Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Marietta Heights Post Acute during CMS and state inspections, most recent first.
The facility failed to maintain an effective RSV infection control program. An LPN worked while symptomatic and after a positive RSV test, and a CNA also worked after reporting RSV and ongoing symptoms. The DON and IP did not timely identify an outbreak, did not use contact tracing or a line list, and did not promptly notify the health department. Multiple residents across two halls later tested positive for RSV, including a resident with COPD, CHF, CKD, and other serious conditions, and another resident with emphysema and asthma; one resident died with RSV listed as a significant condition.
Unsecured Resident Medical Records Found in Open Rooms: Surveyors observed resident medical records stored on surfaces in an open, unlocked room and in another room with the door wide open, including an open binder with medical records and COVID vaccination information. An LPN stated the former memory care unit doors were never locked after closure, and the administrator confirmed that two rooms contained resident medical records and were left unlocked and open despite the facility having a dedicated medical records room.
Failure to Treat a Resident with Dignity and Respect: A resident with ESRD, cognitive communication deficit, DM2, PVD, and chronic foot ulcers reported that a dietary aide threw a pan at her and was rude when she went to the kitchen to check the menu. Interviews also described the aide as rude to residents and staff, slamming items down and yelling, while the DON/Administrator did not personally investigate the abuse allegation and allowed the aide to return to work without further action.
Failure to thoroughly investigate an allegation of staff-to-resident abuse. A resident with multiple chronic conditions and cognitive impairment reported that a Dietary Aide threw a pan at her, but the Administrator did not personally investigate and relied on the DM to review the incident. No witness statements or interview documentation were available, staff accounts were conflicting, and the resident said she was never interviewed after reporting the incident and felt afraid of the aide.
A resident with dementia, DM, morbid obesity, CAD, and COPD sleep apnea was identified as a fall risk with interventions to ask for help with transfers, wear non-skid footwear, and use a walker. After the resident was found on the floor, the nurse assessed him and notified the provider, but there was no documentation of an immediate fall intervention, and the care plan was not updated until the IDT later reviewed the incident and added grip strips to the bed.
Incomplete and inaccurate resident records were documented for two residents. One resident’s RSV lab result was misread and the Infection Control Log did not reflect the correct positive test date. Another resident with CHF and other diagnoses had a daily weight order, but the record showed no physician notification after a 5.4 lb weight gain and no evidence of notification after weight refusals; a late entry note was later added stating the MD and resident representative had been notified, although the DON confirmed there was no evidence of that communication.
Survey results and the plan of correction were not posted in the facility survey book in the main lobby where residents, family members, and legal representatives could readily review them. An observation found the book did not include the most recent survey findings or POC, and the Administrator confirmed the documents had not been placed in the survey book. This deficiency affected all residents.
EBP was not implemented as ordered for multiple residents with urinary catheters, wounds, or other devices. Staff were observed providing direct care or catheter care without the required gown and glove use, and PPE carts were not present outside or inside the rooms despite EBP signs being posted. The facility also did not follow its water management program because weekly checks did not document the required areas, water flow activity, or temperatures for less frequently used locations.
A resident with CHF, cardiomegaly, and severe cognitive impairment had a significant weight gain that was reported to the on-call provider, but the record did not show a documented nursing assessment of the resident’s condition at that time. The resident later received orders for a 2,000 mL fluid restriction, yet staff were not aware of the restriction and the breakfast tray still included milk, juice, and water, with no indication on the meal ticket that the resident was restricted.
A resident with depression, anxiety, and PTSD history repeatedly requested therapist services, but the facility did not document a referral for mental health therapy for an extended period. Records showed worsening mood symptoms, social isolation, poor hygiene, and refusal of care, while care plans lacked individualized PTSD-related interventions and did not reflect the resident’s reported trauma triggers or escalating depression.
Surveyors identified extensive failures in food storage, temperature control, dishwashing, and documentation. In the main kitchen, frozen and dry goods were found open, undated, or past disposal dates, and a walk-in refrigerator and temporary outdoor refrigerator were operating above 41°F with inadequate temperature monitoring. In a resident kitchenette, staff failed to consistently record refrigerator and freezer temperatures and kept undated prepared foods. Dishwashing logs showed identical, twice-daily entries with no lunch readings, and direct observation revealed wash and rinse cycles not consistently meeting manufacturer-required temperatures while staff failed to monitor the machine. Meal service temperature logs were incomplete and often recorded uniform values (e.g., all hot foods at 180°F and all cold items at 33°F) that did not match observed temperatures, and potentially temperature-abused milk and juice from a malfunctioning rental refrigerator were later served before being discarded. These practices conflicted with the facility’s own policies on food receiving, storage, preparation, and equipment sanitization.
Surveyors found that essential kitchen equipment, including a walk-in refrigerator and both ovens, was not maintained in safe operating condition, potentially affecting all 38 residents. The walk-in refrigerator had documented temperatures above safe cold-holding levels over multiple days, with missing temperature entries and no documented food temperature checks or discarding of potentially affected food, despite staff awareness that the unit was in the 50s. The Administrator and Maintenance staff reported delayed notification of the refrigerator problem. Additionally, both kitchen ovens were nonfunctional for an extended period, one having suffered internal fire damage and the other experiencing recurrent failures since purchase, with ongoing electrical and equipment issues despite prior repair attempts.
Dietary staff were not competent with key food service duties. Cooks failed to properly monitor and document dishwasher temperatures, did not accurately record tray line temperatures, and one cook did not know how to reset the dishwasher booster during observed use. Personnel records showed no evidence of on-the-job training for dishwasher operation, booster reset, or meal temperature logging, and a pasta salad containing mayonnaise and eggs was served without a recorded temperature.
The facility failed to maintain an effective QAPI program to address repeated survey concerns and did not hold a QAPI meeting after the bi-annual survey to review whether prior corrective actions were working. Surveyors found the facility lacked a comprehensive RSV infection control and outbreak management process, did not timely identify the outbreak, did not complete contact tracing or a line list, delayed notifying the health department, and allowed communal activities to continue while cases were emerging. The facility also failed to screen an RSV-positive CNA before return to work, and the outbreak was associated with one resident death.
Insufficient nursing staffing led to delayed resident assistance, repeated call light delays, and unmet care needs. Residents reported long waits for help with toileting, transfers, ice water, and Hoyer lift use, with some stating call lights were ignored or answered only after 30 minutes to an hour. Staff also described night-shift shortages, call-offs, and difficulty covering residents who needed two-person assists, while one resident’s spouse reported a fall during a bathroom transfer when only one staff member assisted instead of two.
Binding arbitration agreements were not explained to residents or representatives in a way they could understand, including that they were giving up the right to pursue court litigation and could rescind within 30 days. Several residents or representatives stated they did not remember signing the agreement or being told what it meant, while one family member said she was unaware of the 30-day withdrawal period and would not have signed if she had understood the terms. The AD described the process as focused on bills and insurance, and the Regional President confirmed the agreements should not be a condition of admission and must be clearly explained.
A resident with dementia, dysphagia, weakness, and impaired mobility was observed during lunch being fed by a CNA who stood over the resident’s bedside instead of sitting at the resident’s level. The resident required supervision/verbal cues and assist of one for eating, and the CNA acknowledged that standing while feeding the resident was a dignity issue.
Failure to Report Allegation of Neglect/Mistreatment: A resident with COPD, DM, cirrhosis, Crohn's disease, and vascular dementia required a sit-to-stand lift with 2 staff for transfers, but a CNA completed a one-person toilet transfer instead of following the care plan. The roommate observed the resident make contact with the toilet and surrounding area, and the resident was later found with bruising to multiple areas. The DON and Administrator confirmed the incident and the initial reports of rough care were not reported to the State Survey Agency because the CNA did not intend to hurt the resident.
Inaccurate MDS coding for dental and vision affected two residents. One resident with dementia, mobility issues, and dysphagia had care plans showing prescription glasses and dentures, but MDS assessments coded adequate vision and no dental issues even though she could not read without readers and staff found moldy dentures stored in a drawer. Another resident with bilateral cataracts and a history of poor-fitting dentures was coded as having adequate vision and no loose dentures, despite stating she could not see, could not read with glasses on, and could not wear her loose dentures. RN interviews confirmed the MDS sections were coded incorrectly.
Care plans were not kept current for two residents. One resident with respiratory failure, CHF, obesity, depression, and anxiety had declining activity participation and later received 1:1 visits for increased depression and anxiety, but the activity care plan did not include those visits. Another resident with severe intellectual disability, epilepsy, autism, and mood disorders had discharge planning notes showing work with DDD toward a possible community placement, but the discharge care plan was not updated to reflect that information.
Inadequate denture care for a dependent resident. A resident with dementia, dysphagia, weakness, and impaired mobility was identified as edentulous with upper and lower dentures, but staff did not ensure the dentures were worn or properly cleaned. The resident was not observed wearing the dentures, did not know where they were, and a CNA found them in a bathroom drawer covered with a black substance. The CNA stated staff had not been taught that the resident wore dentures and verified the dentures had not been stored clean.
Resident-Centered Activity Program Not Maintained: A resident with depression, anxiety, insomnia, and social isolation had declining activity participation, repeated refusals, and increasing self-isolation. The activity schedule was largely repetitive, most later-day activities were self-directed, and the resident reported few age-appropriate options such as music, paint-by-number, volleyball, and outside activities. The AD confirmed the resident’s preferences were not updated when the decline was noted.
A resident with dementia, Alzheimer’s disease, bilateral cataracts, dry eye syndrome, and impaired vision did not receive timely ophthalmology follow-through after consults recommended cataract evaluation/surgery. Staff also failed to keep the resident’s prescription glasses available and did not assist with applying them, and the resident was repeatedly observed without glasses and unable to locate them.
Failure to use ordered heel offloading boots occurred when a resident with diabetes, neuropathy, dementia, impaired mobility, and a history of heel pressure ulcers was repeatedly observed without Prevalon boots in bed, in a chair, and in a wheelchair. CNA and LPN staff were unaware of the order, and the LPN could not locate the boots in the room despite the care plan and MD order requiring them for pressure relief.
Unsafe transfer and missing fall prevention intervention: A resident with dementia, weakness, and a care plan requiring a sit-to-stand lift with 2 staff was manually transferred by a CNA who knew the requirement but skipped it because he was rushing at the end of shift; the resident contacted the toilet/surrounding area and later had bruising. Another resident with severe cognitive impairment and a fall history was observed in bed with the call light button hidden under pillows and not within reach, despite that being a documented fall prevention intervention.
Failure to document oxygen administration and maintain humidification per the care plan for two residents. One resident with COPD and chronic respiratory failure had an oxygen order and care plan directing humidification and tubing changes, but the humidification bottle was repeatedly found empty and dated, and oxygen administration was not signed off for the month. Another resident with acute and chronic respiratory failure had a continuous oxygen order, but the MAR/TAR showed no documentation that oxygen was delivered, and a fall note stated the oxygen was off while the resident was untangling tubing.
Dialysis Residents' Fluid Restrictions Were Not Accurately or Timely Implemented Two residents on dialysis had fluid restriction orders that were either inconsistent with dietitian recommendations or not entered in time for staff to follow them. For one resident, the chart contained multiple conflicting 1500 mL fluid restriction instructions, and staff signed off on orders that did not match the dietitian's plan; intake documentation was also incomplete. For the other resident, the dietitian recommended a 1500 mL restriction, but the order was not yet in place when the resident was observed receiving fluids at supper, and CNA staff confirmed the restriction was not in the kiosk.
Failure to provide trauma-informed care for a resident with PTSD history. A resident admitted with anxiety, depression, insomnia, and personal care needs had a hospital discharge summary documenting longstanding PTSD, increased anxiety, and a recommendation for psychiatry follow-up and counseling, but PTSD was not added to the admission dx list and no comprehensive PTSD assessment was found. The resident’s social service assessment noted childhood trauma, a TBS note linked panic when his door was closed to past abuse, and survey observations showed a sign to keep the door open; however, the care plan had no PTSD interventions or trigger management, and the MDS documented mood symptoms without plan-of-care changes.
Failure to Document Monthly Pharmacist Medication Regimen Reviews: The facility did not ensure a licensed pharmacist completed and documented monthly medication regimen reviews for three residents. Medical record review and staff interviews showed no evidence of October medication reviews for a resident with anxiety, insomnia, and depression; a resident with multiple chronic conditions including DM, ESRD on dialysis, AFib, and HTN; and a resident with respiratory failure, COPD, schizophrenia, bipolar disorder, dementia, and HTN. The DON and RDCS confirmed the pharmacy could not provide documentation supporting the reviews, including for residents with no recommendations.
Failure to provide timely dental services affected two residents with significant oral needs. One resident had loose-fitting dentures and impressions were taken for new dentures, but the dentures were not processed after the facility changed dental providers and the resident was not seen again. Another resident had carious, missing, and broken teeth, had not seen a dentist since a prior visit, and there was no evidence of further dental follow-up or consent being obtained despite the resident wanting dental care.
Medical records were not available for inspection for two residents. One resident with lung cancer on hospice had a hospice plan of care at the nursing station, but no hospice visit notes were present for months, and an LPN said the notes had to be obtained from the hospice company. Another resident with anxiety, insomnia, and depression had a psychiatric note recommending follow-up, but no follow-up visit was found in the chart; the DON said the psychiatrist's note was in her email and was never printed into the medical record.
A resident with type I diabetes experienced critically high blood sugar readings and symptoms such as nausea and vomiting, but did not receive scheduled insulin or adequate monitoring. Staff failed to follow physician orders, missed medication administration, and did not respond appropriately to changes in the resident's condition. The resident was later found unresponsive and hospitalized for diabetic ketoacidosis and sepsis, with actual harm resulting from these failures.
A resident with diabetes and cognitive communication deficit was observed eating lunch in his room while three full urinals hung on the footboard of his bed. The resident stated that staff would bring food and medications but did not empty the urinals, which he found undignified during meals. Staff notes indicated the resident had earlier requested privacy, but staff still entered for other tasks without addressing the urinals, resulting in a failure to provide a dignified dining experience.
A resident with multiple chronic conditions was given an incorrect dose of Oxycodone for pain management, and neither the resident nor the primary care physician was notified of the medication error as required by facility policy. The error was discovered during a shift change narcotic count, but there was no documentation of notification to the appropriate parties.
A facility failed to maintain adequate nursing staff levels, resulting in missed blood sugar checks and insulin administration for a resident with type I diabetes. Due to insufficient staffing and communication breakdowns, the resident was not properly monitored, was later found on the floor with severe hyperglycemia and other critical symptoms, and required transfer to the hospital for multiple acute conditions.
Two residents received incorrect medication doses due to failures in following physician orders and medication administration protocols. One resident was repeatedly given a higher dose of Lorazepam than prescribed, while another received an extra dose of Oxycodone without a physician's order. These errors occurred despite facility policies requiring verification of medication orders and proper administration procedures.
A resident with multiple chronic conditions, including DM2, ESRD, and diabetic foot wounds, missed a wound center appointment because the resident was hospitalized. The record showed the last wound visit recommended follow-up within one week, but there was no documentation that the missed appointment was rescheduled or that any follow-up with the wound center occurred. Staff and the wound center confirmed no rescheduled appointment was in place.
The facility did not provide enough nursing staff to meet resident needs, resulting in long call light response times, missed showers, and delays in assistance with activities of daily living. Residents and staff reported that care was compromised, especially on weekends and night shifts, due to inadequate CNA coverage and unfilled call-offs. The issue was ongoing and recognized by both facility staff and the local Ombudsman.
Kitchen Sanitation Deficiencies: Surveyors observed splatters on the backsplash and walls behind the oven and stove area, grime on toaster oven controls, debris on shelves holding hot-well pans, splatters behind the juice machine, and an expired container of sesame seeds. An LTC staff member confirmed the findings, and the facility policy required kitchens, utensils, counters, shelves, and equipment to be kept clean and free of grime.
Infection control deficiencies were identified in the LTC facility. The infection control log was incomplete and inaccurate, with missing infection details and residents added by hand without required information. The legionella water management plan had not been followed, and during wound and incontinence care, an LPN failed to perform hand hygiene between glove changes and before touching a resident’s personal items. The residents involved had significant medical issues including chronic wounds, MRSA, diabetes, ESRD, and an indwelling catheter.
Incomplete Transfer, Bed-Hold, and Discharge Notifications: Multiple residents with significant medical conditions were transferred to the hospital or discharged without complete written notice to the resident or representative regarding transfer details and bed-hold rights, and without required LTC ombudsman notification. One resident also had an incomplete discharge assessment and post-care instruction record, and staff confirmed several notices were missing or incomplete.
Failure to Provide Ordered Nutritional Interventions and Weights: Multiple residents with significant wt loss, dysphagia, malnutrition, and other chronic conditions did not receive ordered nutrition interventions or ordered weights. One resident had no documented weekly wts, another had delayed implementation of an increased Med Pass order after hospital return, a third was not served an ordered frozen nutritional treat because the order was not communicated to dietary, and another was not weighed per MD order. Documentation also lacked amounts consumed for some supplements.
A resident dependent on staff for personal care did not receive scheduled bathing and nail care assistance as required by her care plan. Documentation showed a missed scheduled shower with no record of it being offered or provided, and observations found the resident with dirty fingernails. Staff interviews confirmed the resident's dependency and the lack of documentation for the missed care.
A resident with dysphagia and no teeth was served a hot dog on a bun cut into uneven pieces, which did not meet the prescribed soft, bite-sized texture diet. The LPN was unaware of the resident's dietary requirements until reviewing the tray card, and the dietitian confirmed the meal was inappropriate for the ordered diet. The facility lacked a policy defining soft, bite-sized diets.
Failure to Inform Resident and Obtain Consent for Psychotropic Medication: A resident with type II DM, mild intellectual disabilities, anxiety disorder, and moderately impaired cognition was receiving buspirone and other anti-anxiety medication monitoring, but the record showed no evidence that the resident or representative was informed of the risks vs benefits of psychotropic meds or that consent was obtained. An RN confirmed there was no documentation of education or consent, despite facility policy stating residents and/or representatives have the right to decline psychotropic treatment and review risks and alternatives.
A resident with DM, HF, anxiety disorder, and osteoporosis lived in a bathroom where the toilet was not secured to the floor and the caulking around the base was detached. Surveyors observed the toilet sitting crooked and noted a sewer odor in the bathroom; the Maintenance Director verified the toilet was loose and stated it had been caulked even though it was not secured.
A resident with bipolar disorder, schizophrenia, and depression had no available PASRR Level II determination for review, and the facility did not submit a new Level II screening despite later changes in condition. The resident was receiving routine antipsychotics and an antidepressant, had medication refusals and documented anger/withdrawn-depressed behaviors, and the MDS also showed moderate cognitive impairment, frequent bladder incontinence, and weight loss; however, the assessment inaccurately stated there were no mood indicators or rejection of care.
A resident with multiple diagnoses had no comprehensive care plans for several ordered medications and conditions, including HTN, constipation, hiccups, GERD, insomnia, and BPH. Another resident’s care plan lacked interventions for monitoring side effects of insulin, a diuretic, and an opioid, and a third resident’s active care plans did not address ordered PRN oxygen use; the DON and Regional RN confirmed the missing care plan elements.
Failure to reposition a resident with a Stage III sacral pressure ulcer and to timely treat newly noted peri-wound skin breakdown. The resident had diabetes, weakness, and kidney failure, and was on a care plan with a low air loss mattress, wound care, and turning/repositioning interventions. Despite documentation showing daily turns, staff observations found the resident lying on her back for prolonged periods, including after wound care, with no evidence of repositioning. During wound care, reddened gluteal folds and a small open area were seen without treatment in place, and staff confirmed there was no barrier cream or treatment to the area at that time.
Failure to Ensure Smoking Apron Use During Smoking: A resident with CVA-related deficits, aphasia, hemiplegia, and dexterity impairment was observed smoking in the designated smoking area without the required smoking apron. The resident’s smoking assessment indicated the need for a smoking apron with supervision, and staff confirmed the apron was not being used during smoking time.
Failure to Control RSV Spread and Staff Illness Reporting
Penalty
Summary
The facility failed to develop and implement a comprehensive infection prevention and control program for RSV that included prevention, identification, investigation, and reporting of communicable disease. Survey findings showed that an LPN worked while symptomatic and after testing positive for RSV, and a CNA later also worked after reporting a positive RSV test and ongoing symptoms. The facility did not timely identify an RSV outbreak, did not initiate contact tracing or maintain a line list, and did not timely notify the local health department after multiple cases were present. The infection control log showed RSV-positive staff and residents across two units, including six residents and two staff members. The Infection Preventionist confirmed that the first positive staff member was the LPN, who did not report symptoms or the positive test to management, and that the second positive staff member was the CNA. The DON stated the facility did not have a comprehensive RSV policy to timely identify, monitor, and treat residents, and surveillance had not been implemented for all residents for fever, cough, congestion, or decline in function. Communal dining and group activities continued until after the outbreak was recognized, and the local health department was not notified until later. Resident records showed that Resident #66, who had diabetes mellitus, COPD, chronic respiratory failure with hypoxia, chronic kidney disease, CHF, and anxiety disorder, developed fever, nasal congestion, moist cough, shortness of breath, and crackles, and later tested positive for RSV. Resident #64, who had emphysema, asthma, schizophrenia, and hypertension, developed a non-productive cough and wheezing and later tested positive for RSV; the roommate was not tested until later and was moved to another room. The report also states that Resident #3 expired in the facility with RSV noted as a significant condition on the death certificate, and that six residents in total contracted RSV while residing in the facility.
Unsecured Resident Medical Records Found in Open Rooms
Penalty
Summary
The facility failed to keep residents’ personal and medical records private and confidential when surveyors observed paper medical records stored in unlocked, open resident rooms. On 04/27/26 at 9:44 A.M., room [ROOM NUMBER] contained two hospital beds and a table, and each surface was covered with resident records while the door was open and unlocked. The administrator confirmed this observation during interview. At 10:20 A.M., another room [ROOM NUMBER] was observed with the door wide open, and a box on the floor contained an open binder with medical records, including COVID vaccination information, lying on top of the box; the administrator also confirmed this observation. During interview, an LPN stated the 100 hall had formerly been the memory care unit and that since the unit had been closed, the doors to the unit were never locked. The administrator later confirmed that room [ROOM NUMBER] and room 112 both contained resident medical records and that both rooms had doors that were unlocked and open. The administrator stated the facility had a dedicated medical records room in the 400 hall and that records were managed by the Medical Records Director, but also acknowledged that the facility did not have enough storage space. The Medical Records Director stated paper files were kept in the Medical Records office and that, to his knowledge, there were no other medical records kept elsewhere in the facility.
Failure to Treat a Resident with Dignity and Respect
Penalty
Summary
The facility failed to treat a resident with dignity and respect after a reported incident involving Dietary Aide #207. Resident #2, who had diagnoses including end stage renal disease, cognitive communication deficit, atherosclerotic heart disease, paroxysmal atrial fibrillation, type 2 diabetes with diabetic polyneuropathy, peripheral vascular disease, chronic non-pressure ulcers of both feet, and other encephalopathy, had a care plan focused on cognitive impairment with interventions to anticipate needs and meet them promptly. The resident reported to the Administrator that the dietary aide had thrown a pan at her over the weekend, and the Self-Reported Incident record reflected that the facility investigated the allegation of staff abuse and found it unsubstantiated. Interviews showed the resident felt afraid of the dietary aide and stated the aide was rude to her and threw a pan at her when she went to the kitchen to check the menu. Another dietary employee stated the aide was rude to residents and staff, slammed items down, and yelled at her, causing embarrassment. The Dietary Manager described the resident as non-compliant and vindictive and said the aide "just tells it like it is," while the Administrator stated he had not personally investigated the reported abuse, believed it was more of a Human Resources issue, and allowed the aide to return to work with no interventions, disciplinary action, or further investigation at that time.
Failure to Thoroughly Investigate Allegation of Staff-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of staff-to-resident abuse involving a resident with end stage renal disease, cognitive communication deficit, atherosclerotic heart disease, paroxysmal atrial fibrillation, type 2 diabetes with diabetic polyneuropathy, peripheral vascular disease, chronic non-pressure ulcers of both feet, and other encephalopathy. The resident, who had a care plan addressing cognitive impairment and included interventions to anticipate needs and meet them promptly, reported to the Administrator that a Dietary Aide had thrown a pan at her over the weekend. The self-reported incident was documented as abuse, but the investigation was not completed by the Administrator as required by facility policy. The Administrator stated he did not personally investigate the allegation and instead had the Dietary Manager review the incident and interview staff. He later confirmed that no witness statements or interview documentation were included with the investigation and that he was unable to locate the statements he believed existed. Interviews with staff reflected conflicting accounts of the event, including one staff member stating the aide had thrown a package of rolls and that the resident witnessed it, while another described the aide as rude and intimidating to residents and staff. The resident stated she had not been interviewed by facility staff after reporting the incident and said she felt afraid of the Dietary Aide because of the way she was treated.
Failure to Implement Immediate Fall Intervention After Resident Fall
Penalty
Summary
The facility failed to ensure a fall intervention was implemented immediately after a fall for one resident, who was identified as being at risk for falls. The resident had diagnoses including diabetes mellitus, dementia, morbid obesity, coronary artery heart disease, and chronic obstructive sleep apnea. The care plan directed staff to encourage the resident to ask for assistance with all transfers, wear non-skid footwear, and use a walker for ambulation. The quarterly MDS assessment indicated the resident had intact cognition and required staff assistance with activities of daily living. A nursing progress note documented that the resident was found sitting on the floor in his room by a CNA, after which the nurse assessed him, performed neurological checks, and notified the medical provider. The fall investigation also contained no documentation or evidence of an immediate fall intervention after the fall, and the care plan did not show any new fall interventions following the incident. The IDT later documented that the resident had attempted to stand beside the bed to use a urinal, his foot slipped, and he fell; the DON confirmed that the new intervention was not implemented until the IDT met several days later.
Incomplete and inaccurate resident records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents. One resident had a positive RSV laboratory result on 04/24/26, but the Infection Control Log listed the resident as testing positive on 04/27/26. The Infection Preventionist stated she became aware of the positive result on 04/27/26 after reviewing labs and realized an LPN had misread the RSV result as negative. She confirmed the Infection Control Log was not revised to reflect the correct positive test date, and the DON later confirmed the log was inaccurate. A second resident with diagnoses including chronic respiratory failure, pulmonary embolism, atrial fibrillation, CHF, CKD, diabetes mellitus, cognitive communication disorder, and anxiety disorder had a care plan for altered cardiovascular status and a physician order for daily weights with notification for a gain or loss of 3 lbs in one day or 5 lbs in one week. The resident had a positive RSV laboratory result on 04/22/26, a weight of 112.0 on 04/24/26, no recorded weight on 04/25/26, and a weight of 117.4 on 04/26/26. The record contained no evidence of physician notification after the 5.4 lb weight gain. The resident also refused to be weighed twice on 04/25/26, and the record initially contained no evidence that the physician was notified of either refusal. A late entry nursing progress note was later added by the DON and stated that the MD and resident representative were notified of the refusals, but the DON confirmed she had no evidence that the physician had been notified before charting that information. The Administrator confirmed there was no communication with the on-call physician service related to the refusals, and the facility policy stated that the nurse will notify the attending physician when there has been a significant change in condition or specific instruction to notify the physician.
Survey Results Not Posted in Accessible Location
Penalty
Summary
The facility failed to post the results of the most recent survey, including surveys, certifications, and complaint investigations from the preceding three years, along with any plan of correction in effect, in a place readily accessible to residents, family members, and legal representatives. During an observation of the facility survey book in the main lobby on 04/27/26 at 10:30 A.M., the book did not contain the survey results (2567) from the 03/09/26 survey or the plan of correction for that survey. At 10:34 A.M., the Administrator confirmed that the 2567 survey results and/or plan of correction had not been placed into the survey book from the most recent survey dated 03/09/26. This deficiency affected all residents of the facility, with a census of 37, and was cited under Complaint Number 2968896.
EBP Not Followed and Water Management Checks Incomplete
Penalty
Summary
The facility failed to ensure enhanced barrier precautions (EBP) were implemented as ordered for three residents. Resident #11 had diagnoses including end stage renal disease, paraplegia, colon neoplasm, need for assistance with personal care, and neuromuscular dysfunction of the bladder, with orders for catheter care every shift, monthly and as-needed Foley changes, monitoring of two lumen catheters in the left chest, and EBP due to an indwelling medical device. During observation, the resident had an EBP sign on the door frame, but there was no PPE cart outside the room or in the room. A CNA was observed leaving the room after catheter care and confirmed she had only worn gloves, although she should have also worn a gown because the resident was on EBP. Resident #38 had diagnoses including neuromuscular dysfunction of the bladder, need for assistance with personal care, urinary device, prior MRSA infection, and urine retention, with orders for indwelling urinary catheter care every shift, catheter changes per facility policy, EBP, and treatment of open areas on the left buttocks and right medial thigh. During the initial tour, the resident had an EBP sign outside the room, but no PPE cart was observed outside or inside the room. A CNA entered the room and provided direct care without applying PPE, and the LPN confirmed the CNA should have worn PPE because the resident had a urinary catheter and open wounds. The CNA stated she had not seen the sign indicating EBP. Resident #22 also had an EBP sign outside the room, but no PPE cart was observed outside or inside the room. The LPN who was also the Infection Preventionist reported the resident was on EBP for wounds. In addition, the facility’s water management program was not implemented per protocol. The plan identified less frequently used areas such as soiled utility rooms, medication rooms, shower rooms, and empty resident rooms, and required weekly running of hot and cold water for three minutes in those areas. However, weekly check sheets from 02/04/26 through 02/25/26 listed only resident room numbers with check marks and did not identify what was being checked or include the other less frequently used areas. Another form for hot and cold water temperatures in shower rooms, the bio room, soiled linen area, and empty rooms also contained only check marks with no temperatures documented. The Maintenance Director confirmed the forms did not specify what was being checked, did not include all identified areas, and that he needed further education about the water management plan.
Failure to assess weight gain and communicate fluid restriction
Penalty
Summary
The facility failed to complete a comprehensive assessment for a resident with an identified weight gain and CHF and failed to notify staff of a physician-ordered fluid restriction. Resident #31 was admitted with diagnoses including atrial fibrillation, dementia, COPD, chronic respiratory failure, persistent mood disorder, hypertension, and cardiomegaly. The care plan identified the resident as at risk for decreased cardiac output and abnormal lab values related to atrial fibrillation, hyperlipidemia, hypertension, anticoagulant use, cardiomegaly, and CHF, with interventions including weighing per physician order. The resident’s physician ordered daily weights for CHF and notification of the MD for a 3-pound weight gain or loss in 24 hours. The record showed weights of 216.8 pounds, 214 pounds, and then 220.2 pounds over three days, and an RN documented notifying the on-call provider of a 6.2-pound gain with no new orders. There was no documentation of the resident’s condition or a nursing assessment at the time of the weight gain report. The DON stated she would expect the nurse to reweigh the resident, notify the provider, and complete a respiratory assessment and edema assessment when the weight gain exceeded the ordered parameters. The resident was later seen by the physician for weight gain and increased edema, and new orders were entered for a 2,000 mL fluid restriction, knee-high TED hose, leg elevation, weekly weights, and Lasix. However, a subsequent breakfast tray contained milk, juice, and water, and the meal ticket did not indicate a fluid restriction. The CNA stated she was not aware the resident was on a fluid restriction, and the facility policy stated the resident’s water pitcher and/or water cup should be removed from the room and the fluid restriction instructions followed.
Failure to Provide Mental Health Services for Resident with Depression and PTSD History
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with depression, anxiety, PTSD history, and psychosocial adjustment difficulty. Resident #22 had diagnoses including anxiety, insomnia, and depression, and the hospital discharge summary documented a longstanding history of recurrent depression, increased anxiety, and PTSD that had never been formally treated or addressed. The discharge summary strongly recommended outpatient psychiatry follow-up and outpatient counseling, and noted the resident would benefit from case management to confirm mental health follow-up services. Record review showed the resident repeatedly reported worsening depression and requested to speak with a therapist, but there was no documented evidence that the facility referred him for therapist services for an extended period. The resident’s psychosocial assessments documented childhood trauma, prior psychiatric intervention, depression, social withdrawal, and refusal of care. His care plans addressed depression, anxiety, insomnia, and resistance to care, but the record did not show individualized interventions tied to his behavioral health needs or to the coping skills discussed during behavioral health visits. The record also showed no care plan for PTSD or identified PTSD triggers, despite the resident’s trauma history and later report that a closed door triggered memories of childhood abuse. Survey findings showed the resident’s mental health declined over time. He reported little interest in activities, feeling down, hopelessness, fatigue, poor concentration, and thoughts that he would be better off dead or hurt himself on MDS assessments. He became increasingly self-isolated, stopped attending activities, had poor hygiene, and went more than a month without showering. Behavioral health notes documented that he was unkempt, malodorous, and self-isolating, and that he repeatedly stated he needed a therapist. During interviews, the resident said he had told the Administrator several times that he needed therapy, but nothing was done, and he had withdrawn from family and remained in his room as his depression worsened.
Widespread Failures in Food Storage, Temperature Control, and Dishwashing Practices
Penalty
Summary
The deficiency involves multiple failures in food storage, temperature control, dishwashing, and documentation in the dietary department and a resident kitchenette. Surveyors observed in the main kitchen that several frozen items, including rib-shaped pork patties, breakfast omelets, and precooked hamburger patties, were left open in the walk-in freezer, exposing them to freezer air. In dry storage, several opened pasta products were either past their disposal date, undated, unsealed, or both, including pasta opened in December without a discard date. The walk-in refrigerator had been above 41°F since early in the month and was taken out of use, and a temporary outdoor portable refrigerator showed a temperature of 42°F with a damaged mercury thermometer. In the kitchenette area, staff were not recording refrigerator temperatures consistently, were not recording freezer temperatures at all, and surveyors found undated food items such as a turkey and cheese sandwich and a piece of coconut cream pie. Dishwashing practices and documentation were also deficient. Review of the dishwasher temperature log showed that staff only recorded temperatures twice daily, not for each meal, and that the same wash and rinse temperatures (160°F wash, 190°F rinse) were recorded for every entry without variation, with no lunch temperatures documented. During direct observation of the dishwashing process, the wash cycle initially registered 145°F, below the manufacturer’s minimum effective wash temperature of 150°F, and the staff member operating the dishwasher did not appear to monitor the temperature readings or notice when the machine failed to advance to the rinse cycle until the surveyor intervened. Subsequent cycles showed fluctuating wash and rinse temperatures, with several readings below the manufacturer’s recommended levels before finally reaching 150°F wash and 180°F rinse. The dietary manager confirmed the presence of open and undated food items, the inaccurate and incomplete dishwasher logs, and that the dishwasher temperatures were not reaching sanitary levels during observation. Food service temperature monitoring and documentation for meals were inconsistent and inaccurate. During observation of a lunch tray line, the listed meal included store-bought pasta salad containing mayonnaise and eggs, turkey and cheese croissants, vegetables, cake, and milk. The dietary manager obtained very high temperatures for the hot vegetables (near or above 200°F), but there was no observation of staff taking or logging temperatures for the milk or pasta salad. When the surveyor reviewed the temperature log for that meal, the recorded temperatures for the vegetables and milk (180°F for hot foods and 33°F for milk) did not match the observed readings, and food temperatures were not being recorded consistently across days. Review of the February food temperature logs showed numerous days with missing entries for entire meals, and on several days all hot foods were uniformly recorded as 180°F and all cold items (milk, juice, dessert) as 33°F, suggesting inaccurate or non-specific documentation rather than actual measured temperatures. Refrigeration failures and the handling of potentially temperature-abused milk and juice further contributed to the deficiency. The walk-in refrigerator had been above safe temperatures and taken out of service, leading the facility to use a rented portable refrigerator placed outside. Temperature logs for the portable unit showed it at 50°F on one evening, and interviews revealed conflicting accounts about how long it had been warm and whether food was removed promptly. Staff reported that when the rental refrigerator was found to be “ridiculously warm,” measurements of items inside showed milk and juice at approximately 50°F and potato salad at 42°F. A technician later confirmed the unit was at 50.4°F when he arrived and that milk and juice crates remained in the unit while he repaired it. Despite this, there was no documented testing of milk temperatures after repair, and interviews indicated that milk stored in the rental refrigerator was later served for breakfast and lunch before being discarded the following day, with no additional milk or juice deliveries made specifically to replace discarded product. The administrator and various staff interviews confirmed that the warm milk and juice remained in use through multiple meals before being thrown away, and that documentation on logs (such as the notation that the unit was warm for less than two hours) was based on verbal reports rather than recorded evidence. Facility policies on Food Receiving and Storage and Food Preparation and Service required that refrigerated and frozen foods be covered, labeled, and dated with use-by dates; that dry goods be stored to maintain package integrity; that foods on nursing units be labeled with resident name and use-by date; and that foods requiring refrigeration be kept at or below 41°F. Policies also required use of clean, sanitized, and calibrated thermometers, adherence to manufacturer recommendations for sanitizing equipment, maintenance of proper hot and cold holding temperatures during service, discarding foods held in the temperature danger zone after four hours, and monitoring steam table temperatures throughout meal service. The observed practices in the kitchen, kitchenette, dishwashing area, and with the rental refrigerator did not align with these written policies, leading to the cited deficiency for failure to store and serve food under sanitary conditions.
Failure to Maintain Safe, Functional Kitchen Refrigeration and Ovens
Penalty
Summary
The facility failed to maintain essential kitchen electrical equipment, including a walk-in refrigerator and ovens, in safe operating condition. Surveyors observed that the walk-in refrigerator temperature log showed readings above 41°F beginning on 02/04/26, with temperatures documented at 50°F, 56°F, 54°F, and 58°F on various dates, and missing entries on some days. Staff interviews revealed that when a staff member noticed the walk-in felt warmer than the kitchen and reported temperatures in the 50s, the Dietary Manager instructed staff via text to move perishable items to a reach-in refrigerator but did not direct staff to take food temperatures or discard any items. The Dietary Manager stated she deleted the text messages and could not recall who notified her, and she had no paperwork or identification for any service person who allegedly came to check the unit. The Administrator and Maintenance staff both reported that they were not informed of the refrigerator problem until several days after the first elevated temperature was recorded, and they confirmed there was a multi-day delay between the initial temperature issue and their awareness and response. The facility also lacked a functioning kitchen oven system for an extended period. During observation, neither of the two ovens was operational, and it was reported that both became nonfunctioning between 01/30/26 and 02/05/26. One oven, purchased in June 2025, had experienced an internal fire that welded the heating element to the bottom panel, and the other oven, purchased in March 2025, had ongoing operational problems since October 2025, working only intermittently. Maintenance staff described the second oven as a “lemon” and reported that the manufacturer attributed the failures to incorrect electrical wattage supplied by the facility. An invoice showed both ovens were down and had been repaired on 01/30/26, with additional electrical panel troubleshooting on 02/02/26, but by the time of the survey the kitchen still did not have a working oven. These conditions demonstrated that essential electrical kitchen equipment was not maintained in safe and reliable operating condition, with the potential to affect all 38 residents in the facility.
Dietary Staff Lacked Competency in Dishwasher Operation and Meal Temperature Monitoring
Penalty
Summary
The facility failed to ensure kitchen staff were competent with food and nutrition service job responsibilities. During observation of the kitchen, Cooks #531 and #541 reported they only recorded dishwasher temperatures twice a day on a PPM sanitation log rather than on a dishwasher log, and there were no temperatures recorded for lunch dishes. The dishwasher temperatures were documented for the month as 160 degrees F for the wash cycle and 190 degrees F for the rinse cycle without variation, even though the observed wash and rinse temperatures differed from those entries. When the dishwasher was observed in use, Cook #531 did not know how to reset the booster and needed direction from Cook #541, and he was not paying attention to the temperature readings while dishes were being run through the machine. During lunch meal service, Cook #541 obtained temperatures for the vegetables, but there were no observations of temperatures being taken for the milk, pasta salad, or logging of the temperatures. The Italian pasta salad served to residents contained mayonnaise and eggs, yet there was no temperature recorded for it before service. Review of personnel records showed no evidence of on-the-job training for Cooks #531 and #541, and Human Resource #554 verified there was no documentation that dietary staff had been trained to run the dishwasher, reset the booster, log accurate tray line temperatures, or perform dishwashing tasks. The facility policy required proper temperature monitoring during food service, and the dishwasher manual listed minimum effective temperatures of 150 degrees F for wash and 180 degrees F for rinse.
QAPI Program Failed to Address Ongoing Survey Deficiencies and RSV Outbreak Management
Penalty
Summary
The facility failed to maintain an ongoing, comprehensive, and effective QAPI program to address facility practices and operations, including concerns identified in prior survey activity. Review of QAPI meeting records showed a meeting in February 2026 that focused on internal mock survey findings and readiness for the upcoming state survey, but there was no evidence that the facility held a QAPI meeting after the bi-annual survey and before the alleged compliance date to review whether corrective actions for the cited deficiencies were effective. The facility’s QAPI policy was requested during the survey but was not provided. The bi-annual survey cited the facility for infection control concerns at F880. The facility’s plan of correction stated that the Infection Control Nurse/designee would begin weekly enhanced barrier precaution audits on residents with EBP or isolation orders and forward issues to the QA committee, but during the post-survey revisit the facility was cited again at F880 at Severity Level 4, Immediate Jeopardy, scope and severity L. Survey findings showed the facility lacked a comprehensive infection control program to prevent the spread of RSV, and an outbreak occurred with an infection rate of 16.2% and the death of one resident. Prior to the survey, the facility failed to implement comprehensive and sustainable interventions and failed to ensure staff were educated regarding the communicable disease. Interview and record review showed the outbreak was not timely identified. The Infection Preventionist had not initiated contact tracing, did not have a line list, and did not identify the RSV outbreak until multiple additional residents tested positive, even though two staff members and one resident were already positive. Communal dining and group activities did not stop until that time, and the local health department was not notified until then. The DON and Administrator confirmed the outbreak was not timely identified and that the facility did not have an effective RSV outbreak management plan. The facility also failed to screen a CNA after her positive RSV test and ongoing symptoms before allowing her to return to work. The Medical Director and NP stated they were not directly involved in RSV policy development and were not fully aware of the outbreak details when it began.
Insufficient Nursing Staffing and Delayed Resident Assistance
Penalty
Summary
The facility failed to provide sufficient nursing staff each day to meet residents’ needs and to ensure a licensed nurse was in charge on each shift. Review of resident council minutes, concern forms, interviews, and the facility assessment showed repeated complaints about delayed call light response, staff call-offs, and not enough staff available to assist residents with transfers, toileting, meals, and other care needs. The deficiency affected ten residents in the facility. Resident council minutes documented ongoing concerns that aides took too long to find help for residents using a Hoyer lift and that staff call-offs and staffing shortages were affecting care. Residents also reported meals being served late. Concern forms and interviews reflected repeated complaints that call lights were not answered timely, including reports that staff would acknowledge a call light and not return promptly. One resident reported difficulty locating a night-shift aide for about three hours, and the facility did not document whether that resident’s care needs were met during that time. Interviews with residents and staff described night-shift staffing concerns, including reports of only one CNA for 19 residents, call lights taking up to an hour to be answered, and residents waiting 30 minutes or longer for assistance. One resident’s husband reported that his wife was assisted to the bathroom by one staff member when two were needed for a lift transfer and that she fell and bruised her waist area. Another resident reported waiting over 30 minutes in the bathroom until his legs became numb, and a CNA confirmed the resident had waited at least 20 minutes because she was assisting another resident and the other CNA was on break. The facility assessment stated that 15 to 20 residents required one to two staff assists and 15 to 20 residents were dependent on staff, while the staffing schedule listed two licensed nurses on day and night shift, four CNAs on days, and three CNAs on nights.
Binding arbitration agreements not properly explained
Penalty
Summary
The facility failed to ensure binding arbitration agreements were explained to residents or their representatives in a way they could understand, including that they were giving up the right to litigate in court and could withdraw or terminate the agreement within 30 days of signing. The deficiency affected five of six residents reviewed for arbitration agreements in a facility with a census of 38. The facility Administrator stated that all 38 residents had signed a binding arbitration agreement. Resident #7 had intact cognition with a BIMS score of 15, yet the resident stated he did not remember signing an arbitration agreement electronically and did not remember anything being explained to him about limiting his right to litigation in court. Resident #2 also had intact cognition with a BIMS score of 13 and stated she did not remember signing the agreement or being told it limited her right to court litigation. Resident #19 had moderately impaired cognition with a BIMS score of 12 and stated he did not remember signing the agreement or being told it limited his right to litigation in court; he also stated the papers would take "two lawyers and a little kid" to understand. Resident #17's sister was listed as the signer of the arbitration agreement, but she stated she had not been to the facility to sign any papers and did not remember the agreement being discussed. She said she was overwhelmed during the admission process, would not have signed it if she had understood it limited the right to litigation in court, and was not aware of the 30-day withdrawal or termination period. Resident #10's daughter was listed as the signer, but she stated she lived out of state, had not been to the facility to sign papers, and had not had conversations about the admission paperwork. She said she was told the papers were required and would not have signed the agreement if it had been explained that it limited the right to litigation in court. The Admissions Director stated the arbitration agreement was part of the admission packet and that residents with BIMS scores above 12 could sign, otherwise the family or representative was contacted. She described the explanation as being about insurance, bills, and keeping disputes out of court if payment was not covered, and stated she did not know whether residents or representatives could withdraw or terminate the agreement within a certain time frame. The Regional President confirmed arbitration agreements were not to be a condition of admission, that residents or representatives should be able to withdraw or terminate within 30 days, and that the agreement should be explained well enough for them to understand they could not pursue court litigation for the listed issues. The facility policy stated the agreements were voluntary, must be explained in a way that ensures understanding, and residents are provided 30 days after signing to rescind any agreement not understood at admission.
Dignified Dining Experience Not Provided
Penalty
Summary
The facility failed to ensure a resident was provided a dignified dining experience. Resident #6 was admitted with diagnoses including atrial fibrillation, hypertension, vascular dementia with behavioral disturbance, hypothyroidism, anemia, Vitamin D deficiency, depression, history of falling, insomnia, dysphagia, abnormalities of gait and mobility, long term use of anticoagulants, hypokalemia, muscle weakness, and cognitive communication deficit. The resident’s care plan indicated the resident required assistance related to weakness and impaired mobility, with needs anticipated and met by staff, and that eating required up to supervision/verbal cues with assist of one for task initiation and follow through. The MDS showed the resident was severely impaired for daily decision making and needed supervision or touching assistance for eating. During lunch observation, CNA #551 stood over the resident’s bedside and fed the resident while standing instead of sitting at the resident’s level. The resident was fed pureed fruit cocktail, chicken tortilla soup, broccoli, and a ham sandwich, and was independently drinking coffee from a cup. When interviewed, CNA #551 acknowledged the resident had been needing more help and verified that standing while feeding the resident instead of sitting next to the resident was a dignity issue. The facility policy on assisting the impaired resident with in-room meals stated that if seated during feeding, a chair should be positioned where it is convenient for both the staff member and the resident, but the policy did not address standing while feeding a resident.
Failure to Report Allegation of Neglect/Mistreatment
Penalty
Summary
The facility failed to ensure an allegation of neglect/mistreatment involving a resident was reported to the State Survey Agency as required. Resident #15 had diagnoses including COPD, diabetes, cirrhosis of the liver, Crohn's disease, and vascular dementia, and had a physician order requiring a sit-to-stand lift with a yellow sling and two staff assistance for transfers. The resident's care plan also identified her as at risk for falls and specified use of the lift with two staff for all transfers. On 12/19/25, CNA #553 assisted the resident to the toilet near the end of the night shift. He acknowledged that he performed a one-person manual transfer instead of using the required sit-to-stand mechanical lift and two-person assist, despite knowing the care plan requirements. He stated he was focused on finishing his work before shift change and did not ask for help. The resident's roommate observed the transfer and later reported that the staff member appeared rushed, the bathroom door remained open, and the resident made contact with the toilet and surrounding area during the transfer. The roommate also reported that the resident fell hard onto the toilet and had bruising afterward. After the incident was brought to the facility's attention, the DON initiated an assessment and investigation. The resident was found to have bruising to the right hip, left hand, left wrist, and right lower back, and the provider ordered monitoring, x-ray, and laboratory studies. CNA #553 stated he did not report or document the incident because he did not think the contact was significant and because the resident did not complain of pain right away. The facility's investigation concluded that the staff member knowingly did not follow the resident's established transfer requirements, and the Administrator confirmed that the incident involving the resident and the initial reports that staff had been rough during care were not reported to the State Survey Agency because the staff person did not intend to hurt the resident.
Inaccurate MDS Coding for Dental and Vision
Penalty
Summary
The facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded for dental and vision for two residents. One resident had diagnoses including vascular dementia, gait and mobility impairment, dysphagia, and cognitive communication deficit. Her care plans documented that she wore prescription glasses and had oral/dental health problems with upper and lower dentures, but the 12/31/25 and 02/18/26 quarterly MDS assessments coded her as having adequate vision with no corrective lenses and no dental issues. During interview and observation, the resident was unable to read the daily chronicle without readers, said she did not know where her glasses were, and her son reported she wore reading glasses. Staff also found her dentures in a bathroom drawer covered with mold, and a CNA stated she had never been taught that the resident wore dentures. For the second resident, the medical record included bilateral cataracts, dry eye syndrome, dementia, and a history of poor fitting dentures. Her care plan documented impaired visual function, wears glasses, and oral/dental problems with upper and lower dentures. However, the 02/10/26 quarterly MDS coded her vision as adequate with glasses and stated she had no loose or ill-fitting dentures. During interview and observation, the resident stated she could not see, could not read songbook words even with glasses on, and said her glasses were loose. She also stated her bottom dentures were loose and she could not wear them. A CNA confirmed the resident did not want to wear her dentures because they did not fit right. Interviews with the RN and other staff showed the MDS coding was not based on the resident’s actual condition. For the first resident, the RN stated she changed the dental coding because the resident was not wearing her dentures and did not update the care plan for loose dentures or not wearing them; she also did not know the resident wore glasses and did not have the resident read as directed by the MDS manual. For the second resident, the RN stated she did not know the resident had dentures despite the care plan noting loose fitting dentures, and she verified the MDS dental section was coded incorrectly for loose dentures and vision.
Care plans not updated for activity changes and discharge planning
Penalty
Summary
The facility failed to ensure care plans were revised to reflect current activities and discharge planning for two residents. The report states that the comprehensive care plan was not kept current as resident information and conditions changed, and that the care plans were not updated to match documented activity participation changes or discharge planning events. For Resident #22, the record showed multiple diagnoses including acute and chronic respiratory failure with hypercapnia, obstructive sleep apnea, oxygen dependence, congestive heart failure, morbid obesity, hypertension, anemia, anxiety, depression, unsteadiness, muscle weakness, and need for assistance with personal care. Activity records showed a pattern of declining group participation from September 2025 through February 2026, with increasing refusals and the addition of one-on-one visits in January 2026. The activity care plan dated 03/21/25 identified the resident as at risk for social isolation due to depression, preference to stay in room, and social withdrawal, but it did not include the one-on-one visits. The Activity Director confirmed the one-on-one visits were added recently because the resident voiced increased depression and anxiety and needed someone to talk to, and that these visits were not added to the care plan. For Resident #18, the record showed diagnoses including developmental and epileptic encephalopathy, Lennox-Gastaut syndrome, severe intellectual disabilities, autistic disorder, seizures, malnutrition, hyperlipidemia, major depressive disorder, bipolar disorder, and generalized anxiety disorder. The discharge/transfer planning care plan indicated a preference for long-term care in the current facility and included general discharge planning interventions, but it did not reflect information about the facility working with the Department of Developmental Disabilities to move the resident back to the community. Progress notes documented a discharge meeting and a later visit to a possible discharge location with the resident, POA, and a Department of Developmental Disabilities representative. The Social Worker confirmed the discharge care plan had not been updated to reflect this information.
Inadequate Denture Care for a Dependent Resident
Penalty
Summary
The facility failed to ensure a dependent resident was provided adequate and appropriate denture care. Resident #6 was admitted with diagnoses including atrial fibrillation, vascular dementia with behavioral disturbance, mood disturbance, depression, history of falling, insomnia, dysphagia, abnormalities of gait and mobility, muscle weakness, and cognitive communication deficit. The resident’s care plan identified oral/dental health problems and noted that she was edentulous with upper and lower dentures, with instructions to monitor, document, and report oral/dental problems needing attention as needed. Record review, observation, and interview showed the resident was not wearing her dentures and did not know where they were. The resident’s son stated she had worn dentures when she arrived at the facility but had not been wearing them and complained they did not fit. The resident was not observed wearing dentures on multiple dates. A CNA stated staff had never tried the dentures on the resident because she had not been taught that the resident wore dentures, and the dentures were found in a bathroom drawer covered with a black substance that could not be removed during cleaning. The CNA verified staff were responsible for cleaning the dentures and had not stored them clean.
Resident-Centered Activity Program Not Maintained
Penalty
Summary
The facility failed to provide a comprehensive, resident-centered activity program to meet the needs of one resident who had diagnoses including obstructive sleep apnea, supplemental oxygen dependence, CHF, morbid obesity, anxiety, unsteadiness, muscle weakness, pain, insomnia, osteoarthrosis, and depression. The resident’s behavioral health notes described fluctuating mood, depression, anxiety, low motivation, and increasing self-isolation, with the resident reporting that he was trying to leave his room only briefly each day and later stating he had not been to activities in a while because nothing seemed worth the effort. The resident’s MDS documented intact cognition, frequent symptoms of depression, social isolation, and activity preferences that included music, fresh air, favorite activities, and doing things with groups of people. The resident’s care plans identified risk for social isolation due to depression and included interventions to assess diversional activities, encourage engagement, and maintain a daily activity routine. Activity participation records showed a decline over time, with frequent refusals and very limited attendance in later months. One-on-one visits were added late in the record, but the activity director confirmed these visits were not added to the resident’s plan of care. The activity director also confirmed the resident’s participation had declined, that his anxiety and depression had increased, and that there were no activities specific to his preferences or updates to determine his preferences when the decline was noted. The activity calendar remained largely repetitive from month to month, with most scheduled activities occurring before mid-afternoon and later activities being self-directed. The resident stated there were not many activities appropriate for his age, that he wanted options such as paint-by-number activities, more music suited to him, volleyball, and more outside activities, but these were not offered. The resident also reported that evening activities were mostly self-directed and that the activity director was not present all day. The activity director acknowledged that most residents did not like group activities after 1:30 P.M. and that the resident’s interest had decreased after moving halls, but no resident-specific activity updates were identified when the decline occurred.
Failure to Arrange Ophthalmology Services and Assist With Glasses
Penalty
Summary
The facility failed to provide ophthalmology services as ordered and failed to assist a resident with the application of glasses. Resident #38 was admitted with diagnoses including bilateral sensorineural hearing loss, bilateral age-related nuclear cataracts, dry eye syndrome, dementia, Alzheimer’s disease, visual hallucinations, and other chronic conditions. The resident’s care plan identified impaired visual function, bilateral cataracts, dry eyes, and that the resident wore prescription glasses, with interventions to keep the glasses within reach. A vision consult noted the resident wanted cataract surgery, had mature cataracts in both eyes, and required the facility to schedule the ophthalmology appointment and fax the completed chart to the appropriate office. The record showed that an ophthalmology consult was ordered after a later vision exam, but no ophthalmology appointment had been scheduled by the time of the survey review. The medical record later showed an appointment was scheduled for a future date, but staff interviews confirmed the referral had not been followed through as previously recommended. During observations, the resident was repeatedly seen without glasses and stated she did not know where they were. The CNA stated the resident was not able to read, had not been known to wear glasses, could not find them in the room, and the CNA was not applying the glasses as directed in the care plan.
Failure to Use Ordered Heel Offloading Boots
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met when Resident #38 did not have Prevalon boots in place as ordered. The resident was admitted with multiple diagnoses including diabetes mellitus, neuropathy, dementia, Alzheimer's disease, muscle weakness, and impaired mobility. The care plan identified a risk for altered skin integrity and pressure ulcers related to immobility, incontinence, prior skin breakdown, and other conditions, and included Prevalon boots to keep the heels elevated off the bed with removal every shift for skin checks and hygiene. The resident had a history of pressure ulcers to both heels, including a stage 3 ulcer to the right heel and a stage 4 ulcer to the left heel, which were healed at the time of survey. During observations, the resident was seen in bed and in a chair without the ordered pressure relieving boots in place. She was observed on the pressure relieving mattress in bed without the boots, later up in a chair for lunch without them, later in bingo in her wheelchair without them, and again in bed without them. CNA #568 stated she did not know anything about the resident wearing Prevalon boots and had never put them on her. LPN #532 stated she did not know the resident was supposed to have Prevalon boots on, could not find any in the room, and verified the care plan and physician orders included their use for pressure relief.
Unsafe Transfer and Missing Fall Prevention Intervention
Penalty
Summary
The facility failed to provide adequate assistance and interventions during a transfer for a resident who had multiple documented fall risks and required a sit-to-stand lift with two staff assistance for all transfers. The resident had diagnoses including COPD, diabetes, cirrhosis of the liver, Crohn's disease, vascular dementia, and atrial fibrillation, and her care plan and physician order required use of a yellow sling with a sit-to-stand lift and two-person assist. She was also on Plavix and had care plan interventions related to bruising and gentle handling during activities of daily living. During toileting assistance, a CNA performed a one-person manual transfer instead of using the required mechanical lift and second staff member. The CNA stated he knew the resident's care plan required the lift and two-person assist, but he chose to do the transfer alone because he was near the end of his shift and did not want to ask other staff for help. The resident's roommate observed the transfer and reported that the staff member appeared rushed, the bathroom door remained open, and the resident made contact with the toilet and surrounding area during the transfer. The resident later reported that she bumped her knees and head, and the facility assessment identified bruising to the right hip, left hand, left wrist, and right lower back. The facility investigation documented that the transfer did not follow the resident's established plan of care and that the CNA acknowledged skipping the mechanical lift. The resident's husband later reported that one staff person assisted her to the bathroom when two staff should have been assisting with a lift, and that she fell in the bathroom with bruising to her waist area. The facility also found that staff education records for the mechanical lift incident were incomplete, with only some nursing assistants, LPNs, and RNs documented as having signed the attendance record. The facility also failed to ensure fall prevention interventions were in place for another resident at risk for falls. That resident had diagnoses including atrial fibrillation, dementia, COPD, chronic respiratory failure, persistent mood disorder, hypertension, and cardiomegaly, and was described as very impulsive with severe cognitive impairment. His care plan included keeping the call light accessible, anti-roll backs to the wheelchair, and encouraging hipsters. During an observation, the resident was in bed and the call light button was not visible or within reach. A CNA verified that the call light button was located under pillows at the foot of the bed and was not accessible to the resident, despite being a documented fall prevention intervention.
Failure to Document Oxygen Administration and Maintain Humidification
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care by not documenting oxygen administration and not maintaining humidification per the residents’ plans of care. For Resident #37, who was admitted with diagnoses including COPD, chronic respiratory failure, nicotine dependence, edema, anxiety, and palliative care, the plan of care directed staff to administer oxygen per order and change humidification and tubing as indicated. Although the resident had an order for oxygen 4 liters via nasal cannula every 4 hours as needed for shortness of breath and the MDS reflected oxygen use, there was no documented evidence that oxygen was signed off as administered for the entire month of February 2026. During observations on 02/23/26, 02/24/26, and 02/25/26, the humidification bottle was empty and dated 02/06/26 while the resident was observed on oxygen at 3.5 to 4 liters. An LPN confirmed the empty humidification bottle and confirmed the oxygen had not been signed off on the administration record. For Resident #3, who had diagnoses including acute and chronic respiratory failure with hypoxia and hypercapnia, COPD with acute exacerbation, asthma, dementia, and other chronic conditions, the physician ordered continuous oxygen at 2 liters per minute via nasal cannula after the resident returned from the hospital. The MDS indicated the resident was receiving oxygen therapy, and a progress note documented the resident returned from the hospital on 2 liters of oxygen. However, after a fall on 02/22/26, nursing documentation noted the resident’s oxygen was not on at the time because the resident was trying to untangle the tubing from the wheelchair, and there was no further documentation by licensed nursing staff of oxygen use. Review of the February 2026 medication and treatment administration records showed no documentation that the continuous oxygen order was being delivered, and the RDCS confirmed there was no documentation on the MAR/TAR that the oxygen was administered.
Dialysis Residents' Fluid Restrictions Were Not Accurately or Timely Implemented
Penalty
Summary
The facility failed to ensure dialysis residents had accurate and timely implementation of fluid restrictions for two residents. Resident #2 was admitted with diagnoses including dependence on renal dialysis, ESRD, and heart disease. The record showed multiple fluid restriction instructions that did not match each other: a nutritional recommendation called for a 1500 mL restriction split between nursing and dietary, while the nutritional and dehydration care plans and later physician orders reflected different amounts and different distributions across meals and shifts. The dialysis care plan also directed monitoring intake and output. For Resident #2, the March 2026 MAR showed dietary and nursing were following one set of fluid restriction amounts, but the record also showed the resident received 1520 mL on one day and 460 mL plus an unrecorded amount on another day. Staff signed off on the fluid restriction without documenting the intake amount. During interview, the DON confirmed there were two active fluid restriction orders entered and that staff were signing off on both orders even though they were not consistent with the dietician order. The DON stated she entered the second order on 03/02/26, but it did not match the dietician's recommendation. Resident #11 had diagnoses including dependence on renal dialysis, ESRD, chronic respiratory failure, cardiovascular accident, neurogenic urinary bladder, and other chronic conditions. The care plan identified risk for fluid imbalance related to ESRD and dialysis, and the dietitian documented a recommendation for a 1500 mL fluid restriction after reporting high interdialytic weight gains and a changed target weight. However, physician orders on 03/02/26 did not yet include the fluid restriction, and observation showed the resident received 8 ounces of lemonade and 8 ounces of hot tea at supper with no knowledge of a fluid restriction. A CNA confirmed the restriction was not in the kiosk information. The DON later stated the dietitian recommendations had been emailed after hours and were missed, and the fluid restriction order was entered later.
Failure to Provide Trauma-Informed Care for Resident with PTSD History
Penalty
Summary
The facility failed to ensure a comprehensive, trauma-informed approach to care was implemented for one resident with PTSD-related history and symptoms. The resident was admitted with diagnoses including anxiety, insomnia, depression, and need for assistance with personal care, and the hospital discharge summary documented a longstanding history of PTSD that had never been formally treated or addressed. The discharge summary also noted increased anxiety, recommended outpatient psychiatry follow-up and counseling, and stated case management should confirm mental health follow-up. However, PTSD was not included on the resident’s admission diagnosis list, and no comprehensive assessment for PTSD was found in the medical record. The resident’s admission social service assessment documented drug history, prior psychiatric intervention, and that he had experienced childhood trauma, but the assessment indicated the care plan did not reflect the resident’s trauma-related needs and wishes. A later TBS note recorded that the resident became panicked when his door was shut while sleeping and linked this reaction to childhood trauma involving being locked in a closet while his mother was assaulted. The resident was instructed in a calming breathing technique during the session. Observation during the survey showed a sign on the resident’s door directing staff to leave the door open, and the resident confirmed this was due to past trauma and that closing the door caused him to cry and panic. The resident’s quarterly MDS showed intact cognition and documented multiple mood concerns, including little interest or pleasure, feeling down or hopeless, fatigue, feelings of worthlessness, and thoughts of being better off dead or hurting himself. Despite these findings, no changes were made to the plan of care to address the mood changes. The current care plan contained no evidence of a PTSD plan or identification of PTSD triggers such as keeping the door open. The DON stated she was unaware of the TBS note describing childhood trauma and was unaware until the week of the survey that the resident became distressed when the door was closed. The SSD confirmed the hospital discharge summary identified PTSD and recommended treatment, but no PTSD care plan was initiated, and the yearly assessment later stated the resident had no trauma history despite prior documentation.
Failure to Document Monthly Pharmacist Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist completed monthly drug regimen reviews for residents, including review of the medical chart, in accordance with its policy and procedures. Medical record review, staff interviews, and policy review showed that Resident #22 had no documented evidence of a pharmacist medication regimen review for October 2025, and the DON and Regional Director of Clinical Service confirmed there was no documentation that the review occurred. The same issue was identified for Resident #2 and Resident #3. Resident #2 had diagnoses including osteomyelitis, cellulitis, diabetes, depression, hypotension, renal dialysis, chronic ulcers, long-term anticoagulant use, insulin use, aspirin use, colon neoplasm, hyperlipidemia, anemia, vitamin D deficiency, hypertension, heart disease, atrial fibrillation, gout, irritable bowel syndrome, exocrine pancreatic insufficiency, and urinary incontinence, yet there was no documented evidence of a completed October 2025 medication regimen review. The DON stated the pharmacist emailed a blank list of residents reviewed with no recommendations and never sent an updated list, and the Regional Director of Clinical Service confirmed there was no documentation supporting reviews for residents without recommendations. Resident #3, who had diagnoses including acute and chronic respiratory failure with hypoxia and hypercapnia, COPD with acute exacerbation, asthma, paranoid schizophrenia, unspecified psychosis, bipolar disorder, extrapyramidal and movement disorder, diabetes, dementia, and hypertension, also had no documentation of a pharmacy record review for October 2025. The facility policy stated medication regimen reviews were to be completed upon admission and at least monthly thereafter.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to ensure dental services were provided to meet residents’ needs for two residents reviewed for dental care. One resident was admitted with diabetes, GERD, moderate protein-calorie malnutrition, anemia, aphasia, and heart disease, and had a care plan for loose-fitting dentures that directed staff to inform the dentist of problems. A dental note documented that impressions were obtained for new dentures, but the record showed no evidence that the new dentures were ever received or that the resident was seen again by the dentist after the impression was taken. The resident reported that impressions for new dentures had been taken weeks earlier and that she had not heard anything further. Staff confirmed the resident had been seen by the in-house dentist and that impressions were obtained, but the facility later cancelled its contract with that dentist. The new dental provider visited the facility, but the resident was not seen. Staff also confirmed the dentures were not processed because the facility cancelled services, and the resident’s dental care had not been effectively monitored to prevent delays. A second resident had diagnoses including hepatic failure, alcoholic cirrhosis, diabetes, and COPD, and the care plan identified oral and dental problems related to carious teeth, multiple missing teeth, decayed teeth to the gumline, and a chipped tooth, with a referral to a dentist. The resident stated she had broken and missing teeth and wanted to see the dentist, and she was observed with dark, carious-looking teeth. Dental records showed she had not been seen by a dentist since a prior visit, and after she refused one appointment there was no evidence of any further attempts for a dental consult. Social services confirmed there was no evidence she had been seen again and that no dental consent had been obtained for her.
Medical Records Not Available for Inspection
Penalty
Summary
Medical records were not available for inspection for two residents. For Resident #4, the record showed an admission date of 11/05/25 and diagnoses including malignant neoplasm of the lung, adult failure to thrive, acute kidney failure, and esophageal obstruction. The resident had a physician order dated 11/10/25 for hospice services for malignant neoplasm of the lung. A notebook at the nursing station contained the hospice plan of care and indicated visits from hospice staff, including a nurse, chaplain, and nursing assistant, but there were no hospice visit notes in the notebook since December 2025. An LPN confirmed there were no hospice visit notes by nurses, aides, or chaplains since December 2025 and stated she had to call the hospice company to get the notes. For Resident #22, the record showed diagnoses of anxiety, insomnia, and depression. A prior psychiatric behavioral note documented weight gain, inability to effectively bathe himself, resistance to bathing, and that he remained unkempt and malodorous. The note also stated he wanted to see a therapist, was seeing someone from ViaQuest, slept adequately, attended some activities, was out of his room some, and had no side effects to medications, with a recommendation for follow-up in 1.5 months. Review of the resident's medical record showed no evidence of a follow-up visit. The DON confirmed the resident was seen by the psychiatrist on 10/30/25, but the note was in her email and was never printed and placed in the resident's medical record.
Failure to Monitor and Treat Diabetes Leads to Resident Harm
Penalty
Summary
A deficiency occurred when the facility failed to comprehensively assess and timely identify an acute change in a resident's condition, resulting in hospitalization for diabetic ketoacidosis (DKA) and sepsis. The resident, who had a history of type I diabetes with diabetic neuropathy and muscle weakness, was admitted with orders for scheduled and sliding scale insulin, as well as regular blood glucose monitoring. On multiple occasions, the resident's blood sugar was recorded as 'hi' (above the glucometer's readable range, typically >600 mg/dL), but there was inadequate monitoring and treatment. The resident did not receive scheduled insulin or blood sugar checks as ordered, and there was a significant lapse in monitoring between the evening and the following day. Documentation revealed that the resident experienced symptoms such as nausea, vomiting, and confusion, which were reported to staff but not adequately addressed. Staff interviews indicated that there was confusion and lack of communication regarding the resident's care, with missed medication administration and insufficient follow-up on abnormal blood sugar readings. Additionally, there was a lack of root cause analysis regarding a fall that occurred during this period, and the potential link between the fall and the resident's elevated blood sugar was not explored. Staffing shortages and unclear delegation of responsibilities contributed to the failure to provide necessary care and monitoring. The resident was eventually found unresponsive on the floor in her room, with critically high blood sugar, low blood pressure, and low oxygen saturation. She was transferred to the hospital, where she was diagnosed with DKA, sepsis, and other acute medical issues. The facility's failure to follow physician orders for insulin administration, monitor blood glucose as required, and respond to changes in the resident's condition resulted in actual harm and hospitalization.
Failure to Ensure Dignified Dining Experience Due to Unattended Full Urinals
Penalty
Summary
A deficiency was identified when a resident with diagnoses including type II diabetes, muscle weakness, and cognitive communication deficit was observed eating lunch in his room while three full urinals were hanging by the handle on the footboard of his bed. The resident reported that staff would enter his room to deliver food, pick up trays, or administer medications, but did not address the full urinals. He expressed that he did not like having full urinals hanging on his bed during meals. The care plan did not note any behavioral concerns related to urinal use, and the resident's cognition was documented as intact, with some decline in care acceptance on certain days. Staff documentation indicated that the resident had requested staff to stay out of his room earlier in the day, which may have contributed to the urinals not being emptied prior to his meal. However, staff still entered the room for other reasons without addressing the urinals. Facility policy states that residents have the right to be treated with respect, kindness, and dignity. The presence of full urinals during mealtime was confirmed by both the resident and the facility administrator, indicating a failure to provide a dignified dining experience.
Failure to Notify Resident and Physician of Medication Error
Penalty
Summary
The facility failed to notify both the resident and the resident's primary care physician of a medication error involving the administration of pain medication. The resident, who had multiple diagnoses including diabetes mellitus, chronic obstructive pulmonary disease, asthma, hypertension, chronic kidney disease, polyneuropathy, severe morbid obesity, osteoarthritis, and obstructive sleep apnea, was prescribed Oxycodone ER 10 mg every 12 hours for moderate to severe pain and Oxycodone 5 mg every 12 hours as needed for pain rated five to ten. On a specific date, the nurse documented administering the scheduled Oxycodone 10 mg dose but did not document administration of the as-needed 5 mg dose. However, controlled drug records indicated that the resident received the 5 mg dose instead of the prescribed 10 mg dose at that time. During a shift change narcotic count, it was discovered that the nurse had administered the incorrect dose of Oxycodone. There was no documented evidence in the medical record that either the resident or the resident's physician was notified of this medication error. Facility policy required prompt notification of the resident, physician, and resident representative of changes in the resident's medical condition or status, but this was not followed in this instance.
Failure to Maintain Adequate Nursing Staff and Monitor Resident with Diabetes
Penalty
Summary
The facility failed to maintain adequate nursing staff levels to meet the needs of all residents, resulting in a deficiency that directly affected one resident and had the potential to impact others. On the day in question, the facility did not have the required number of licensed nurses on duty due to call-offs and scheduling issues. The staffing plan called for at least three LPNs or RNs on dayshift, but only two nurses were present, and attempts to secure additional coverage were unsuccessful. Communication breakdowns occurred between the nightshift nurse, the Director of Nursing, the Administrator, and Human Resources, leading to confusion about who was responsible for medication administration and resident care during the shift change. A resident with type I diabetes and a history of unstable blood glucose levels experienced significant lapses in care. The resident did not receive scheduled blood sugar checks or insulin administration as ordered by the physician. Documentation showed that the resident's blood sugar was not monitored for an extended period, and there was no evidence that insulin was administered when indicated. The resident was later found on the floor in her room, lying in vomit, with critically low blood pressure, irregular pulse, and severe hyperglycemia. Staff were initially unaware of the resident's whereabouts, and it was only after a search that she was located and assessed. The resident was subsequently transferred to the emergency department, where she was diagnosed with diabetic ketoacidosis, high anion gap metabolic acidosis, acute urinary tract infection, non-ST elevated myocardial infarction, and sepsis. The facility's failure to provide adequate staffing and ensure proper monitoring and care for the resident's complex medical needs contributed to the adverse outcome. The deficiency was further evidenced by the lack of a root cause analysis for the resident's fall and the absence of timely interventions in response to her deteriorating condition.
Medication Administration Errors Result in Unnecessary Drug Use
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary medications, as evidenced by medication administration errors affecting two residents. One resident with multiple diagnoses, including anxiety disorder and moderate cognitive deficit, was prescribed Lorazepam 0.25 mg twice daily for anxiety and Lorazepam 0.5 mg as needed. However, the resident was repeatedly administered Lorazepam 0.5 mg instead of the prescribed 0.25 mg dose on multiple occasions, with no evidence that the higher dose was given as an as-needed medication. Documentation showed that staff were signing off on the administration of the incorrect dose, contrary to the physician's orders. Another resident with a history of chronic pain and multiple comorbidities was prescribed Oxycodone 5 mg every six hours for pain and Hydromorphone 2 mg as needed for severe pain. The resident was administered an extra dose of Oxycodone 5 mg without a physician's order, and there was no documentation in the medical record or medication administration record (MAR) to support the administration of this extra dose. The incident was discovered during a narcotic shift count, but the error was not documented in the resident's records. Review of facility policy indicated that medications are to be administered as prescribed, with staff required to verify the right resident, medication, dosage, time, and method before administration. Despite these policies, the facility did not ensure adherence to medication orders, resulting in residents receiving unnecessary or incorrect doses of medication.
Missed wound care follow-up was not maintained
Penalty
Summary
The facility failed to ensure that Resident #3’s outside wound care appointment was maintained after the resident missed the scheduled visit because the resident was in the hospital. Resident #3 was admitted with multiple diagnoses including polyneuropathy, end stage renal disease, atrial fibrillation, cardiomyopathy, thoracic aortic aneurysm, aphasia, type 2 diabetes, hypertension, gout, chronic pain syndrome, and acute kidney injury. The resident’s records showed diabetic foot wounds and ongoing wound care orders, including treatment to the left foot and protective dressing to the right foot. A wound center note documented the last visit on 08/19/25 with a recommended follow-up within one week. The record showed a wound center appointment was scheduled for 08/26/25, but on that date the resident was documented as being in the hospital and remained hospitalized through 08/27/25. There was no documentation that the missed wound care appointment was rescheduled, no evidence of follow-up with the wound center, and no active ordered appointment for wound care center follow-up after 08/19/25. The wound care center receptionist confirmed the resident did not attend the 08/26/25 appointment because of hospitalization and that no appointment had been rescheduled. The Assistant Clinical Regional Director stated the canceled appointment was rescheduled by the hospital while the resident was inpatient, but confirmed there was no documentation or evidence that an appointment had been scheduled.
Insufficient Staffing Resulting in Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all 48 residents, as evidenced by multiple sources including staff schedules, facility assessments, resident council meeting minutes, and interviews with residents and staff. The facility assessment indicated that staffing decisions should be informed by resident needs and contingency plans were in place for unplanned staffing shortages. However, review of staffing schedules revealed instances where only two or three CNAs were available for 48 residents during certain shifts, and staff interviews confirmed that call-offs were not always covered, leading to inadequate staffing levels, particularly on weekends and night shifts. Residents consistently reported long wait times for call light responses, sometimes up to 30-60 minutes, and difficulty receiving assistance with activities of daily living such as bathing, toileting, and scheduled showers. Several residents also noted that they were unable to participate in activities like smoking breaks due to lack of available staff. Resident council meeting minutes documented ongoing concerns about delayed care and insufficient help, especially for tasks requiring two staff members, such as using a mechanical lift. Staff interviews corroborated these concerns, with CNAs and LPNs stating that the workload was unmanageable with the current staffing levels, especially given the high number of residents requiring two-person assistance. Staff reported that routine care such as two-hour checks, showers, and restorative programs were not consistently completed. The staffing coordinator acknowledged the use of agency and temporary staff but confirmed that management did not always come in to cover shifts when call-offs occurred. The local Ombudsman was also aware of the ongoing staffing issues.
Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary manner. During observation of the kitchen, surveyors found splatters on the backsplash and walls behind the oven and stove area, grime on the toaster oven controls, debris on the shelves containing hot-well pans, splatters on the wall behind the juice machine, and a half-full 19-ounce container of sesame seeds that had expired. An interview with staff member #149 confirmed the splatters, grime, debris, and expired sesame seeds. The cited policy stated that kitchens, kitchen areas, and dining areas must be kept clean and free from litter and rubbish, and that utensils, counters, shelves, and equipment must be kept clean and maintained in good repair, with surfaces cleaned on a regular schedule to prevent the accumulation of grime.
Infection Control Program Deficiencies
Penalty
Summary
The facility failed to develop and implement a comprehensive infection prevention and control program. Survey findings showed that hand hygiene was not performed during resident care, the infection control log was incomplete and inaccurate, and the water management plan for Legionella was not followed according to facility policy. These issues were identified through observation, record review, policy review, and interview. The infection control log for April, May, and June 2025 contained missing and incomplete information. One resident was listed with a wound infection without signs or symptoms documented, several residents were listed with unknown infections without signs or symptoms, and multiple residents were added by hand at the bottom of the log without information about where the infections were acquired, signs and symptoms, or treatment. The DON stated the log was generated from the electronic chart and confirmed it should be completed entirely. The facility policy for surveillance for infections required collection of identifying information, diagnoses, onset date, infection site, pathogens, risk factors, remarks, treatment measures, and precautions. The facility also did not follow its Legionella water management program. Review of the Water System Infection Control Log showed the legionella control plan had not been followed since 03/19/25. The facility’s control measure document described required monitoring activities including weekly flushing of less-used water outlets, monthly checks, and other maintenance tasks. The Regional RN confirmed there was no additional information showing the legionella control plan had been followed since that date. During wound care for one resident with diabetic foot ulcers, an LPN repeatedly removed and reapplied gloves without performing hand hygiene between glove changes. The resident had diagnoses including end stage renal disease, atrial fibrillation, cardiomyopathy, thoracic aortic aneurysm, aphasia, type 2 diabetes, hypertension, gout, chronic pain syndrome, and acute kidney injury, and had chronic diabetic foot ulcers requiring dressings. In another observation, two LPNs were providing wound care and incontinence care to a resident with MRSA, a stage 3 pressure ulcer, an open lesion, and an indwelling catheter. After incontinence care, one LPN removed gloves and performed hand hygiene, while the other did not remove gloves or perform hand hygiene before touching the resident’s call light, remote, and bedside table. The facility’s hand hygiene policy stated that gloves do not replace hand hygiene and identified hand hygiene as required after glove removal and after contact with contaminated surfaces.
Incomplete Transfer, Bed-Hold, and Discharge Notifications
Penalty
Summary
The facility failed to provide residents or their representatives with complete written notice of transfer to the hospital, bed-hold days remaining, and notification to the ombudsman for multiple residents reviewed for transfer and discharge. The deficiency affected six residents reviewed for transfer and discharge, including residents with diagnoses such as diabetes, intellectual disabilities, anxiety, COPD, dementia, renal disease, atrial fibrillation, cardiomyopathy, neurocognitive disorder, malnutrition, heart failure, kidney disease, and other chronic conditions. The record review and staff interviews showed that the required notices were either absent or incomplete for hospital transfers and discharges. For one resident admitted with diabetes, intellectual disabilities, and anxiety, nursing notes documented a decline in condition and transfer to the hospital for decreased oxygen saturation, but the record contained no evidence that the family was notified of the transfer, informed of bed-hold days left, or that the ombudsman was notified. For another resident with COPD and dementia, the discharge summary and post-care instructions were completed only in the social services section and were not completed for the nursing assessment, and the social worker confirmed the discharge assessment and instructions were not completed and should have been sent with the resident at discharge. For a resident with polyneuropathy, ESRD, atrial fibrillation, cardiomyopathy, aphasia, diabetes, hypertension, gout, chronic pain syndrome, and AKI, the record showed multiple hospital transfers and returns, but bed-hold notices were incomplete or absent for several admissions, and there was no documentation that the ombudsman was notified for the transfers. For another resident with metabolic encephalopathy, neurocognitive disorder, malnutrition, and constipation, the emergency transfer and bed-hold notices did not contain all required components and there was no evidence the ombudsman was notified. Similar failures were documented for a resident with a stroke history, hemiplegia, CHF, cholecystitis, peritoneal abscess, and pancreatitis, and for a resident with a knee sprain, heart failure, aortic stenosis, diabetes, CKD, OSA, cellulitis, and knee arthroplasty, whose record lacked evidence of transfer notice, bed-hold notice, or ombudsman notification after hospital transfer.
Failure to Provide Ordered Nutritional Interventions and Weights
Penalty
Summary
The facility failed to ensure residents received nutritional interventions after weight loss was identified and failed to ensure residents were weighed as ordered. The deficiency involved four residents reviewed for nutrition, including residents with diagnoses such as dysphagia, diabetes, schizophrenia, bipolar disorder, CVA with hemiplegia, CHF, chronic kidney disease, paraplegia, depression, adult failure to thrive, and protein-calorie malnutrition. The report states that the census was 48. For one resident, the record showed a physician-approved recommendation for weekly weights for four weeks, but there was no evidence the weekly weights were obtained as ordered. The same resident had a significant weight loss, poor and variable meal intake, and was identified as meeting criteria for protein-calorie malnutrition related to weight loss, decreased intake, and muscle wasting. The dietitian recommended increasing a nutritional supplement and monitoring weight, and later recommended adding ice cream to lunch and an appetite stimulant due to poor appetite. The record showed no documentation of the amount of ice cream administered or consumed, no evidence an appetite stimulant was initiated or ordered, and the e-MAR did not include the amount of supplement to be administered or how much was accepted. Another resident had significant weight loss documented over multiple time periods and was on Med Pass once daily when the dietitian recommended increasing it to 4 oz twice daily. The physician was made aware and the increase was to be implemented when the resident returned from the hospital, but the MAR showed the supplement remained once daily until the order was entered later. The DON confirmed the recommended increase was not implemented upon return from the hospital and was not started until after the dietitian reviewed the resident again. A third resident had severe ongoing weight loss and poor eating habits. After the NP requested a dietitian evaluation, the dietitian recommended a frozen nutritional treat once daily because the resident continued to lose weight and had significant weight loss over one, three, and six months. The physician order was not entered until several days later, and the supplement was not communicated to the kitchen list used by dietary staff. Observation showed the resident was not served the frozen nutritional treat with the snack pass, and dietary staff confirmed the resident was not on the list they used to distribute kitchen supplements. A fourth resident had a physician order to be weighed weekly for four weeks and then monthly, but the resident was not weighed in August as ordered, which the DON confirmed.
Failure to Provide Scheduled Bathing and Nail Care Assistance
Penalty
Summary
A deficiency occurred when a resident who was dependent on staff for personal care did not receive scheduled bathing and nail care assistance as required. The resident, who had diagnoses including rheumatoid arthritis, osteoarthritis, difficulty walking, and diabetes, required partial to moderate assistance with bathing and set up or clean-up assistance for personal hygiene. Her care plan specified that staff should provide showers or bed baths and nail care according to her preferences. Documentation showed her last completed shower and nail care occurred on 08/23/25, with a refusal documented on 08/27/25. There was no documentation that a shower or bath was offered or provided on her next scheduled day, 08/30/25. Observations on 09/02/25 and 09/03/25 found the resident in bed with a dark substance under her fingernails. Interviews with staff confirmed the lack of documentation for the missed scheduled shower and acknowledged the resident was dependent on staff for nail care. The CNA who provided a bed bath on 09/03/25 reported cleaning the resident's dirty fingernails at that time and confirmed the resident could not perform her own nail care. The DON verified the absence of documentation for the missed scheduled shower and confirmed the resident's dependency on staff for these activities.
Failure to Provide Diet Consistent with Resident's Needs
Penalty
Summary
A deficiency was identified when a resident with dysphagia, oropharyngeal phase, and who was edentulous, was not served food in accordance with her prescribed diet. The resident's care plan and physician orders specified a regular diet with soft, bite-sized textures and thin liquids, and the dietary card for the dinner meal reflected these requirements. However, during observation, the resident was served a hot dog on a bun cut into uneven pieces ranging from 0.5 to 1 inch, along with other meal items. The hot dog was not considered soft or appropriately bite-sized for the resident's needs, and there were no condiments provided. The resident was observed eating the hot dog and bun without staff present in the room. Further review and interviews confirmed that the LPN assigned to the resident was unaware of the specific diet order until reviewing the tray card, and acknowledged that the hot dog as served did not meet the soft, bite-sized texture requirement. The registered dietitian also verified that a hot dog is not part of a soft diet and that the pieces served were not bite-sized. Additionally, the facility did not have a policy defining a soft diet with bite-sized texture for review. This failure to provide food in a form designed to meet the resident's individual needs constituted the deficiency.
Failure to Inform Resident and Obtain Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that Resident #2 was fully informed and understood the risks versus benefits of psychotropic medication use. Record review showed the resident was admitted with diagnoses including type II diabetes, mild intellectual disabilities, and anxiety disorder, and the care plan identified a need for psychotropic medications related to anxiety. The MDS showed moderately impaired cognition and no behaviors. Physician orders dated 05/19/25 and 05/23/25 showed the resident was receiving anti-anxiety medication monitoring and buspirone 10 mg, two tablets by mouth every morning and at bedtime, for dementia with agitation. The medical record contained no evidence that Resident #2 or the resident’s representative was made aware of the risks versus benefits of the psychotropic medication or that consent was obtained for the medication. During interview on 09/09/25 at 12:45 P.M., the Regional Support Nurse confirmed there was no evidence of consent and education for Resident #2 to receive psychotropic medications. The facility policy titled Psychotropic Medication Use stated that residents and/or representatives have the right to decline psychotropic treatment and that staff and the physician will review the risks of not taking the medication as well as appropriate alternatives.
Unsecured Toilet With Sewer Odor in Resident Bathroom
Penalty
Summary
The facility failed to maintain a safe and comfortable living environment for one resident. Resident #12 was admitted with diagnoses including diabetes mellitus, heart failure, anxiety disorder, and osteoporosis. The annual MDS assessment showed the resident was moderately impaired for daily decision-making, used a wheelchair and walker for mobility, required supervision or touch assistance with toilet transfers, and was frequently incontinent of bowel and bladder. On observation, the resident’s bathroom toilet was positioned across from the bathroom door, and the caulking at the base of the toilet was not attached on the front and left sides. Later observation with the Maintenance Director showed the bathroom door closed, the toilet base sitting crooked, and the caulking not attached around the base of the toilet. A sewer odor was present in the bathroom. The Maintenance Director verified the toilet was not secured, moved the toilet base back and forth with his foot, and stated the toilet should not have been caulked because it was not secured to the floor, allowing sewer gas to escape into the bathroom. He also stated he was not aware of the concern and did not know who had tried caulking around the toilet.
Missing PASRR Level II Determination and Updated Screening
Penalty
Summary
The facility failed to ensure PASRR Level II screenings were completed as determined by resident needs and that the state Level II determination was available for review for Resident #9. The resident was admitted with diagnoses including bipolar disorder, schizophrenia, and depression. A significant change PASRR dated 07/28/23 noted a decline and listed paranoid schizophrenia, bipolar disorder, insomnia, and another psychotic disorder, while also stating the resident had no functional limitations due to the mental disorder and had not been prescribed psychotropic medications in the previous six months. The facility was unable to provide the screening results showing the state Level II PASRR determination. Review of the resident’s June/July 2025 physician orders showed routine psychotropic use, including haloperidol 2 mg daily, Risperdal 4 mg daily, and venlafaxine ER 150 mg daily. The eMAR from 06/27/25 through 07/01/25 documented medication refusals on three days and behaviors of anger and/or withdrawn/depressed on multiple days. The annual MDS showed moderate impairment in daily decision-making, frequent bladder incontinence without a toileting program, weight loss, routine antipsychotic use, and no mood indicators or rejection of care, although those indicators were documented on the eMAR during the assessment reference dates. Staff interviews confirmed the 07/28/23 PASRR was the last submitted and that no additional PASRR or result was available for review, and no new Level II screening had been submitted despite the resident’s documented changes.
Incomplete Care Plans for Ordered Treatments and Monitoring Needs
Penalty
Summary
Comprehensive care plans were not developed for multiple residents with identified needs and ordered treatments. Resident #4 was admitted with diagnoses including metabolic encephalopathy, hypertension, GERD, BPH, insomnia, osteoarthritis, history of fractures, and constipation. Review of physician orders and the MAR showed the resident received baclofen as needed for hiccups, cholecalciferol weekly, cyanocobalamin monthly, losartan daily, magnesium hydroxide as needed for constipation, mirtazapine at bedtime for difficulty sleeping, maalox four times daily and protonix for GERD, tamsulosin daily for BPH, and guaifenesin twice daily. The medical record contained no comprehensive care plans for hypertension, constipation, hiccups, vitamin-D and vitamin-B deficiency, allergies, insomnia, GERD, or BPH, and the DON verified there was no evidence those care plans had been developed. Resident #2 was admitted with diagnoses including type II diabetes, mild intellectual disabilities, and anxiety disorder. Orders showed the resident received hydrocodone-acetaminophen for pain, insulin glargine twice daily for diabetes, and Aldactone for edema. The MDS also identified use of a diuretic, opioid, and hypoglycemic medication, but the care plan dated 08/06/25 did not include interventions for monitoring side effects related to insulin, a diuretic, or an opioid, which was confirmed in interview by the Regional RN. Resident #7 was admitted with diagnoses including atrial fibrillation, malignant neoplasm of unspecified site of unspecified female breast, neoplasm of unspecified behavior of bone, soft tissue, and skin, and syncope and collapse. Her physician’s order allowed oxygen at 2 LPM as needed to keep oxygen saturation above 90%, but her active care plans did not address oxygen use until after it was brought to the facility’s attention, and the MAR/TAR did not document oxygen use despite observation of oxygen in place at 2 LPM with no distress noted.
Failure to Reposition and Treat New Skin Breakdown
Penalty
Summary
The facility failed to ensure care planned interventions for turning and repositioning were completed to promote timely and adequate healing of a Stage III pressure ulcer for one resident, and failed to ensure newly identified skin breakdown was timely identified and treated. The resident had diagnoses including type II diabetes, muscle weakness, and acute kidney failure, and had a care plan addressing altered skin integrity, a Stage III sacral pressure ulcer, and a boil to the left hip. The care plan included interventions such as a low air loss mattress, Prevalon boots, wound monitoring, and turning and repositioning as needed. The resident also had orders for Juven twice daily for wound healing and wound care to the sacrum with cleansing, Hydrofera Blue, and foam dressing. Wound documentation showed the sacral pressure ulcer remained present over time, with measurements that were unchanged or only slightly improved, and later increased in size. The wound notes described moderate exudate, 100% granulation tissue, distinct wound edges, and a pink peri-wound area. Task documentation showed the resident was turned and repositioned daily from 08/05/25 through 09/03/25. However, direct observation on 09/03/25 showed the resident resting on her back for extended periods, including during continuous observation from 9:28 A.M. to 10:23 A.M., from 12:26 P.M. to 2:53 P.M., and after wound care and a bed bath, with no evidence staff turned or repositioned her to reduce pressure to the sacral area. During wound care observation, the peri-wound area was noted to be reddened to the bilateral gluteal folds with a small open area with a red wound bed, and no treatment was in place to that area at the time. The CNA stated residents should be turned and repositioned every two hours but could not verify that resident checks or rounds had actually been completed every two hours. The resident stated staff did not offer to turn or reposition her to help relieve pressure from her coccyx/sacral area. An LPN confirmed there was no documented evidence the resident was non-compliant with care and stated the resident tended to remain on her back due to chronic pain. The DON and another LPN confirmed there was no barrier cream or treatment to the reddened peri-wound areas, and a new order for moisturizing barrier cream after each incontinence episode was not entered until after the skin breakdown was observed.
Failure to Ensure Smoking Apron Use During Smoking
Penalty
Summary
The facility failed to ensure smoking aprons were worn during smoking time. Resident #49, who was admitted with diagnoses including cerebral infarction, aphasia, hemiplegia, lupus, stage 3 chronic kidney disease, hypertension, hyperlipidemia, GERD, muscle weakness, obesity, depression, apraxia, and anxiety, had a quarterly MDS showing a BIMS score of 13 and upper extremity impairment. The resident’s most recent quarterly smoking observation/assessment documented that the resident smokes cigarettes, has dexterity impairment, needed a smoking apron with supervision, and had previously been observed to drop ashes and a cigarette on self while smoking. The care plan identified potential for injury related to smoking due to poor safety awareness and CVA, with a goal that resident safety be maintained every shift. During observation in the designated smoking area, Resident #49 was seen actively smoking without a smoking apron on at 3:15 P.M. and again at 3:30 P.M. On the second observation, the receptionist confirmed the resident did not have an apron on while smoking and stated that as of the prior day the resident no longer wore a smoking apron, adding that it was a lot for one person to round everyone up and get everyone situated and set up for smoking. The facility’s Smoking Policy states that a resident’s smoking status is evaluated on admission, including ability to smoke safely with or without supervision based on a completed safe smoking evaluation, and that staff consult with the attending physician and DON to determine whether safety restrictions are needed.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Marietta
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arbors At Marietta | 0.7 mi | ★★★★★ | 5 | 0 |
| Harmar Place Nursing And Rehabilitation | 0.8 mi | ★★★★★ | 1 | 0 |
| Waterview Pointe Nursing & Rehabilitation | 1.1 mi | ★★★★★ | 0 | 0 |
| Worthington Healthcare Center | 9.5 mi | ★★★★★ | 0 | 0 |
| Belmont Healthcare Center | 10.1 mi | ★★★★★ | 10 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.