain remained uncontrolled. The nurse practitioner documented obvious discomfort with neck, low back, and sacral pain that was uncontrolled with conservative treatments, and oxycodone was ordered due to increased pain unrelieved by non-pharmacological interventions. The resident continued yelling out in pain, was noted to have acute uncontrolled back pain, and was sent to the hospital for evaluation. The DON later confirmed the resident did not have a plan of care for pain.
Failure to Address Mental Health Diagnoses in Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan for Resident #8. The resident was admitted with diagnoses including cerebral infarction due to occlusion or stenosis of a small artery, hypertension, and PTSD. The medical record also showed that major depressive disorder and generalized anxiety were added by the nurse practitioner on 01/22/26, and the most recent MDS assessment validated diagnoses of major depressive disorder, generalized anxiety, and PTSD. However, the care plan dated 03/11/26 did not address anxiety, depression, or PTSD. Social Services Director #366 verified on 03/26/26 at 12:10 P.M. that the care plan did not address these conditions.
Care Plan Missing Constipation Interventions
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident’s constipation within 7 days of the comprehensive assessment, and the plan of care was not prepared, reviewed, and revised by a team of health professionals. Resident #78 was admitted with diagnoses including constipation, diabetes, convulsions, panic disorder, and chronic kidney disease. The resident reported ongoing constipation, believed it was related to narcotic pain medication taken for back pain, and stated she usually took the pain medication twice daily. She also reported trying different constipation medications without success, having recently received a new medication, undergoing abdominal x-rays about a month earlier, and sometimes needing to digitally remove stool that would not come out. The record showed multiple current orders for constipation management, including Linzess, Miralax, Senna, Lactulose, Milk of Magnesia, Dulcolax suppository, fleets enema, Fibercon, and docusate sodium, along with PRN bisacodyl. Nursing notes documented episodes of stool retention, blood-tinged water and clots after manual stool removal, education not to manually remove stool, abdominal pain and distention, and repeated abdominal x-rays showing moderate to prominent fecal loading consistent with constipation. Despite these ongoing bowel issues, the resident’s plan of care did not include constipation or any related interventions. Corporate Clinical Nurse #400 confirmed the plan of care did not address constipation.
Failure to Administer PRN BP Medication per Order
Penalty
Summary
The facility failed to provide blood pressure medication according to the physician-ordered parameters for one resident. Resident #7 had diagnoses including cerebral infarction, anxiety disorder, chronic kidney disease stage four, major depressive disorder, diabetes, dementia, unspecified protein-calorie malnutrition, and abdominal aortic aneurysm without rupture. The resident’s MDS indicated severe cognitive impairment. A physician order dated 02/11/26 directed clonidine 0.2 mg by mouth every six hours as needed for hypertension, to be given if blood pressure was greater than 140. Review of the MAR showed Resident #7 did not receive clonidine during March 2026. The MAR also showed blood pressure checks twice daily, with readings of 148/89, 146/88, 147/88, 150/81, 149/78, and 149/87 on multiple dates in March. During interview, the LPN confirmed the resident had not received clonidine that month and confirmed those blood pressure results indicated the medication should have been given. The facility policy titled Administering Medication stated medications are to be administered in accordance with physicians orders.
Urinary Catheter Bag Positioned Above Bladder
Penalty
Summary
The facility failed to ensure an indwelling urinary catheter collection bag was positioned below the bladder for Resident #108. The resident was admitted with diagnoses including chronic kidney disease, paraplegia, urinary retention, diabetes mellitus, end stage renal disease, benign prostatic hyperplasia, bladder neck obstruction, obstructive and reflux uropathy, kidney transplant status, spinal stenosis, and need for assistance with personal care. The care plan identified an indwelling suprapubic catheter size 16 French, and monthly physician orders included catheter care every shift and changing the collection bag every 30 days or if visibly soiled. During observation, the resident’s urinary catheter collection bag was hanging above the bladder on the left enabler bar of the bed. The RN verified that the bag was above the bladder and stated this posed the potential for urine to backflow into the bladder. The facility policy for urinary catheter care stated the drainage bag must be held or positioned lower than the bladder at all times to prevent urine in the tubing and drainage bag from flowing back into the urinary bladder.
Failure to Address Significant Weight Loss and Nutrition Monitoring
Penalty
Summary
The facility failed to address significant weight loss for three residents who had documented nutritional risks and ongoing weight monitoring needs. The report states that the facility did not consistently re-weigh residents after large weight changes, did not always notify the RD of significant losses, and did not reliably document meal intake or ensure ordered nutrition support was provided. The facility policy required a recheck of any weight change of 5% or more and immediate notification of the dietician if the weight was verified, but the records showed these steps were not consistently followed. Resident #90 had diagnoses including Alzheimer's disease, diverticulosis, prostate cancer, dysphagia, and abnormal weight loss. The care plan identified nutritional problems and included interventions for meal assistance, fluid encouragement, supplements, diet orders, intake monitoring, RD evaluation, and ordered weights. The resident's record showed a 16.3-pound loss in one month, but no re-weigh was documented. The DON confirmed the weight loss was documented without a re-weigh or evidence that the RD was notified, and the RD confirmed she had not been informed of the documented loss. Resident #29 was admitted with vascular dementia, cerebral infarction, hepatitis C, and substance dependence, and staff documented meal refusal and limited intake soon after admission. The resident lost 11.8 pounds in one week and later had a total loss of 15.6 pounds in one month, but there was no evidence of timely re-weighing after the initial significant loss and no further weights were documented after 03/10/26. Meal intake was not documented for at least one day despite observations showing partial intake, and the resident did not receive an ordered nutritional supplement on the lunch tray. The RD and other nursing leadership acknowledged there was no timeline in the plan or policy for re-weighing after significant loss. Resident #17 had diagnoses including dementia with anxiety, dysphagia, chronic kidney disease, GERD, and depression. The resident's care plan identified nutritional risk and included weights as ordered and RD review. The record showed a 14.6-pound, 10.3% weight loss in 30 days, and the RD notified the physician and recommended a re-weigh to confirm accuracy. However, no re-weigh was obtained and the RD did not follow up on the missing re-weigh. The resident's meal tray was also observed without the ordered Healthshake supplement, and the RD later observed that the resident's weight on a new scale did not appear to match the stated weight.
Missing Order for Continuous Supplemental Oxygen
Penalty
Summary
The facility failed to ensure a physician or practitioner order was in place for supplemental oxygen for Resident #4, who was observed using oxygen continuously. Resident #4 was admitted and later readmitted to the facility and had diagnoses including chronic obstructive pulmonary disease, COPD with acute exacerbation, emphysema, shortness of breath, acute and chronic respiratory failure, pleural effusion, personal history of pulmonary embolism, and obstructive sleep apnea. The MDS dated [DATE] identified the resident as cognitively intact and indicated the resident did not wear oxygen therapy. Review of the medical record on 03/25/26 showed a discontinued order for oxygen via nasal cannula at 4-5 L to maintain saturation above 90%, which had been discontinued on 01/13/26, and no active order for supplemental oxygen was found. Despite this, the resident was observed on 03/25/2026 and again on 03/26/2026 wearing oxygen at 3 liters via nasal cannula, and the resident stated that oxygen was required continuously at that setting. An LPN confirmed that no physician or practitioner order was in place and stated the resident required continuous oxygen and should have an order. Facility policy on Oxygen Administration stated that safe oxygen administration includes verifying that there is a physician's order for the procedure.
Failure to Assess and Manage Resident Pain
Penalty
Summary
The facility failed to recognize, evaluate, and manage acute pain for a resident admitted after a fall with multiple diagnoses including osteoporosis, chronic kidney disease, hypertension, depression, and anxiety disorder. Hospital records showed the resident had been hospitalized after a fall with a head hematoma, altered mental status, left-sided weakness, an acute traumatic subarachnoid hemorrhage, and an acute traumatic glenoid fracture. At discharge to the facility, Tylenol 1000 mg three times daily was ordered, and the resident was documented as tolerating therapies and oral pain medication. After admission, the resident had pain monitoring ordered every shift, but the pain records documented 0 pain from 03/18/26 through 03/23/26. The resident did not have a pain care plan. On 03/19/26, the resident was found on the floor in her room, was alert and oriented x2, denied pain, then reported mild left shoulder pain; an X-ray was ordered and later reviewed as non-acute. A lidocaine patch was ordered as needed on 03/19/26, but the medication administration record did not document that it was given before 03/24/26. A nurse practitioner note on 03/20/26 stated the resident reported pain at 5/10 but was managed well, with only Tylenol given. Family and staff observations showed worsening pain and distress that were not consistently assessed or documented. The resident’s daughter reported the resident was sleeping more, more confused, and more delirious after the fall, and that she did not feel the resident’s pain was being managed. On 03/24/26, the resident was observed flat in bed refusing breakfast, complaining of back pain, later moaning and yelling out in pain in the recliner, and no staff responded when the sounds were heard in the hallway. An agency LPN gave scheduled Tylenol and later repositioned the resident, but the resident continued to yell out. The nurse practitioner documented obvious discomfort with neck, low back, and sacral pain that was uncontrolled with conservative treatments. Oxycodone 2.5 mg was ordered for increased pain unrelieved by non-pharmacological interventions, and the resident was sent to the hospital for uncontrolled pain. Nursing notes on that day did not include a 0-10 pain score, and the MAR did not document administration of the lidocaine patch.
Failure to Complete Ordered Medication Monitoring Labs
Penalty
Summary
The facility failed to monitor medications by completing physician-ordered laboratory work for two residents. One resident had diagnoses including schizophrenia, drug induced subacute dyskinesia, diabetes, dementia, hypothyroidism, hyperlipidemia, and normal pressure hydrocephalus, and was receiving simvastatin 40 mg daily for hyperlipidemia. A pharmacy review recommended a fasting lipid panel and liver function tests to monitor the cholesterol-lowering medication, and the physician ordered both tests; however, only the lipid panel was completed and there were no liver function test results. The DON verified that the liver function test was not completed in November or at any time since. A second resident had diagnoses including diabetes, cerebral infarction, hypertension, Parkinson's disease, and chronic pain, and had been receiving glargine insulin 30 units daily. The physician had ordered a quarterly Hemoglobin A1C, but there was no evidence that an A1C had been completed since the last result, which was 5.4. The DON confirmed that there was no evidence the Hemoglobin A1C had been completed since that result.
Incomplete and Inaccurate Medical Record Documentation for Wound Care
Penalty
Summary
The facility failed to ensure that residents' medical records were complete and accurate, specifically regarding the documentation of wound care and the identification of pressure ulcers. For one resident, review of the treatment administration record (TAR) revealed that a nurse did not document completion of required tracheostomy and PEG tube site care on several night shifts. The nurse later confirmed that the treatments were performed but had not been documented in the electronic TAR, leaving several entries blank for those dates. The Director of Nursing verified that the nurse was responsible for the missing documentation and acknowledged that the medical record was incomplete until the nurse retroactively initialed the TAR. Another resident's medical record contained conflicting and inaccurate information regarding the type, location, and origin date of skin impairments, including a Stage II pressure ulcer and moisture-associated skin dermatitis (MASD). The care plans for this resident contradicted each other, with one indicating a Stage II ulcer and MASD on the left buttock and the other indicating these conditions on the right buttock. Additionally, a wound assessment incorrectly stated that the pressure ulcer was present on admission and listed an incorrect origin date. Progress notes from the wound nurse practitioner also misidentified the locations of the wounds, which was later clarified through an addendum after the discrepancies were discovered. Interviews with facility staff, including the wound nurse and the DON, confirmed that the medical records did not accurately reflect the residents' wound status, locations, and dates of origin. Staff acknowledged ongoing issues with proper documentation and data entry in the electronic medical record system, leading to incomplete and conflicting information in the residents' records.
Failure to Use PPE and Perform Hand Hygiene During Tracheostomy and PEG Tube Care
Penalty
Summary
The facility failed to ensure that appropriate personal protective equipment (PPE) was worn and proper hand hygiene was performed during the care of a resident with a tracheostomy and a percutaneous endoscopic gastrostomy (PEG) tube, who was under enhanced barrier precautions (EBP) due to the presence of medically invasive devices. During an observation, two nurses, an LPN and an RN, entered the resident's room, which was clearly marked for EBP and had PPE available outside the door, but neither donned any PPE before providing tracheostomy and PEG tube care. The resident, who had diagnoses including acute and chronic respiratory failure and required regular tracheostomy and PEG tube care, was observed coughing during the procedure, which included suctioning and removal of the inner cannula. After removing the resident's inner cannula, the LPN removed her gloves without performing hand hygiene and searched through supplies in the room with bare hands. The RN, after removing the old split gauze dressing from the PEG tube site, also removed her gloves without performing hand hygiene before leaving the room to retrieve a needed supply. Both nurses only performed hand hygiene upon the RN's return to the room, prior to resuming care. Interviews with both nurses confirmed their awareness of the EBP requirements and the need for PPE and hand hygiene, but acknowledged that these protocols were not followed during the observed care. Review of facility policies confirmed that EBP required gown and gloves for high-contact care and that hand hygiene was mandated after glove removal and before handling invasive devices or environmental surfaces. The failure to adhere to these protocols was observed and confirmed through staff interviews, record review, and policy review, affecting one resident who required enhanced infection prevention measures due to his medical condition.
Failure to Ensure Timely Payment to Food Vendor Resulting in Disrupted Food Deliveries
Penalty
Summary
The facility failed to administer its operations in a manner that ensured effective and efficient use of resources, specifically regarding compliance with financial obligations necessary for the delivery of care. Review of the facility's open payables log and interviews revealed that the facility did not pay its food supply vendor, resulting in a missed food delivery. Staff confirmed that the food delivery truck did not arrive as scheduled, and the menu had to be altered due to unavailable planned menu items. The food delivery service resumed only after a payment was made, but there was a period during which the facility operated without its regular food supply schedule. Further investigation showed that the business office manager was unable to provide invoices or details on the amounts owed to the food vendor, and the facility's records indicated a significant outstanding balance to the food supplier. The administrator's job description included responsibilities for ensuring compliance with regulations and managing vendor contracts, but there was a lack of evidence that these duties were fulfilled in relation to the food supply payments. This deficiency affected all 133 residents in the facility.
Failure to Thoroughly Investigate Alleged Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation following an allegation of abuse involving Resident #131, who had diagnoses including seizures and other specified brain disorders and was noted to have intact cognition and no behaviors. Upon review of a self-reported incident, it was found that while a questionnaire indicated the resident felt mistreated, there was no documentation of follow-up questions to clarify the nature, timing, or circumstances of the alleged mistreatment. The Director of Nursing confirmed that although a skin check was performed with no findings, no further inquiry was made to determine details of the alleged mistreatment. Facility policy required that residents on the same unit and the resident making the allegation be interviewed, but this was not fully carried out.
Failure to Document and Justify Resident Transfer/Discharge
Penalty
Summary
A deficiency occurred when the facility failed to provide evidence that a transfer from the facility was necessary for a resident's welfare and that the resident's needs could not be met in the facility. The resident involved had diagnoses including schizophrenia, hypertension, benign neoplasm of cranial nerves, and hearing loss, with a legal guardian who was his brother. The resident had severe cognitive impairment and was independent with mobility, with no prior history of elopement until a single incident occurred when the resident exited the facility during a fire alarm. The facility's root cause analysis identified a lack of staff education regarding supervision during fire alarms, as all exit doors became unlocked during such events. Following the elopement incident, the facility initiated a referral to another nursing facility located approximately 170 miles away. Documentation in the medical record was lacking regarding the basis for the transfer, why the resident's needs could not be met at the current facility, or any attempts to address those needs. There was also no documentation explaining how the receiving facility could better meet the resident's needs or was different from the current facility, which also had locked doors. The discharge paperwork did not specify the details of the transfer, and there was no evidence of physician documentation supporting the necessity of the transfer or outlining the specific services the new facility would provide. The resident's guardian was not involved in the selection of the receiving facility and expressed that he did not want the resident to move, citing the distance as a barrier to visitation. The guardian reported feeling that the decision had already been made by the facility and that he was not given a choice. Facility staff interviews confirmed that there was no documentation related to the decision-making process for the transfer, the resident's unmet needs, or efforts to find a facility closer to the guardian. The facility's policy required proper documentation and involvement of the resident or representative, which was not followed in this case.
Failure to Provide Required Transfer Notice and Appeal Rights Prior to Resident Discharge
Penalty
Summary
The facility failed to provide the required written notice to a resident and their legal guardian prior to transferring the resident to another nursing facility. The resident, who had severe cognitive impairment and multiple medical diagnoses, was involved in an elopement incident when he exited the building while the fire alarm was sounding and was subsequently returned by staff. Following this event, a referral was made to transfer the resident to a sister facility located approximately 170 miles away, which was described as having a more secure environment suitable for mental health needs. Documentation in the medical record did not include the required details regarding the transfer, such as the reason for transfer, effective date, location, appeal rights, or Ombudsman contact information. The discharge recap form indicated that notice was given to the resident or representative, but there was no evidence that the guardian received the required written notice or information about appeal rights prior to the transfer. Interviews with facility staff confirmed that the decision to transfer was initiated by the facility, and that the required documentation and notifications were not provided or properly recorded in the medical record. The resident's guardian reported that he was not given a choice in the transfer, was not provided with a discharge notice, and did not receive information on how to appeal or contact the Ombudsman. He also expressed concern about the distance to the new facility and the quality of care there. Facility policy requires written notice at least 30 days in advance of a planned discharge or transfer, including information about appeal rights, but this was not followed in this case.
Failure to Implement Fall and Elopement Prevention Measures
Penalty
Summary
The facility failed to ensure that accident prevention interventions were in place for two residents, resulting in deficiencies related to fall prevention and elopement. For one resident with dementia, muscle weakness, and moderately impaired cognition, the care plan included specific fall prevention interventions such as keeping a urinal at bedside, placing a bedside toilet in the room, and posting a 'please call don't fall' sign. However, during observation, none of these interventions were present in the resident's room, and the DON confirmed that the fall prevention measures were not in place at the time of the survey. Another resident with severe cognitive impairment and a history of schizophrenia eloped from the facility. The resident was found missing during staff rounds, and was later located and returned by a staff nurse who saw him walking outside. The facility's investigation revealed that the resident exited through a door that was unlocked while the fire panel was alarming. Staff interviews indicated a lack of awareness regarding the unlocking of exit doors during fire panel alarms, and there was inconsistent documentation and statements about the timing and awareness of the elopement. The medical record contained minimal documentation about the incident, and a statement from the nurse responsible for the resident was not obtained. The facility's policies required documentation and investigation of missing residents and the implementation of interventions to prevent accidents. However, the failure to implement and maintain required safety interventions for fall prevention, as well as inadequate supervision and documentation related to the elopement, led to non-compliance with accident prevention standards. These deficiencies were identified through observations, record reviews, and staff interviews.
Failure to Maintain Clean and Sanitary Resident Equipment
Penalty
Summary
Staff failed to maintain clean and sanitary resident equipment for a resident with multiple complex medical diagnoses, including metabolic encephalopathy, mood affective disorder, heart transplant, cardiomyopathy, and frontotemporal neurocognitive disease. The resident, who utilized a wheelchair, had previously sustained a skin tear to the left eyelid after hitting his face on a bedrail, leading staff to place white cloth bandage padding on the bedrails as an intervention. During observations, surveyors noted that the white padding on the right side of the bedrail had a visible rust-colored stain, and the wheelchair had white cloth bandage wraps with a large patch of brown substance on the right side of the frame. The wheelchair cushion also had black and brown smears. Interviews with an LPN and the DON confirmed the presence of these stains and that nursing staff were responsible for cleaning resident equipment as needed. Facility policy required maintaining a clean, sanitary, and orderly environment, but this was not followed in this instance.
Failure to Involve Responsible Party in Care Planning
Penalty
Summary
The facility failed to ensure that a resident's responsible party participated in the development and implementation of the resident's person-centered care plan. Medical record review showed that the baseline care plan for a resident with diagnoses including heart disease, acute and chronic respiratory failure, seizures, and COPD was not reviewed with the resident or their Power of Attorney (POA) as required. Staff interviews confirmed that there was no documentation or signature indicating the POA was informed or involved in the initial care planning process, despite the facility's usual practice of obtaining such signatures to demonstrate participation.
Failure to Notify Correct Resident Representative After Fall
Penalty
Summary
A deficiency occurred when the facility failed to notify the appropriate resident representative, specifically the Power of Attorney (POA), following a fall incident involving a resident with dementia, cognitive communication deficit, and schizoaffective disorder. The resident, who was at risk for falls and had interventions in place to mitigate this risk, experienced a fall resulting in a forehead laceration. The incident was documented by nursing staff, and the resident's daughter was notified of the fall, despite the medical record indicating that the resident's wife was the designated POA. The facility's policy required that the resident's physician and responsible party be notified after a fall. However, the correct representative was not informed until the day after the incident, as confirmed by staff interviews and record review. This lapse in timely notification of the POA constituted non-compliance with facility policy and regulatory requirements for notification of changes affecting residents.
Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by 5 medication errors out of 43 administrations, resulting in an 11.9% error rate. During medication administration observations, one LPN gave a resident an 81 mg chewable Aspirin tablet along with other medications, without ensuring it was chewed as intended. The LPN confirmed that the chewable tablet was not separated and was consumed whole. In another instance, a different LPN administered all medications, including a chewable Phenytoin 150 mg tablet, whole and at the same time, rather than ensuring the chewable tablet was chewed, as confirmed by the LPN. Additionally, the same LPN was observed administering medications to another resident by crushing all ordered medications or opening capsules and mixing them with pudding. The resident's orders included delayed release and extended release medications, which the LPN confirmed were not to be crushed or opened, as this could alter their absorption. Review of the facility's medication administration policy indicated the need to double-check the right medication, dose, route, and time, but the observed practices did not align with these requirements.
Failure to Maintain Infection Control During Medication Administration
Penalty
Summary
During a medication administration observation, an LPN failed to follow infection control protocols for three residents. After checking one resident's blood pressure, the LPN did not perform hand hygiene before preparing medication for the next resident. The LPN was also observed dropping medication onto the medication cart, then picking it up with an ungloved hand and placing it back into the medication cup for administration. Additionally, the LPN used an ungloved hand to remove medication from the cup prior to crushing it for administration. These actions were confirmed during an interview with the LPN, who acknowledged not performing hand hygiene and handling medication without gloves. Review of the facility's policy indicated that pills should never be touched with bare hands to prevent contamination.
Failure to Conduct Background Checks and Investigate Abuse Allegations
Penalty
Summary
The facility failed to complete required federal criminal background checks for new employees who had not lived in the state for the last five years. This oversight was identified through a review of the facility's Bureau of Criminal Investigation log and personnel records, which showed that nine new hires did not have federal background checks completed. Additionally, the facility's new hire application form lacked a section to determine if applicants had lived in the state for the required period, and there was no specific policy in place for conducting federal background checks. Interviews with the Human Resources Director and the Administrator confirmed these deficiencies. The facility also failed to implement its abuse policy effectively in the case of a resident who reported feeling intimidated and verbally abused by staff. The resident, who had a range of complex medical conditions including hepatic failure and major depressive disorder, reported feeling intimidated by three staff members. Despite this, the facility did not conduct a thorough investigation, as evidenced by incomplete documentation and a lack of interviews with other residents or staff. The alleged perpetrators continued to work during the investigation, contrary to the facility's policy of placing staff on administrative leave during such investigations. The facility's policy required immediate removal of staff accused of abuse and notification of the state department of health, neither of which occurred in this case. The Administrator confirmed that the investigation was incomplete and that the incident was not reported to the state as required. The resident confirmed feeling intimidated and that the abuse ceased only after being moved to a different room, away from the staff involved.
Inadequate Staffing and Training in Dietary Services
Penalty
Summary
The facility failed to provide sufficient staff with the necessary competencies and skills to effectively carry out the functions of the food and nutrition services, affecting 137 of 139 residents. Observations revealed that meal delivery was inconsistent, with breakfast trays being delivered late and supper sometimes served as late as 8:00 P.M. The Dietary Manager, who also served as the Activity Director, confirmed that only one kitchen was operational, leading to delays in meal service. The facility lacked specific meal times for each hallway, and the dietary staff were not adequately trained, as evidenced by the absence of training records for new hires on diet types and menu usage. Interviews with staff and residents highlighted the issues with meal service. An LPN noted the lack of a set schedule for meal delivery, while dietary staff reported being short-staffed and untrained, resulting in delays and errors in meal preparation. Residents expressed dissatisfaction with the late and cold meals, with one resident noting that supper was served as late as 8:30 P.M. The Administrator acknowledged multiple resident complaints about late meals and cited issues such as a locked kitchen, a ceiling leak, and a non-functional dishwasher as contributing factors. The Dietician, who visited the facility twice a week, confirmed that test trays often revealed cold food and that the facility did not have enough staff to operate both kitchens. The Dietary Manager admitted feeling overwhelmed by her dual roles and unable to provide adequate support to her staff. The facility's monitoring of meal service times showed consistent delays, and the lack of resident preference determination for meal times further compounded the issue. This deficiency was investigated under Complaint Number OH00161227.
Inconsistent Meal Service Times and Cold Food
Penalty
Summary
The facility failed to ensure meals were served at regular times and in accordance with resident needs and preferences, affecting 137 of 139 residents. Observations revealed that breakfast service was inconsistent, with meal carts arriving late and meals being served over an extended period. The Dietary Manager confirmed that there was no set schedule for meal delivery, and the facility was operating with only one kitchen, causing delays in meal service. Additionally, there were instances where supper was served as late as 8:00 P.M., and residents reported receiving cold food. Staff interviews highlighted several operational challenges contributing to the deficiency. The Dietary Manager, who also served as the Activity Director, acknowledged the lack of specific meal times and insufficient dietary staff to operate both kitchens. Staff shortages and equipment issues, such as a non-functioning dishwasher, further exacerbated the delays. The Administrator noted that resident preferences for meal times had not been determined, and the facility had only recently begun monitoring meal service times. Interviews with residents and staff indicated frequent complaints about late meals and cold food. The Dietician confirmed that test trays often revealed cold hot foods and noted that the facility lacked sufficient staff to operate both kitchens. The deficiency was investigated under Complaint Numbers OH00161464 and OH00161227, with the facility's meal service practices failing to meet the needs and preferences of the residents.
Facility Lacks Qualified Social Worker
Penalty
Summary
The facility failed to employ a full-time, qualified social worker, which is a requirement for facilities with more than 120 beds. This deficiency potentially affected all 139 residents in the facility. The Social Service Director, hired on July 22, 2022, held a bachelor's degree in business administration, not in social work or a human services field as required. The last licensed social worker was employed from September 23, 2024, to December 6, 2024, but was no longer with the facility. Interviews with the Social Service Director and the Administrator confirmed the absence of a licensed social worker at the time of the survey. This deficiency was identified during a complaint investigation.
Failure to Schedule Activities for Memory Care Residents
Penalty
Summary
The facility failed to schedule activities to meet the needs of residents in the memory care unit, affecting all 21 residents in that unit and one resident outside of it. Observations and reviews of the activity calendars from November 2024 to January 2025 revealed that no activities were scheduled for weekends in the memory care unit. On January 15, 2025, no activities were observed in the memory care unit during scheduled times, and staff were occupied with breakfast and morning hygiene routines instead. Similarly, in the non-memory care unit, activities were not occurring as scheduled, with staff assisting with meal duties instead. Interviews with activity assistants and the activities director confirmed that activities were delayed or not conducted as scheduled due to staff being overwhelmed with meal duties and other responsibilities. The activities director admitted to prioritizing activities in other parts of the building due to limited staff and confirmed that activities were often late because of the time taken to serve meals. A resident expressed frustration over activity delays, which sometimes required her to wait in her wheelchair for extended periods, causing discomfort. The deficiency was investigated under Complaint Number OH00161522.
Failure to Provide Adequate Care and Notify Physician of Changes
Penalty
Summary
The facility failed to ensure adequate treatment and care for a resident, Resident #145, who was admitted with multiple complex medical conditions, including systolic heart failure, diabetes, and a gastrostomy tube. Upon admission, the resident had specific physician's orders for insulin administration and blood sugar monitoring, but there were no parameters set for notifying the physician about abnormal blood sugar levels. The resident's blood pressure readings were inconsistently documented, with some readings being carried over from previous days without new measurements being taken. On one occasion, a low blood pressure reading was not followed up with a recheck or physician notification. On 12/17/24, the resident's blood pressure was significantly lower than previous readings, but there was no evidence of physician notification or further action taken. The resident's blood sugar levels were also elevated, reaching 380 mg/dl on 12/19/24, yet the physician was not notified. The resident was receiving morphine for pain, and vital signs were not consistently monitored or documented. The LPN on duty attempted to take the resident's blood pressure but was unable to obtain a reading due to an error with the machine and did not follow up with a manual check or notify the physician. The Director of Nursing confirmed that the facility lacked a policy on vital sign monitoring, although the procedure was to take vital signs every shift for Medicare-skilled residents. The facility's policy on diabetes management required physician orders for glucose monitoring parameters, which were not in place for Resident #145. The deficiency was identified during an investigation of a complaint, highlighting the facility's failure to provide adequate care and notify the physician of significant changes in the resident's condition.
Failure to Ensure Safe Smoking Practices and Assessments
Penalty
Summary
The facility failed to ensure that residents followed safe smoking provisions and did not assess residents for safe smoking prior to smoking while residing in the facility. Observations revealed that used cigarette butts were found in trash cans on the front porches of the buildings, which were not designated smoking areas. The trash cans were lined with plastic bags, making them unsafe for disposing of smoking materials. Interviews with the administrator and a resident confirmed that residents smoked on the front porches and disposed of cigarette butts in the trash cans, contrary to the facility's policy that required residents to sign out and go off property to smoke. The facility's smoking policy, dated November 2024, stated that residents' right to smoke would be respected, and a safe environment would be maintained, with the policy reviewed with residents upon admission and annually. The facility also failed to conduct smoking assessments for residents who smoked, as required by their policy. Residents identified as smokers, including those with significant medical histories such as COPD, heart failure, and chronic respiratory conditions, had not been assessed for safe smoking since their admission. The Director of Nursing confirmed that smoking assessments were not completed upon admission or quarterly thereafter for the residents involved. The facility's smoking policy required that residents be assessed on admission, quarterly, and as needed to determine if they were safe to smoke independently or required supervision and adaptive equipment. This deficiency was investigated under Master Complaint Number OH00161522.
Failure to Follow Prescribed Menus and Serving Sizes
Penalty
Summary
The facility failed to ensure that menus were followed, affecting 11 residents who received nutrition from the kitchen. The surveyor observed that the facility did not provide specific food items or serving sizes for various diets, including mechanical soft, pureed, and finger foods. Staff used the packaging of food items to determine serving sizes, which led to inconsistencies in meal preparation. For instance, residents on regular, mechanical soft, and finger food diets received three ounces of peas and carrots instead of the required four ounces. Additionally, residents on finger food diets did not receive mashed potatoes or a substitute, and a resident on a pureed diet received tomato soup instead of pureed peas and carrots. The dietary manager and dietician were unaware that staff did not have access to menus with serving sizes. The dietician confirmed that the new menu system implemented in December 2024 should have included printed menus with serving sizes for staff use. However, these were not available, leading to reliance on recipes that did not specify the necessary food items or quantities for different diets. The dietary manager, who had recently assumed the role, and the dietician, who visited the facility twice weekly, did not monitor meal tray preparation, contributing to the oversight. Specific residents were affected by these deficiencies. Resident #86, with severe cognitive impairment and on a pureed diet, did not receive the appropriate vegetables as per the menu. Similarly, Resident #25, also with severe cognitive impairment and on a pureed diet, did not receive pureed green beans or a replacement. These deficiencies were part of a broader issue investigated under Master Complaint Number OH00161522 and Complaint Number OH00161227, highlighting the facility's failure to meet the nutritional needs of its residents as per the prescribed menus.
Deficiency in Meal Temperature and Palatability
Penalty
Summary
The facility failed to ensure that meals were palatable, appetizing, and served at appropriate temperatures, affecting six residents who were interviewed about food temperatures and palatability. Observations on a specific date revealed that the breakfast meal cart was delivered to the hallway at 9:10 A.M. but was not fully distributed until 9:55 A.M., resulting in food being served cold. A test tray confirmed that the food was not at the required temperatures, with items like hash browns and scrambled eggs measuring significantly below the standard for hot foods. Interviews with residents and staff confirmed that cold food was a frequent issue, and the facility had received multiple complaints about this problem. The facility's policy requires that hot foods be maintained at or above 135 degrees Fahrenheit and cold foods at or below 41 degrees Fahrenheit. However, the observations and interviews indicated that these standards were not met. The dietician, who visits the facility twice a week, also confirmed that during her test trays, the hot foods were cold. The administrator acknowledged receiving multiple complaints about cold food and late tray delivery. The deficiency was investigated under specific complaint numbers, indicating ongoing issues with meal service in the facility.
Failure to Provide Pureed Diet to Resident
Penalty
Summary
The facility failed to ensure that Resident #86 received food prepared in a form to meet their individual needs, specifically a pureed texture diet. The resident, who had severely impaired cognition and was on a pureed diet due to pocketing food, was observed during lunch service receiving a meal tray that included regular texture pineapple, contrary to the dietary orders. The meal card on the tray clearly indicated the resident was on a pureed texture diet, yet the regular texture pineapple was included and delivered to the resident. During the observation period, the Licensed Practical Nurse (LPN) confirmed the dietary error and removed the pineapple from the resident's tray. However, shortly after, the resident was observed with another bowl of regular texture pineapple, which the LPN attributed to another resident possibly giving it to her. Throughout the observation, Resident #86 did not consume any of her food. This deficiency was investigated under Complaint Numbers OH00161321 and OH00161227.
Failure to Notify Resident Representatives of Significant Changes
Penalty
Summary
The facility failed to notify resident representatives of significant changes in the condition of two residents, leading to a deficiency. For Resident #145, the facility did not inform the family about the resident's declining vital signs and the inability to obtain a blood pressure reading. The resident, who had a complex medical history including heart surgery, a pacemaker, and other serious conditions, expressed a desire for comfort care only. Despite this, the LPN did not contact the family about the resident's low pulse and inability to obtain a blood pressure until after the resident had passed away. The hospice care transition was also mishandled, as the resident was not under the care of any hospice agency at the time of death. For Resident #86, the facility did not notify the resident's power of attorney (POA) about changes in the resident's swallowing ability and subsequent diet modification. The resident, who had severe cognitive impairment and other chronic conditions, was observed pocketing food, prompting a consultation with a speech therapist and a change to a puree diet. However, there was no evidence that the POA was informed of these changes, as confirmed by the Director of Nursing. The facility's policy required notification of significant changes, which was not adhered to in these cases.
Failure to Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse to the state survey agency, affecting one resident. The resident, who was cognitively intact, had a history of multiple serious health conditions, including hepatic failure, diabetes, and major depressive disorder. She was moved to a different room without documented reasons, and a concern was raised about two aides on her previous hallway regarding lack of respect and proper care. The facility's investigation documents did not show evidence that this incident was reported to the state survey agency, as required by their policy. The resident confirmed feeling intimidated and verbally abused by three staff members, including an LPN and two CNAs, who mocked her for requesting incontinence care. This behavior ceased after her room change, as the staff involved did not work on her new floor. The facility's policy mandates immediate notification to the state department of health within two hours of an abuse allegation, which was not followed in this case. The administrator confirmed the failure to report the incident, and the resident was not interviewed about the incident by facility staff.
Failure to Investigate Abuse Allegation Thoroughly
Penalty
Summary
The facility failed to conduct a thorough investigation of an abuse allegation involving a resident, identified as Resident #8, who was cognitively intact and had a complex medical history including hepatic failure, diabetes, and major depressive disorder. The incident involved allegations of intimidation and verbal abuse by three staff members, including two CNAs and an LPN, which led to the resident feeling intimidated and verbally abused. The resident reported that the abuse ceased after being moved to a different room, where the alleged perpetrators did not work. Despite the resident's claims, the facility did not document interviews with the resident or other potential witnesses, and the alleged perpetrators continued to work during the investigation period. The facility's policy required immediate removal of staff accused of abuse pending investigation, but this was not followed. The Director of Nursing (DON) confirmed that interviews were conducted with the accused staff and the resident, but these were not documented, and there was no record of other staff or residents being interviewed. The facility's failure to adhere to its policy and thoroughly investigate the abuse allegation resulted in a deficiency, as confirmed by the Administrator and DON during interviews. This deficiency was investigated under Complaint Number OH00161464.
Medication Availability Deficiency
Penalty
Summary
The facility failed to provide pharmacy services to ensure medications were available for administration as per physician orders, affecting two residents. Resident #39 had a physician's order for ergocalciferol (Vitamin D2) to be administered once weekly for Vitamin D deficiency. However, during a medication administration observation, the LPN noted that the Vitamin D was not available and was unsure of the reason. The Director of Nursing confirmed that the medication was supposed to come from the pharmacy but was unavailable at the time of administration. Similarly, Resident #71 had physician's orders for Mucinex DM ER and fexofenadine for cough/congestion and seasonal allergies, respectively. During the medication administration observation, the LPN reported that both medications were not available. The Assistant Director of Nursing confirmed that these were stock medications but were not available for administration. This deficiency was investigated under Complaint Number OH00161227.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 499 citations issued within 25 miles in the last 12 months — including the 6 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
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lancaster
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arbors At Carroll | 2.4 mi | ★★★★★ | 8 | 0 |
| The Springs At Wyandot Trail | 3.5 mi | ★★★★★ | 9 | 0 |
| Main Street Terrace Care Center | 4.2 mi | ★★★★★ | 14 | 0 |
| Lanfair Center For Rehab & Nsg Care Inc | 4.9 mi | ★★★★★ | 0 | 0 |
| Buckeye Care And Rehabilitation | 5.1 mi | ★★★★★ | 21 | 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 August 2026) and official state health department websites.