Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mckinley Nursing during CMS and state inspections, most recent first.
The facility failed to ensure CNAs had yearly performance evaluations. Record review showed three CNAs did not have annual evaluations in their files, and the HR Director confirmed the evaluations had not been completed as required and that the facility was behind on them.
Meal service failed to provide planned portion sizes and all menu components for residents. Residents reported menus were not consistently posted, alternate choices were not being collected, and portions were too small. During observation, ham and beans were served with an inadequate scoop size, mechanical soft items were unavailable, and puree diet items such as cornbread and fruit cobbler were not provided as planned. The DM confirmed the facility was not serving alternate menu items with the main meal and could not describe a current system for tracking resident food preferences.
Meals were served at unpalatable temperatures and with poor presentation. Residents reported cold food and said meals were not hot or appealing. Surveyors observed lunch trays delayed well past the scheduled mealtime, with the facility out of insulated dome lids and insulated bowls and not using heated or insulated bases. A test tray showed ham and beans and turnip greens at lukewarm temperatures, and cornbread was soggy from juices; the DM confirmed the food was not at a palatable temperature.
Meals were not served at scheduled times, with lunch trays repeatedly delayed across multiple units and residents reporting late food service. Staff confirmed trays were late or had not arrived, and a CNA said meal timing was "hit or miss." Surveyors observed lunch trays leaving the kitchen at staggered times and tray pass not finishing until mid-afternoon; the dietary director said a broken cooler caused prepped lunch food to be discarded, and the dietitian reported minimal onsite oversight.
Unsanitary food storage, kitchen conditions, and hand hygiene lapses were observed in the dietary area. The walk-in cooler was at 60°F with warm food inside, multiple foods in a reach-in refrigerator were unlabeled and undated, and the dish room, stove, fryer, freezer, and dry storage area had heavy debris, grease, dust, and ice buildup. During tray service, staff handled trash, dropped food on the floor and reused it, and worked without proper hand hygiene or hair restraints.
Improper Dumpster Area Sanitation and Refuse Disposal: Surveyors observed multiple dumpsters in an enclosed indoor area with a strong foul odor, debris on the floor, and equipment stored in the dumpster area, including floor cleaners and a plastic wrapped recliner on a pallet. The DM confirmed the area was not being kept clean and free of debris, while the Dietitian reported minimal onsite oversight and was unaware of the issues. Facility policy required the dumpster area to remain clean, secure, and inspected daily.
Failure to Maintain Effective Administrative Oversight: The facility did not maintain effective oversight across multiple departments, including social services staffing, controlled medication handling, dietary services, infection control, and QAPI. A resident census of 151 was served without a current LSW, multiple controlled medication misappropriation events involved several residents and were not fully reported, kitchen sanitation and meal service problems persisted despite prior QAPI discussion, infection control documentation lacked a comprehensive legionella water management program, and QAPI action plans lacked clear accountability, dates, and evidence of completion.
Facility assessment was not accurately completed because the staffing plan did not list the required numbers or ranges for CNAs, LPNs, RNs, and other staff, and it still identified a former administrator as the current administrator. The current administrator said he had reviewed the assessment twice, could not explain the CMS minimum staffing rule notation, and confirmed the staffing levels he described were not included in the assessment.
Failure to employ a required full-time LSW in a facility with 151 residents. Personnel records showed the SSD was not an LSW and did not have a bachelor's degree in a human services field, and the only LSWs on record were terminated or separated from the facility. Interviews with HR, the SSD, and the Administrator confirmed the social services department had no LSW at the time of the survey, and the job description did not state the LSW requirement for a census over 120.
The facility’s QAPI process was found ineffective because multiple QAPI action plans lacked a specific point person, clear completion dates, and documented monthly progress. Review of QAPI minutes showed repeated issues involving falls, dietary services, infection control, wound care, discharge documentation, pharmacy services, MDS assessments, and other areas, with no evidence that prior action items were revisited or that full PIPs were completed. The Administrator, DON, and RDI acknowledged there was no evidence of auditing, education, or other documented monitoring tied to the identified concerns, and the Administrator stated there was not yet a mechanism for residents and staff to report issues to QAPI.
Infection control standards were not maintained during medication administration and incontinence care, and contact precautions were not in place for a resident on CRAB isolation. An LPN was observed touching unit-dose meds with an ungloved hand, and a CNA placed soiled items on the floor during perineal care without a lined trash container ready. The facility also had an outdated infection control policy review process and an incomplete Legionella water management program lacking key risk and monitoring elements.
Failure to Provide Required QAPI Training: The facility failed to provide mandatory QAPI training to staff, with no documented evidence of training in five of 11 personnel files reviewed, including CNAs, an LPN, and the HRD. Interviews confirmed that no QAPI in-services had been provided since the HRD and Administrator began working at the facility, and the facility assessment did not include QAPI education among staff training topics.
Failure to provide required annual CNA in-service training. Review of employee files showed three CNAs had hire dates in 2025 and had not completed the required 12 hours of annual in-service education. The HR Director verified the missing training and stated the facility was in the process of setting up an online education system.
Failure to Hold Quarterly Care Conferences The facility did not conduct quarterly care conferences for multiple residents with varied medical and cognitive conditions, including dementia, respiratory failure, diabetes, schizoaffective disorder, Parkinson’s disease, and CKD. Record review and staff interviews showed several residents had only one documented care plan meeting or no evidence of a required quarterly meeting, and the DON and SSD confirmed that care conferences were missed or not being done. One resident’s guardian also reported concern that no care conference had occurred for months.
The facility failed to promptly notify responsible parties and physicians of significant resident changes. A resident with severe cognitive impairment fell, another resident repeatedly removed a wanderguard and refused meds and showers, a resident with dementia had significant weight loss, and another resident developed wrist redness, swelling, and pain with new orders for x-ray and pain management. The DON confirmed the records did not show timely notification for these changes.
Controlled medication records were inaccurate and several doses or cards could not be accounted for. One resident’s oxycodone entries did not match the MAR and an extra dose was signed out, another resident’s oxycodone card with remaining tablets was removed and later could not be produced, a resident’s Lyrica was reported misplaced and not fully investigated, and two oxycodone doses for another resident were signed out but not documented in the MAR. The DON confirmed multiple discrepancies, missing medication, and incomplete documentation involving controlled substances.
A facility failed to follow its abuse prevention policy for multiple allegations involving a missing controlled med, unexplained bruising and swelling, and a verbal abuse complaint. Investigations were incomplete, with missing resident and staff interviews, no documented root cause, inconsistent SRI reporting, and no evidence of required family notification or staff education. The DON and Administrator confirmed the gaps in the facility’s handling of the allegations.
Incomplete investigations were found for allegations involving a missing controlled medication card, unexplained bruising and wrist swelling, and resident-to-staff abuse complaints. Records showed conflicting accounts about an oxycodone card removed from a med cart, repeated unexplained injuries in a resident with dementia and impaired decision-making, and missing interviews, assessments, dates, and family notification in other allegations. The DON and Administrator confirmed key elements of the investigations were not completed, and the facility policy required interviews, written statements, and review of pertinent records.
Inaccurate MDS assessments were completed for multiple residents. One resident was incorrectly coded as having an ostomy and an indwelling catheter, another as using restraints, another as having no falls despite a documented fall, another as not receiving oxygen despite continuous O2 orders and TAR documentation, and another as taking hypoglycemic medication despite no active anti-diabetic orders during the look-back period.
Incomplete Baseline Care Plans After Admission: Surveyors found that baseline care plans were not completed timely or were only assessment forms without interventions for multiple residents with conditions such as dementia, schizophrenia, diabetes, COPD, wounds, pain, falls, and oxygen dependence. The MDS/LPN could not locate several baseline care plans, and the DON confirmed the plans were not being completed appropriately and residents were not being given copies as required by policy.
The facility failed to maintain accurate, comprehensive care plans for several residents. One resident with dementia and hospice/pain orders had no care plan for pain or opioid use, another resident with dementia and repeated falls had delayed fall and psychotropic care planning, a resident with diabetes had no care plan for insulin refusals, and two residents had code status care plans that did not match their DNR orders and forms. The DON verified several of these mismatches and omissions.
Failure to Complete Post-Fall Assessments and Ordered Fall Interventions The facility failed to complete required post-fall risk reassessments and full neuro checks after multiple falls, and also failed to carry out ordered fall interventions for a resident with repeated falls. A resident with cognitive impairment and several medical conditions had repeated unwitnessed and witnessed falls, while another resident with dementia and severe cognitive impairment was found without ordered non-skid strips in place. The DON confirmed the missing reassessments and neuro checks, and the facility policy required fall evaluation and 72-hour neuro monitoring after unwitnessed falls.
Physician Visits Not Provided as Required: The facility failed to ensure required physician face-to-face visits for five residents. The affected residents had significant medical and cognitive conditions, including dementia, schizophrenia, COPD, diabetes, and severe cognitive impairment. Record review and DON interview confirmed gaps in physician visits, with some residents seen only by the NP and not by the physician within the required timeframes.
Significant Medication Errors: Multiple residents had medication administration errors involving missed, delayed, or incorrectly timed doses. One resident did not receive Oxycodone at the ordered q4h intervals, another missed scheduled IV Meropenem doses, a third received Oxycodone/APAP too soon, and a fourth did not receive a scheduled Lyrica dose as ordered. Staff interviews and MAR/controlled substance record reviews confirmed the errors, and the facility policy required accurate verification of the right drug, dose, route, rate, time, and resident.
Mechanical soft diet meals were not prepared in the required texture for residents who needed them. Surveyors observed that residents ordered for a mechanical soft diet were served regular texture ham and beans, greens, and cornbread instead of ground or chopped items. The DM confirmed the modified ham and beans were not available, and the dietitian reported minimal kitchen oversight and was unaware of the issue.
Incomplete and inaccurate documentation was found for multiple residents. One resident’s fall risk assessments were signed off as completed even though they were not actually done, another resident had missing MAR/TAR documentation for behavior monitoring, catheter care, barrier precautions, and topical treatment, a third resident had a medication marked as given without a matching count-sheet sign-out, and a fourth resident had multiple wound care and other ordered tasks not signed off, with dressings observed dated earlier than the observation dates. The DON verified several of these documentation errors.
Unclean Resident Rooms and Missing Bathroom Soap: Surveyors observed debris on floors, personal care wipes under a bed, stained carpeting, a urine odor in one resident room, and an empty soap dispenser in a bathroom. A resident stated housekeeping had not vacuumed her floor for two weeks and denied refusing services. The HD verified the findings, and facility policy required daily room cleaning, floor care, odor control, and soap dispenser checks.
A resident with dementia and severe cognitive impairment was given psychotropic medications including Xanax, Zoloft, Depakote, Remeron, and Trazodone, but the record showed no evidence that the resident’s representative was notified of or assisted with consent. The original consent was completed despite the resident’s impaired cognition, and it was not updated when additional psychotropic medications were added; the DON confirmed the consent issue and was unsure whether the son had been notified.
The facility failed to ensure resident fund management authorizations were signed and witnessed when accounts were set up for residents. Three residents reviewed for personal funds had unwitnessed authorizations, including residents with dementia, stroke-related impairment, and lung cancer, and the BOM verified the missing witness signatures.
Failure to Report Abuse, Injury of Unknown Origin, and Possible Misappropriation The facility did not file required SRIs for three residents involving possible misappropriation of an opioid card with remaining tablets, repeated unexplained bruising/swelling/pain with no identified root cause, and a resident’s allegation that a roommate squeezed her butt and made a sexual comment. The DON confirmed the reports were not made to the State Agency, and the facility’s abuse policy required immediate reporting and investigation of abuse, mistreatment, exploitation, and injuries of unknown source.
A resident with HIV, anemia, psoriasis, anxiety, depression, homelessness, and financial hardship was discharged without a safe and appropriate discharge plan. The record showed limited housing support, repeated LOAs, invalid contact information, no LOA order in the chart, and unsuccessful attempts by staff to locate or reach him. The resident also expressed concern about where he would live after discharge and declined offered community contacts.
Failure to Provide Transfer Notice and Ombudsman Notification: The facility failed to provide a written transfer notice for a resident discharged to the hospital and failed to notify the LTC Ombudsman of discharges for two residents. One resident was severely cognitively impaired and dependent for most ADLs, while the other had HIV, depression, homelessness, and limited support, with discharge planning noting no housing or finances. Staff confirmed the transfer notice was not given and ombudsman notifications were not made.
A resident with dementia, schizophrenia, depression, and anxiety had an aggressive behavioral incident, was sent for psychiatric assessment, and was later discharged to a psychiatric facility. The record showed no new PASARR was completed after the significant change in mental status, and the SSD verified the omission.
The facility failed to update care plans for three residents when their conditions or treatments changed. One resident’s fall plan did not include non-skid strips in front of a recliner after a fall-related intervention was ordered and discussed by the IDT. Another resident’s psychotropic care plan was not specific to a newly ordered antipsychotic and instead used a general template focused on anti-anxiety medications. A third resident’s care plan was not updated to reflect hospice enrollment or end-of-life care despite hospice services being in place.
A resident with HTN, dementia, and COPD had BP meds and a monthly vitals order, but BP monitoring was not documented and several scheduled vital sign checks were missed. Two residents with multiple skin conditions and chronic lower-extremity wounds had ordered dressing changes that were not carried out as ordered; one dressing remained unchanged for several days with drainage noted, and another resident’s BLE dressings were repeatedly observed dated from earlier days, with some wounds left uncovered.
Failure to assess and treat a pressure ulcer timely: A resident with dementia and multiple chronic conditions was assessed as at moderate risk for skin breakdown, yet a skilled nursing assessment documented intact skin and no wound care. The resident was later found by the NP to have a right ankle pressure ulcer, but the ordered dressing, ointment, and offloading boot were not entered into the computer, and the wound MD then documented a stage III pressure injury to the lateral ankle.
The facility failed to maintain adequate nutrition monitoring for three residents with weight loss, poor appetite, dysphagia, and meal refusal. Records showed inconsistent weighing methods, missing ordered weights, struck-out or questioned weights, and no clear system for keeping food preferences current. Staff and the dietitian documented repeated refusals of meals and supplements, while an LPN ADON and CNA reported ongoing scale and weight-process problems, and the DM could not describe a reliable process for maintaining resident food preferences.
The facility failed to keep oxygen tubing hygienic and per orders for three residents receiving respiratory care. One resident’s tubing was overdue for weekly change, another resident’s tubing was not dated and the resident lacked a current O2 order, and a third resident’s O2 concentrator was set at 4.5 liters instead of the ordered 2 liters; staff including the DON, RN, CNA, and LPN verified the issues.
Missing Pre- and Post-Dialysis Monitoring: A resident with ESRD received off-site dialysis, but the chart lacked pre- and post-dialysis assessments, including BP, weight, and access-site checks. The resident’s notes did not document dialysis care, and the ADON and DON confirmed the required monitoring and dialysis communication form were not found in the record.
Failure to provide adequate social services and psychosocial support for a resident with dementia, anxiety, delusions, depression, and impaired cognition. The resident had poor activity participation, tearfulness, and repeated injuries of unknown origin with no documented root cause in the facility investigations. Records showed missed or delayed care plan meetings and no evidence of ongoing social service assessments to address emotional and psychosocial needs.
A resident with schizoaffective disorder, dementia, anxiety, HTN, and COPD did not receive several ordered meds as scheduled, including eye drops, an antipsychotic, a hypnotic, and artificial tears. MAR review and nursing notes showed the meds were unavailable, on order, awaiting refill, or documented as recalled/on hold, and the physician was not updated when doses were held. An LPN/ADON verified the missed administrations and noted OTC meds and an emergency kit were available.
Failure to provide timely dental services for a resident with DM, HTN, chronic pain, and malnutrition. The resident had impaired cognition, obvious or likely cavities or broken natural teeth, a loose tooth, and intermittent pain, with an order for dental evaluation and an order for Orajel for tooth and gum pain. Records and staff interview confirmed the resident had not been seen by the dentist since admission, despite the facility policy stating routine and emergency dental services were available.
Failure to Coordinate Hospice Documentation and Care: A resident receiving hospice services had diagnoses including chronic respiratory failure, COPD, CHF, and chronic pain, but the care plan was not updated to reflect hospice or end-of-life care. The medical record lacked documentation of hospice RN and HHA visits, and the hospice RN and HHA stated they did not provide visit documentation to the facility. The DON confirmed only the hospice enrollment form and plan of care were in the record, and the hospice policy did not address coordination of care related to hospice visit summaries.
The facility did not ensure accurate documentation of medication administration and bathing records for two residents. One resident's IV antibiotic doses were not consistently signed off in the medication administration record, and nursing notes did not address these omissions. Another resident's bathing records were incomplete over several months, with missing entries for multiple shifts. The DON confirmed these documentation gaps.
A resident with cognitive impairment, multiple mental health diagnoses, and a recent leg fracture was found unable to reach her call light, which was stuck between the bed and the wall. The resident, identified as a high fall risk with recent falls, demonstrated her inability to access the call light, and an LPN confirmed and rectified the situation by retrieving the call light from the floor.
The facility failed to update menus and ensure correct portion sizes, affecting all residents. Outdated menus were used, and meal portions were inconsistent due to a lack of proper documentation and oversight. Residents' concerns about meal inaccuracies and small portions were not addressed, as the Dietary Manager was absent and meetings were not rescheduled.
The facility failed to maintain a sanitary kitchen and proper infection control during meal service. Observations showed unsanitary conditions in the kitchen, including littered floors and dirty equipment. A Dietary Aide handled food with ungloved hands, touching various surfaces and placing food on residents' plates, which was confirmed by the Assistant Dietary Manager. These deficiencies were investigated under specific complaint numbers.
A facility failed to ensure a clean and homelike environment for a resident with multiple medical conditions, including diabetes and gastroenteritis. The resident's room was found in disarray, with a strong odor, scattered food, and trash, and the resident reported being too ill to clean. Despite staff acknowledging the room's condition, it remained uncleaned, and the Director of Nursing confirmed that sanitation issues should have been addressed promptly.
A facility failed to eradicate cockroaches from a resident's room due to sanitation issues. The resident, with multiple health conditions, displayed behavioral symptoms leading to unsanitary conditions, including scattered food and waste. Despite multiple pest control treatments, the presence of personal items and poor sanitation hindered effective pest eradication.
The facility failed to ensure cinnamon rolls were properly prepared, resulting in them being hard, unpalatable, and unappetizing. Multiple residents and staff confirmed the issue, and the Dietary Manager acknowledged the preparation error.
Failure to Complete CNA Annual Performance Evaluations
Penalty
Summary
The facility failed to ensure certified nursing assistants had yearly performance evaluations. Record review showed that CNA #325, CNA #386, and CNA #425 did not have annual performance evaluations completed in their employee files. CNA #325 was hired on 03/13/25, CNA #386 was hired on 01/15/25, and CNA #425 was hired on 03/04/25. During an interview on 04/28/26 at 1:15 P.M., the Human Resources Director confirmed that the yearly performance evaluations had not been completed as required and stated the facility was behind on evaluations but working to get caught up.
Meal Portions and Menu Alternatives Not Provided as Planned
Penalty
Summary
The facility failed to ensure appropriate portion sizes were served and that all meal components were provided to meet resident needs and preferences. During interviews, residents reported that menus were not always posted in common areas, alternate choices were not being communicated to the kitchen, portion sizes were too small, and food substitutions were not available. One resident stated the portions were "child-like" and another reported not receiving enough food at meals. A resident also stated dietary and nursing staff were not asking residents what they wanted to eat, and that posted menus were old. During meal observation, regular texture ham and beans were served with a six-ounce ladle, and the dietary manager confirmed the portion size was inadequate and did not follow the spreadsheet recommendations. The facility also did not have mechanical soft texture available for that meal. During lunch service, there was no pureed cornbread or pureed fruit cobbler dessert available for puree diets, the fruit cobbler was substituted with pudding, and later the kitchen ran out of fruit cobbler for other textures and substituted applesauce. The dietary manager confirmed there was no puree cornbread served and stated the facility was not serving the alternate menu in addition to the main menu. The dietitian reported minimal oversight in the kitchen and was unaware of the issues, and the dietary manager could not describe a current system for maintaining resident food preferences.
Meals Served at Unpalatable Temperatures
Penalty
Summary
The facility failed to serve meals at palatable temperatures and with an appealing presentation. Review of food committee meeting minutes from 11/25/25, 02/24/26, and 03/31/26 showed residents complaining of cold food. During interviews on 04/19/26, Resident #12 said the food was not served hot enough and was not appealing, Resident #91 said the food was never hot, and Resident #117 said the food was not hot. On 04/22/26, surveyors observed lunch meal service and found that temperatures taken before lunch showed ham and beans at 187 degrees F, turnip greens at 190 degrees F, and cornbread at room temperature. Lunch service began at 12:27 P.M. and continued until 2:13 P.M., with nurse aides finishing tray delivery at 2:38 P.M.; the facility had run out of insulated dome lids and insulated plastic bowls and did not use heated or insulated bases. A test tray at 2:38 P.M. showed ham and beans at 115 degrees F in a ceramic bowl, turnip greens at 125 degrees F on a plate with cornbread, and the cornbread was soggy from the juices. The Dietary Manager confirmed the ham and beans were not at a palatable temperature and the cornbread was soggy. The Dietitian stated she was at the facility only every other week for one day, completed the rest of her work offsite, had minimal oversight in the kitchen, and was unaware of the issues identified.
Late Meal Service Across Multiple Units
Penalty
Summary
Meals were not served at regularly scheduled times for residents receiving meals from the kitchen. The facility’s meal schedule listed breakfast from 8:15 A.M. to 9:20 A.M., lunch from 12:30 P.M. to 1:35 P.M., and dinner from 5:15 P.M. to 6:20 P.M., but survey observations and interviews showed lunch trays were repeatedly delayed across multiple units. Food Committee meeting minutes documented resident complaints about late lunches and trays sitting for 15 minutes after arriving on the unit before staff passed them out, and earlier minutes also noted meals were not on time. During observation, lunch service was still in progress well after the scheduled lunch period, with trays not yet delivered to several units and residents stating the food was late. Staff on multiple units confirmed trays had not arrived or were late, and one CNA stated it was "hit or miss" whether meals were on time. On one day, the dietary director reported the lunch trays were late because the cooler had broken and prepped food had to be thrown away. On another day, tray service was observed leaving the kitchen at staggered times across units, and lunch tray pass was not completed until 2:38 P.M. The dietitian stated she was only in the facility every other week for one day, completed most work offsite, had minimal oversight in the kitchen, and was unaware of the kitchen issues identified.
Unsanitary Food Storage, Kitchen Conditions, and Hand Hygiene Lapses
Penalty
Summary
The facility failed to ensure food was stored, prepared, distributed, and served under sanitary conditions. During an early morning kitchen observation, the walk-in refrigerator was reading 60 degrees Fahrenheit and food inside was warm to the touch. The dish machine area had dried splatter and debris on the floors and walls, sticky floor mats with debris, dust on walls, ceiling, vents, and fans, a dish machine with dried splatters and white buildup, and a soiled rag sitting on top of the machine. The main kitchen area also had burnt food debris and grease buildup on the stove, food splatter on the wall and prep areas, a dried spill on the floor, and a deep fryer with empty oil and heavy grease buildup. The reach-in refrigerator by the tray line contained multiple unlabeled and undated foods, including a peanut butter and grape jelly mixture, sliced deli ham, deli turkey, a cut cucumber, hard-boiled eggs, sliced tomatoes, and mixed fruit cocktail. The walk-in freezer had significant ice buildup on the condenser, ceiling, door, storage rack, and food items, and the dry storage room had an open, unsealed box of powdered sugar and debris on the floor. The dietary aide confirmed the cooler was warm and stated staff were not using food from it because all the food was warm. The dietary manager later confirmed the freezer and cooler findings, stated the ice buildup had been present for a while, and acknowledged the fryer had not been used in over a year. During lunch tray service, multiple staff were observed handling food and kitchen items without performing hand hygiene. One dietary aide picked up spilled plastic lids from the floor with bare hands, touched the trash can lid, and returned to the tray line without hand hygiene; the same aide drank from a cup, adjusted hair net and clothing, and continued working without hand hygiene, and had facial hair without a beard net. A CNA entered the kitchen to fill an ice cooler without a hair net or hand hygiene. Another dietary aide dropped a dessert on the floor, picked it up, and placed it on a lunch tray, then handled dirty trays and returned to the tray line without hand hygiene. A staff member rinsed hands without soap, dried them on pants, prepared multiple desserts without hand hygiene, handled a cellphone and returned to work without hand hygiene, came back from the breakroom to remove cakes from the oven without hand hygiene, and coughed without covering her mouth and did not perform hand hygiene. The dietary manager confirmed the hand hygiene and hair restraint concerns.
Improper Dumpster Area Sanitation and Refuse Disposal
Penalty
Summary
The facility failed to properly dispose of garbage and refuse. During observation with the Dietary Manager, multiple dumpsters were found in an enclosed indoor space with a very strong, pervasive foul odor. The area contained various debris, including plastic gloves, dried leaves, and a tied black trash bag on the floor. In the dumpster area, there was also equipment present, including two floor cleaners and a plastic wrapped recliner on a wooden pallet. The Dietary Manager confirmed the foul odor and that garbage and refuse were not being properly disposed. The Dietary Manager stated all staff were responsible for keeping the area clean and free of debris. The Dietitian stated she was only at the facility every other week for one day, completed the rest of her work offsite, had minimal oversight in the kitchen, and was unaware of the issues identified. The facility policy required the dumpster area to be kept clean, secure, and accessible for waste removal services, with daily inspection for cleanliness and loose trash or spills and periodic pressure washing to control odor.
Failure to Maintain Effective Administrative Oversight
Penalty
Summary
The facility failed to administer operations in a manner that enabled effective and efficient use of resources and failed to identify care concerns, implement appropriate and sustainable corrective actions, and maintain oversight for all 151 residents. The Administrator had assumed the position on 12/08/25, and the report reviewed the Administrator and DON job descriptions, which described responsibilities for maintaining effective systems, monitoring compliance, and overseeing quality assurance. During the survey, multiple areas of concern were identified across departments and records, and the Administrator stated he was unaware that prior QAPI plans had not been completed from meetings held before his employment began. In social services, the facility did not maintain a Licensed Social Worker after the prior LSW was terminated on 01/09/26. The only current social services employee was a Social Service Designee who was not a LSW, and the facility had only brief LSW coverage from 02/12/26 until 02/27/26. Census data showed the facility remained over 120 residents and had 151 residents upon survey entry. Interviews with HR, the former LSW, the SSD, and the Administrator confirmed the staffing concern. The survey also identified repeated medication misappropriation involving controlled medications for four residents between November 2025 and April 2026. Review of SRIs, MARs, controlled substance administration records, and controlled medication shift change logs showed the issue affected multiple residents, and not all incidents were reported to the state agency as required. Staff were not re-educated on medication administration or narcotic handling in response to the events. Interviews with RN #457, the DON, and LPN #431 verified the medication concerns. Additional concerns were found in dietary services, infection control, and QAPI oversight. Observations on 04/19/26 and 04/22/26 showed kitchen sanitation issues, garbage disposal concerns, menu and portion inconsistencies, improper food temperatures and consistencies, and delays in meal service to resident units. The facility had discussed dietary concerns in QAPI meetings on multiple occasions, but the issues continued to recur without resolution. Infection control documentation lacked a comprehensive legionella water management program, and survey observations identified concerns with handwashing, contact isolation, and provision of personal care. QAPI minutes from multiple meetings showed action plans that lacked a point person, dates, or evidence of completion, and the survey found deficiencies in several of the same areas that had previously been listed in those plans.
Facility Assessment Missing Staffing Details
Penalty
Summary
The facility failed to ensure the facility assessment was accurately completed. Review of the revised facility assessment dated 08/01/25 showed Former Administrator #448 listed as the current administrator. The assessment also contained a staffing plan section with tables listing positions such as licensed nurses providing direct care, nurse aides, other nursing personnel, other staff needed for behavioral healthcare and services, dietitian or other clinically qualified nutrition professional, food and nutrition services staff, and respiratory care services staff, but the adjacent column for the total number needed or average or range was blank. A second table in the staffing plan section listed licensed nurses, direct care staff, and other staff with a notation to refer to CMS minimum staffing rule, but it did not specify the numbers or ranges of staff required to meet resident needs. During interview, the current Administrator stated he had reviewed the assessment twice since starting on 12/08/25 and said it was due to be reviewed again in August 2026. He also stated he could not speak to the CMS minimum staffing rule notation and acknowledged the assessment was not done how he would do it. He confirmed the staffing levels he provided for CNAs, LPNs, and RNs were not located within the facility assessment and should have been.
Failure to Employ Required Full-Time LSW
Penalty
Summary
The facility failed to employ a full-time Licensed Social Worker (LSW) in a building with a census of 151 residents. Review of personnel records showed that Social Services Director #373 was hired on 03/11/25, but her application and resume did not show a degree in social services. The personnel file for LSW #360 showed he was terminated on 01/09/26, and the personnel file for LSW #451 showed she was hired on 02/12/26 and separated from the facility on 02/27/26. During interview, the Human Resources Director verified that Social Services Director #373 was the only employee in the social services department and that she was not a Licensed Social Worker and did not hold a bachelor's degree in a human services field. The Social Services Director also verified that she was not a LSW and did not have a bachelor's degree in a human services field, and stated she had been the Social Services Director since LSW #360 was fired. The Administrator confirmed the facility did not have a LSW and had not had one in the social services department since 02/27/26, stating that candidates were being interviewed but the hiring process had not been completed. Review of the undated job description for social services showed the purpose of the position was to provide services to meet residents' social and/or emotional needs, but it did not state that the Social Services Director was required to be a Licensed Social Worker when the census was over 120 residents.
Ineffective QAPI Oversight and Incomplete Performance Improvement Plans
Penalty
Summary
The facility failed to ensure an effective QAPI committee was in place to identify and address concerns in a timely and effective manner. Review of QAPI minutes and PIP documentation showed multiple action plans for issues including physical environment/pest control, care plan revisions, falls, leave of absence, dietary services, therapy/equipment, smoking policy, pharmacy services, infection control, wound care, discharge documentation, MDS 3.0 assessments, nursing point of care documentation, abuse reporting and prevention, laundry services, and PASRR. In the reviewed minutes, the plans generally identified the department responsible for the corrective action, but most did not identify a specific point person, and the monthly progress sections were blank or lacked dates and other information showing when completion was expected. The record also showed no additional information to verify that the correction plans were completed, revised when needed, or changed when they were ineffective. In several sets of QAPI minutes, previously identified action items were not revisited or followed up on, including pharmacy services, nutrition, infection control, wound care for pressure and non-pressure wounds, discharge documentation, dietary services, physical environment, and MDS assessments. During the annual survey, deficiencies were identified in many of the same areas listed in the QAPI action plans, including physical environment, care plan revisions, falls, inappropriate discharge, dietary services, pharmacy services, nutrition, infection control, wound care, discharge documentation, and MDS assessments. During interview, the Administrator, DON, and RDI stated that QAPI was intended to identify and resolve issues. The Administrator acknowledged that none of the QAPI meeting minutes had a full PIP developed and that there was no evidence of auditing, education, or other corrective measures completed to address the facility-identified concerns or ongoing monitoring to prevent recurrence. The Administrator also stated he was unaware the PIPs were not completed from QAPI meetings prior to his employment in December 2025 and confirmed there was not yet a mechanism for residents and staff to report issues to the facility's QAPI program.
Infection Control Program Deficiencies
Penalty
Summary
Infection prevention and control standards were not maintained during medication administration for a resident who had diagnoses including schizophrenia, anxiety, depression, and hypertension. During observation, an LPN was seen popping the resident’s medications out of the medication card into her ungloved hand and then into a medication cup. The LPN stated she was in a hurry and did not notice she was placing the pills into her hands first. The facility policy stated staff were not to touch medication when opening a bottle or unit dose package. Incontinence care was also observed to be performed without proper infection control practices for a resident with dementia, chronic kidney disease, repeated falls, and dependence on staff for toileting. During the observation, the CNA removed the resident’s brief and placed it on the floor by the resident’s shoes, then continued perineal care. Soiled disposable wipes, including wipes contaminated with bowel movement, were attempted to be placed on top of the soiled brief on the floor, with some landing directly on the floor. A trash can was present by the head of the bed, but there was no trash bag in it, and the CNA stated she should have opened a bag before starting care. Contact precautions were not in place for a resident with an order for contact isolation for CRAB in the blood and a quarterly MDS noting an MDRO. The resident’s care plan did not indicate the need for contact isolation, and observation of the room showed no isolation supplies outside the room, no signage, and no PPE available outside the room. The facility’s infection prevention and control policy had not been reviewed annually, and the Legionella water management program lacked a resident risk profile, overall risk determination, control measures, monitoring plan, water schematic map, and annual review documentation.
Failure to Provide Required QAPI Training
Penalty
Summary
The facility failed to conduct mandatory QAPI training for staff, as reflected in the review of personnel files and interviews. Five of 11 personnel files reviewed showed no documented evidence of QAPI training for CNA #464, CNA #465, CNA #466, LPN #338, and HRD #307. The cited employees had hire dates ranging from 04/21/25 through 02/26/26, and the facility census was 151 residents. During interviews, the HRD stated that the facility had not provided any QAPI training or in-services to staff since she began employment in April 2025 and believed the Administrator would handle that area. The Administrator confirmed that QAPI training had not been completed yet since he started employment on 12/08/25. Review of the facility assessment revised 08/01/25 showed staff training topics including communications, residents' rights, abuse, infection control, culture change, identification of changes in condition, and cultural competency, but it did not include education for staff on QAPI as required.
Failure to Provide Required Annual CNA In-Service Training
Penalty
Summary
The facility failed to ensure Certified Nursing Assistants had at least 12 hours of annual in-service training as required. Review of the employee files for CNA #325, CNA #386, and CNA #425 showed each had a hire date in 2025 and had not received the required 12 hours of in-service training annually. During an interview, the Human Resources Director verified that the CNAs had not completed the required annual in-service training and stated the facility was in the process of setting up an online education system. The census was 151 residents.
Failure to Hold Quarterly Care Conferences
Penalty
Summary
The facility failed to conduct care conferences at least quarterly for nine residents reviewed for care planning. The deficiency was identified through record review, interviews, and review of the facility’s care conference policy. The cited residents included individuals with a range of diagnoses and cognitive statuses, including dementia with behavioral disturbance, chronic respiratory failure, diabetes, depression, anxiety, cerebral infarction, seizures, schizoaffective disorder, Parkinson’s disease, and chronic kidney disease. The facility census was 151, and the issue affected nine of nine residents reviewed for care planning. For Resident #139, the record showed an admission date of 09/05/24 and diagnoses including dementia with other behavioral disturbance, depression, anxiety, hypertension, and osteoarthritis. A quarterly MDS assessment showed cognitive impairment. The record reflected only one care conference completed on 07/31/25. The resident’s guardian stated by telephone that she was concerned the resident had not had a care conference since July 2025, and the MDS/LPN confirmed that July 2025 was the last care conference and that the facility was supposed to complete care conferences at least quarterly for all residents. For Resident #119, the record showed an admission date of 11/22/19 and diagnoses including chronic respiratory failure, anxiety disorder, diabetes mellitus, and recurrent major depressive disorder. A quarterly MDS showed the resident was cognitively intact. Plan of care meeting notes showed a meeting on 10/02/25, but the resident did not attend, and there was no evidence of any additional care plan meeting afterward. The DON confirmed no additional care plan meetings could be located. For Resident #138, the record showed diagnoses including dementia with mood disturbance, chronic kidney disease, generalized anxiety disorder, hyperlipidemia, osteoarthritis, and hypertension. A plan of care meeting note from 07/31/25 stated the meeting needed to be rescheduled, but there was no evidence it was rescheduled or that another care plan meeting occurred after 04/10/25. The SSD confirmed the resident had not had a care plan meeting since April 2025. Additional residents also lacked documented quarterly care conferences. Resident #62’s record showed diagnoses including cerebral infarction, seizures, depression, anxiety, chronic kidney disease, neurocognitive disorder, insomnia, and alcohol-induced dementia; the resident stated the facility did not include her in care plan meetings or follow her preferences, and the DON later stated care plan meetings were currently not being done. Resident #6, who had traumatic brain injury, respiratory failure, tracheostomy, kidney failure, and cerebral vascular disease, had a last documented care conference on 09/21/25 with no evidence of another quarterly conference afterward. Residents #65, #66, #74, and #75 also had last documented plan of care conferences in late 2025, with no documented quarterly conference completed afterward; interviews with the SSD confirmed many care conferences were missed or not done recently. The facility policy stated residents and families were encouraged to participate in assessment and care planning conferences and that advance notice was provided, but the policy did not address the required frequency of care planning conferences.
Failure to Timely Notify Responsible Parties and Physicians of Resident Changes
Penalty
Summary
The facility failed to timely notify residents’ responsible parties and physicians of changes in condition for four residents reviewed. For Resident #56, who had schizoaffective disorder, anxiety, depression, dementia with mood disturbance, chronic kidney disease, and severe cognitive impairment, a fall occurred when she tried to transfer from her wheelchair to the toilet and fell to the floor. The record showed the nurse practitioner was notified, but the resident’s family member was not documented as notified until two days later. The DON confirmed that notification to the family two days after the fall was not timely as required. For Resident #153, who had dementia with behavioral disturbance, malnutrition, psychosis, hypertension, altered mental status, and depression, the record showed repeated removal or loss of a wanderguard, refusal of Depakote, and refusal of a shower. The medical record contained no evidence that the physician or family member was notified about the repeated wanderguard removals, medication refusal, or shower refusal. The DON verified there was no evidence of notification for those events. For Resident #2, who had dementia, multiple fractures, repeated falls, unsteadiness, weakness, and significant weight loss, the weight record showed a drop from 184.0 pounds on admission to 128.5 pounds, with additional low weights recorded afterward. The record contained no evidence that the resident’s son, identified as the emergency contact, was notified of the significant weight changes. For Resident #138, who had dementia with mood disturbance, chronic kidney disease, anxiety, hyperlipidemia, osteoarthritis, and impaired decision-making, the resident developed right wrist redness, swelling, and pain, and the NP ordered an x-ray and pain medication. The resident representative was not documented as notified until several days later, and the DON confirmed there was no evidence of timely notification of the change in condition, x-ray, or medication change.
Controlled Medication Misappropriation and Documentation Failures
Penalty
Summary
The facility failed to ensure residents were free from misappropriation of controlled medications. The deficiency involved discrepancies in controlled substance records, missing or unaccounted-for medication, and incomplete investigations related to several residents receiving or being prescribed controlled drugs. The report cites four residents affected out of five reviewed for controlled substances, with the facility census at 151. For one resident with chronic respiratory failure, COPD, heart failure, and arthritis, the physician ordered oxycodone 10 mg every four hours. The MAR showed the medication was administered at the scheduled times, but the controlled substance administration record contained out-of-order times and did not match the MAR. An extra dose was signed out on the controlled substance record but was not administered to the resident. The DON and RN confirmed the resident did not receive an extra dose, but the medication associated with the incorrect entry could not be accounted for. The DON also stated one nurse documented an administration time while not actually working that shift. For another resident with lung cancer, COPD, diabetes, and back pain, the controlled substance record showed 23 oxycodone tablets remaining when the medication card was removed from the cart by an RN. The RN later stated she destroyed the medication, but she could not produce the card or explain why it had been removed. A witness statement from an LPN conflicted with the RN’s account, and the DON verified the facility had not filed a self-reported incident related to the missing oxycodone. The report also describes a resident with schizoaffective disorder, depression, anxiety, bipolar disorder, and impaired cognition whose Lyrica was reported misplaced; the dose was not available, no dose was signed out on the count sheet, and the resident did not receive the medication. The facility’s investigation did not interview the resident or family, and the family was not notified. The report further describes a mentally intact resident with diabetes, neuropathy, peripheral vascular disease, and a chronic leg wound who had oxycodone orders for wound care days. Two nurses signed the controlled substance administration sheet indicating doses were given, but the doses were not documented in the electronic MAR. The DON stated an investigation and SRI would be initiated. Facility policies cited in the report required verification of controlled medications, proper documentation, and witness requirements for destruction of controlled substances, and defined misappropriation as wrongful use of a resident’s belongings without consent.
Failure to Follow Abuse and Misappropriation Investigation Policy
Penalty
Summary
The facility failed to implement and follow its abuse prevention policy for multiple allegations involving residents with injuries of unknown origin, a missing controlled medication, and an allegation of verbal abuse. The report states the facility did not complete thorough investigations, did not consistently interview residents or staff as required, did not document root cause findings, and in some cases did not file self-reported incidents with the State Agency when required by policy. The cited deficiencies affected four residents out of fifteen reviewed for abuse, in a facility with a census of 151. For one resident with diagnoses including lung cancer, COPD, diabetes, and back pain, the record showed an order for oxycodone 5 mg PRN. The controlled substance record showed 30 tablets were received, 23 tablets remained, and an RN/ADON removed the medication card from the cart with only her signature documented. Witness statements conflicted about whether the medication was destroyed and whether another nurse assisted. The DON verified the facility did not file an SRI for misappropriation and did not complete a thorough investigation, despite the facility policy requiring immediate reporting and investigation of misappropriation of resident property. For another resident with dementia, CKD, anxiety, hyperlipidemia, osteoarthritis, and hypertension, the record showed repeated bruising, swelling, redness, and pain to the arm and wrist with no observed accident or event explaining the injuries. The facility filed SRIs for some episodes as injuries of unknown origin, but the investigations did not identify a root cause, did not include evidence of environmental inspection, and did not show staff retraining or broader resident evaluation. The DON confirmed that when the resident later developed wrist redness, swelling, and pain, no SRI was filed even though the resident had a history of similar unexplained injuries. The report also describes a missing Lyrica card for a resident with schizoaffective disorder, depression, anxiety, bipolar disorder, and another allegation involving a resident with diabetes, COPD, CHF, anxiety, depression, and CKD who reported that a CNA spoke to her in an unfriendly way and cursed at her. In the medication incident, the resident was not interviewed, other residents were not interviewed, and the family was not notified. In the verbal abuse allegation, resident statements were not dated, not all residents in the area were interviewed, no resident assessment was completed, and staff statements were not specific to the allegation. The Administrator confirmed the investigation documentation was incomplete and that no abuse training had been completed for staff.
Incomplete Investigation of Abuse, Misappropriation, and Unexplained Injury Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse, misappropriation, and injuries of unknown origin involving four residents. For one resident with diagnoses including lung cancer, COPD, diabetes, and back pain, the record showed an order for oxycodone, 30 tablets received, and 23 tablets remaining when the medication card was removed from the medication cart by the ADON. The ADON’s signature was the only signature on the shift change log for removal, and witness statements conflicted about whether the medication was destroyed and whether another staff member was present. The DON verified that no self-reported incident for misappropriation was filed with the State Agency and that a thorough investigation was not completed. For another resident with dementia, CKD, anxiety, hyperlipidemia, osteoarthritis, and hypertension, the record documented repeated bruising, swelling, and pain to the arm and wrist with no reported accident or event. The facility submitted SRIs for injuries of unknown origin, but the investigations did not identify a root cause. The record showed no evidence of environmental inspection, no evidence of staff retraining related to the injuries, and no evidence that additional residents were evaluated when similar unexplained bruising and wrist symptoms recurred. The DON confirmed the facility could not locate evidence supporting a root cause sufficient to rule out abuse, and an SRI was not filed for later wrist redness, swelling, and pain despite the prior pattern of unexplained injuries. For a resident with schizoaffective disorder, depression, anxiety, bipolar disorder, and impaired cognition, the facility reported a missing Lyrica card as a misappropriation concern, but the investigation did not include an interview of the resident, did not notify the family, and did not include interviews with other residents in the area. For another resident who alleged a CNA spoke unfriendly and cursed at her, the investigation was incomplete because resident statements were not dated, not all residents in the area were interviewed, no resident assessment was completed, and staff statements were not specific to the allegation or dated. The Administrator confirmed the missing documentation and lack of abuse training, and the facility policy required interviews, written statements, and review of pertinent records for such allegations.
Inaccurate MDS Assessments
Penalty
Summary
The facility failed to ensure MDS 3.0 assessments were accurately completed for five residents reviewed. For Resident #5, the record showed diagnoses including multiple sclerosis, dementia, and obstructive reflux uropathy, with physician orders and nursing notes documenting an indwelling Foley catheter, but the quarterly modified MDS incorrectly coded both an indwelling catheter and an ostomy. An LPN verified the resident did not have an ostomy and that the MDS was inaccurate. For Resident #15, the record showed diagnoses including Alzheimer's disease, hypertension, and depression, with no restraint orders and no restraints documented in nursing notes, yet the quarterly modified MDS coded the resident as having other restraint used in bed daily; an LPN confirmed the resident did not have restraints and the MDS was inaccurate. For Resident #35, the record showed a fall on 10/29/25 after being pushed by another resident, but the quarterly MDS stated the resident had not had any falls since the prior assessment. For Resident #107, the admission MDS coded the resident as not receiving oxygen therapy even though physician orders and the TAR documented continuous oxygen at 2 liters per minute via nasal cannula, and an LPN confirmed the admission MDS was coded incorrectly. For Resident #9, the quarterly MDS coded the resident as taking hypoglycemic medication, but physician orders showed no active anti-diabetic medications and the LPN stated the resident last received Metformin before the assessment reference date, so no diabetic medications were received during the relevant look-back period.
Incomplete Baseline Care Plans After Admission
Penalty
Summary
The facility failed to formulate a complete baseline care plan within 48 hours of admission for multiple residents, and several records reviewed showed either no baseline care plan could be located or the document present was only an assessment form without interventions. The deficiency affected 22 of 62 residents reviewed for care plans, including residents with diagnoses such as dementia, schizophrenia, bipolar disorder, diabetes, chronic kidney disease, COPD, heart failure, pain, falls, wounds, and other complex conditions. Facility census was 151. For several residents, surveyors reviewed the medical record and found no baseline care plan. Examples included residents with severe or moderate cognitive impairment, disorganized thinking, depression, pain, falls, skin impairment, incontinence, oxygen use, and multiple chronic illnesses. In multiple interviews, the MDS/LPN stated she was unable to locate baseline care plans for residents such as those with Alzheimer’s disease, dementia, schizoaffective disorder, Crohn’s disease, and other diagnoses. For some residents, the interim or baseline care plan was present but was in assessment form and did not identify interventions. The report also identified residents whose records showed baseline or interim care plans dated at admission but lacking interventions. For one resident admitted for short-term rehab with oxygen dependence, shortness of breath, skin impairment, fall risk, nutritional problems, and pain risk, the care plan contained goals and interventions, but there was no evidence the resident was provided a copy of the baseline care plan. The DON confirmed baseline care plans were not being completed appropriately, that no interventions were in place until the comprehensive care plan, and that residents were not being given a copy of the baseline care plan as required. Facility policy stated a baseline care plan would be completed within 48 hours of admission and a summary provided to the resident and/or representative upon request.
Incomplete and inaccurate comprehensive care plans
Penalty
Summary
The facility failed to develop and maintain accurate, comprehensive care plans for multiple residents, including residents with pain management needs, psychotropic medication use, falls, insulin refusals, and code status orders. The report states that five residents were affected out of 62 residents reviewed for care plans. The facility policy required each resident’s comprehensive care plan to be reviewed and updated at least quarterly, after each comprehensive assessment, or whenever there was a change in condition, needs, or preferences. For one resident with dementia, depression, anxiety, hypertension, osteoarthritis, hospice services, and an order for morphine sulfate as needed for pain and dyspnea, the care plan did not include pain or opioid medication use. The DON verified that no care plan was in place for pain and/or opioid use even though the resident had a current morphine order. Another resident with dementia, fractures, repeated falls, hallucinations, and severe cognitive impairment had multiple falls and a serious injury, including a lumbar spine fracture and rib fractures. The record showed the fall care plan was not initiated until after several falls had already occurred, and the psychotropic medication care plan was not initiated until later despite orders for alprazolam, sertraline, divalproex, mirtazapine, and trazodone. A resident with diabetes, neuropathy, chronic kidney disease, heart failure, depression, and a prior femur fracture regularly refused insulin coverage, but the comprehensive care plan did not address the refusals. The record also showed a fall related to the resident sitting on a rollator while trying to reach a refrigerator, and staff noted the refrigerator was supposed to be moved but remained in the same place. In addition, two residents had mismatched code status documentation: one resident’s physician order and DNR form reflected DNR-CC while the care plan stated full code, and another resident’s physician order and DNR form reflected DNR-CC while the care plan stated DNR-CCA. The DON verified that the code status orders and care plans did not match.
Failure to Complete Post-Fall Assessments and Implement Ordered Fall Interventions
Penalty
Summary
The facility failed to implement effective fall interventions and post-fall assessments, including neurological checks, for multiple residents. The deficiency involved four residents reviewed for falls, with the report stating that the facility did not complete required fall risk reassessments after several falls and did not complete full neurological check series after unwitnessed falls. The facility policy required fall risk identification, documentation of risk factors, evaluation after falls, and neurological assessments for 72 hours after unwitnessed falls. Resident #42 had diagnoses including acute and chronic respiratory failure, type 2 diabetes, peripheral vascular disease, anxiety, and schizoaffective disorder, and was assessed as having moderate cognitive impairment and being at risk for falls. The record showed multiple falls in which the resident was found on the floor, reported falling, or was discovered after an unwitnessed event. For several of these falls, the report states there was no fall risk assessment completed with the investigation, and neurological checks were either singular entries or not completed at all. The DON confirmed that fall risk assessments were to be completed on admission, quarterly, and after each fall, and that neurological checks were to be done for unwitnessed falls for 72 hours. Resident #56 had diagnoses including schizoaffective disorder bipolar type, generalized anxiety disorder, depression, type 2 diabetes, dementia with mood disturbance, and chronic kidney disease stage three, and was documented as having severe cognitive impairment and multiple falls. The record showed physician-ordered fall interventions, including non-slip strips in front of the toilet and recliner, but observation with the DON found those interventions were not in place. The resident also had several falls where staff found the resident on the floor or sliding from a recliner, and the report states that multiple falls lacked a fall risk reassessment and/or complete neurological checks. The DON verified the missing post-fall reassessments and neurological checks. Resident #2 had diagnoses including dementia, lumbar vertebra fracture, multiple rib fractures, repeated falls, scalp contusion, unsteadiness, weakness, and need for assistance with personal care. The resident’s assessments showed severe cognitive impairment, hallucinations, inattention, disorganized thinking, and dependence for several ADLs. After an unwitnessed bathroom fall with head contusion and anticoagulant use, the resident was sent to the hospital and later returned with fractures; subsequent falls were also documented. The report states that post-fall risk assessments were not completed after several of these falls, and the DON and ADON confirmed missing neurological checks and that the resident could not reliably use the call light due to cognition. Resident #91 had diagnoses including right femur fracture, diabetes, weakness, chronic kidney disease, anxiety, heart failure, and major depression, and had a fall care plan and fall risk assessments documented, but the report did not identify a specific missing intervention or post-fall assessment for this resident beyond noting the fall risk assessment dates and care plan interventions.
Physician Visits Not Provided as Required
Penalty
Summary
The facility failed to ensure physician visits were provided as required for five residents reviewed for physician visits. Resident #42, with diagnoses including acute and chronic respiratory failure, type 2 diabetes, peripheral vascular disease, anxiety, and schizoaffective disorder, had moderate cognitive impairment and rejected care one to three days in the seven-day look-back period. The record showed physician visits on 04/24/25, 08/07/25, 09/11/25, 09/25/25, and 03/05/26, and the DON confirmed there were no other visits and that the resident was not seen by the physician as required between 09/25/25 and 03/05/26. Resident #44, with dementia with behavioral disturbance, psychosis, anxiety, type 2 diabetes, and schizophrenia, had moderate cognitive impairment with inattention and disorganized thinking; physician visits were documented on 07/03/25, 07/10/25, 08/21/25, 02/19/26, and 03/19/26, and the DON confirmed there were no other visits and that the resident was not seen as required between 08/21/25 and 02/19/26. Resident #53, admitted with Alzheimer’s disease, dementia, depression, anxiety, and Crohn’s disease, had severe cognitive impairment and was seen by the physician only once, on 09/04/25; the DON confirmed there were no other visits and that the resident had not been seen as required since that date. Resident #5, with multiple sclerosis, COPD, dementia, and chronic kidney disease, had severe cognitive impairment, rejected care four to six days in the review period, and was dependent for most ADLs; the record showed physician visits on 09/11/25 and 01/22/26, and the DON stated there were no other physician visits, only the nurse practitioner. Resident #35, with schizoaffective disorder, dementia, anxiety, hypertension, and COPD, had impaired cognition with moderate depression and fluctuating disorganized thinking; physician visits were documented on 07/10/25 and 11/20/25, and the DON verified the resident had not seen the physician since 11/20/25, only the nurse practitioner.
Significant Medication Errors
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors, affecting four residents reviewed for medication administration concerns. The cited events involved missed, delayed, or incorrectly timed administration of ordered medications, including opioid pain medications, an IV antibiotic, and a controlled substance used for pain. In each case, the record review and staff interviews showed that the medications were not given as ordered, and the facility policy required verification of the right drug, dose, route, rate, time, and resident before administration. For one resident with chronic respiratory failure, COPD, heart failure, and arthritis, Oxycodone 10 mg ordered every four hours was not administered at the ordered intervals on multiple occasions, with gaps of six to eight hours documented in the controlled substance record and one missed MAR entry. The DON verified the medication was not administered every four hours as ordered, and the resident stated concern about receiving pain medication timely and about remembering whether he had received it. For another resident with paraplegia, COPD, diabetes, and a UTI, Meropenem 1 gram IV three times daily was not administered on multiple scheduled doses, and nursing notes showed the pharmacy delay with no indication the physician was updated at the time of the missed doses. A nurse later verified the antibiotic was not administered as ordered. A third resident with an amputation after orthopedic surgery and pain diagnoses received Oxycodone/APAP 5-325 mg too soon on the same day, with the controlled substance record showing doses given at intervals shorter than the ordered every-eight-hours schedule. An RN verified the medication was administered too early and that one nurse failed to recognize a prior dose documented by another nurse. A fourth resident with fibromyalgia and dorsalgia had Lyrica 100 mg twice daily ordered, but the morning dose was not available and was not administered, while the MAR reflected an evening dose as given despite no dose being signed out on the count sheet; the DON verified the resident did not receive the medication as ordered and the physician was not notified.
Mechanical Soft Diet Meals Not Prepared as Ordered
Penalty
Summary
The facility failed to ensure that residents receiving a mechanical soft diet were served food prepared in the proper texture to meet their individual needs. The diet spreadsheet for the Spring/Summer 2024 menu showed that the mechanical soft diet should include ground ham and beans, soft chopped greens, cornbread with margarine, and soft chopped fruit cobbler. The recipe for Ground Ham and Beans stated that the ham would be ground before being added to the recipe. During lunch tray service, surveyors observed that there was no ground, mechanical soft ham and beans prepared for the mechanical soft diets. Residents identified on the tray line as receiving a mechanical soft texture were served regular texture ham and beans, greens, and cornbread instead of the modified texture meal. The Dietary Manager confirmed that a mechanical soft texture ham and beans was not available for the lunch meal and was not served to residents who required the texture modification. The dietitian stated she was only at the facility every other week for one day, completed the rest of her work offsite, had minimal oversight in the kitchen, and was unaware of the issues identified. The facility policy stated that a mechanical soft diet consists of foods that are easy to chew and that regular diet menu items should be mechanically altered, chopped, or ground.
Incomplete and inaccurate resident documentation
Penalty
Summary
Medical records were not kept complete and accurate for multiple residents, as shown by missing or incorrect documentation of ordered assessments, treatments, and services. The cited deficiency involved four residents out of 62 records reviewed in a facility census of 151. The facility’s documentation policy required that observations, medications administered, and services performed be documented in the resident’s clinical record. For one resident with schizoaffective disorder, anxiety, depression, diabetes, dementia with mood disturbance, and chronic kidney disease, the record showed nursing fall assessments were signed off as completed on two dates in the TAR, but there was no evidence those fall risk assessments were actually completed on those dates. The only documented fall risk assessment during the reviewed period was completed later, and the DON verified that staff signed off the assessments even though they were not actually done and were not documented accurately. For another resident with multiple sclerosis, COPD, and dementia, the MAR and TAR lacked documentation for behavior monitoring, catheter care, enhanced barrier precautions, and buttocks treatment on multiple shifts and dates. For a resident with schizoaffective disorder, depression, anxiety, bipolar disorder, fibromyalgia, and dorsalgia, the MAR showed a dose of Lyrica was administered, but the medication count sheet did not show the dose signed out, and the DON confirmed the resident did not receive the medication even though it was marked as given. For a resident with malnutrition, BLE cellulitis, diabetes, PVD, failure to thrive, chronic BLE ulcers, impaired cognition, deep tissue injuries, and vascular ulcers, multiple ordered treatments and care tasks were not signed off on several dates, and observations showed BLE dressings dated earlier than the observation dates; the DON confirmed the inaccurate documentation and stated staff were not signing off the orders within the electronic record system.
Unclean Resident Rooms and Missing Bathroom Soap
Penalty
Summary
The facility failed to maintain a clean, sanitary, and homelike environment for residents. During observation of multiple resident rooms, debris was found all over the floor in Resident #20's room, personal care wipes were noted under Resident #24's bed, a pervasive urine odor was present in Resident #65's room, large stained areas and debris were observed in Resident #75's room, and large yellow and red stained areas with debris on the floor were observed in Resident #29's room. Resident #29 stated it had been two weeks since housekeeping had vacuumed her floor and denied refusing housekeeping services. In Resident #62's bathroom, no soap was present in the dispenser. The Housekeeping Director verified these findings during the observation. Facility policy required routine and thorough cleaning of resident rooms, including daily cleaning of floors, high-touch surfaces, and bathroom fixtures, as well as daily checks and replacement of soap dispensers when empty. The Housekeeping Director stated floors were to be cleaned seven days a week, staff should be cleaning under the bed each time, a new chemical had just been received to address urine odors, and soap dispensers should be checked and replaced daily if empty. The deficiency was cited under complaint investigations involving Complaint Numbers 2677432, 2668600, and 2593029.
Psychotropic Medication Consent Not Properly Obtained
Penalty
Summary
The facility failed to ensure consent for psychotropic medications was in place for a resident with dementia, generalized anxiety disorder, recurrent major depressive disorder, restlessness and agitation, and suicidal ideations. The resident was admitted with severe cognitive impairment, hallucinations, inattention, and disorganized thinking, and later psychiatry notes described the resident as forgetful, confused, and having impaired insight and comprehension. A consent for psychotropic medications was completed for Xanax and Zoloft, with the resident giving verbal consent, despite the resident’s cognitive impairment. The resident’s medication regimen was expanded over time to include Zoloft, Xanax, Depakote, Remeron, and Trazodone, but the record showed no evidence that the resident’s representative was notified of or assisted with consent for the psychotropic medications. There were no updates to the original psychotropic consent form to include Depakote, Remeron, or Trazodone. The DON confirmed the original consent had been issued despite the resident’s cognitive impairments and was unsure whether the resident’s son had been notified.
Unwitnessed Resident Fund Management Authorizations
Penalty
Summary
The facility failed to ensure resident account management authorizations were signed and witnessed when setting up accounts managed by the facility for residents. This deficiency involved three residents out of five reviewed for personal funds, and the report states that the facility census was 151. The issue was identified during record review and interview, and the Business Office Manager verified that the authorizations were not witnessed. Resident #56 had diagnoses including schizoaffective disorder, dementia, anxiety, and depression, and the Resident Fund Manage Service authorization and agreement to handle resident funds showed the facility signed as the resident's representative payee without a witness. Resident #62 had diagnoses including cerebral infarction, alcohol induced persisting dementia, anxiety, and depression, and the same type of authorization also lacked a witness. Resident #154 had diagnoses of malignant neoplasm of the lung, anxiety, and depression, and the authorization signed by the resident's power of attorney likewise had no witness.
Failure to Report Abuse, Injury of Unknown Origin, and Possible Misappropriation
Penalty
Summary
The facility failed to report allegations of abuse, injury of unknown origin, and possible misappropriation to the State Agency as required. The deficiency involved three residents and was based on record review, staff interviews, review of self-reported incidents, and review of the facility’s abuse policy. The facility policy required immediate reporting, or no later than 24 hours, to the State Agency and other authorities for abuse, neglect, exploitation, or misappropriation, and required investigation of injuries of unknown source when the source was not observed or could not be explained and the injury was suspicious due to location, extent, or repeated occurrence. For one resident, the record showed an order for oxycodone 5 mg PRN pain, with 30 tablets received and 23 tablets remaining when the medication card was removed from the cart by the ADON. Staff statements conflicted about whether the remaining tablets were destroyed and whether another staff member witnessed the destruction. The ADON could not produce the medication card with the remaining tablets and could not explain why it had been removed. The DON verified that no SRI was filed with the State Agency for possible misappropriation related to the oxycodone. For a second resident, the record showed repeated episodes of bruising, swelling, redness, and pain to the arm and wrist with no documented accident or event explaining the injuries. The facility filed SRIs for two earlier episodes of injury of unknown origin, but the investigations did not identify a root cause and there was no evidence of environmental inspection, additional resident evaluation, or staff re-training. When the resident later developed redness, swelling, and pain to the wrist, the DON confirmed no SRI was filed because there was no bruise, despite the resident’s history of similar unexplained injuries and the facility’s inability to determine an underlying cause. For a third resident, staff separated the resident from a roommate after complaints about the roommate. The resident later stated the roommate squeezed her butt and made a sexual comment, and the resident said she did not feel safe and felt the facility was not helping her. The DON stated no SRI was completed because no mental anguish was noted. The facility’s abuse policy required investigation of any incident involving abuse, mistreatment, or exploitation, including interviewing the resident if interviewable and others with direct knowledge, and sending a complete report of the investigation within five working days.
Unsafe discharge planning and unmanaged LOA pattern
Penalty
Summary
The facility failed to ensure a safe and appropriate discharge for Resident #165. The resident was admitted on 02/26/25 and discharged on 07/01/25. His diagnoses included HIV disease, psoriasis, anemia, homelessness, anxiety disorder, recurrent major depressive disorder, and noncompliance with medical treatment and regimen due to financial hardship. The discharge planning assessment documented barriers to returning home, including health, finances, housing, and lack of support, and noted that the resident had numerous health needs with no finances, support system, or housing, so discharge would not be considered safe. The social service history also identified the resident as homeless and unemployed, while the BIMS score of 14 indicated intact cognition. During the stay, the resident was frequently absent from the facility on LOA, and the record showed repeated episodes where staff could not locate him or contact him. Notes documented that his cellphone number was disconnected, the emergency contact information was not valid, and staff called local hospitals and the county jail without finding him. The DON confirmed residents should have an order for LOAs, but the order summary report showed no order for LOAs. The SSD stated the resident often went on LOA, treated the facility as a shelter, and there were no services arranged for him when he did not return from LOA on 07/02/25. The SSD also stated he did not sign AMA paperwork to acknowledge his risks. The record further showed that the resident reported concern about where he would live after discharge and was given community resources, but he declined contact numbers for services. A 30-day discharge notice was issued for failure to pay or have Medicare or Medicaid pay for care, with a planned discharge to another nursing facility. Later notes showed the resident continued to leave the facility, remained absent for extended periods, and staff were unsuccessful in contacting him. The last progress note in the record documented attempts to reach him by phone without success, and the plan of care contained no discharge planning or frequent LOA care planning.
Failure to Provide Transfer Notice and Ombudsman Notification
Penalty
Summary
The facility failed to ensure Resident #16 was provided a written transfer notice when the resident was discharged to an acute care hospital, and failed to ensure the State and local ombudsman were notified of the resident’s discharge. Resident #16 had Parkinson’s disease, acute and chronic respiratory failure, dysphagia, and a history of cerebral infarction. The record showed the resident was severely cognitively impaired and dependent on staff for most ADLs. Review of the electronic and paper charts found no evidence that the resident or the resident’s representative received a written transfer notice, and the Social Service Designee confirmed the transfer notice was not provided and ombudsman notifications were not made because responsibility had shifted after the former social worker left the facility. The facility also failed to notify the LTC Ombudsman of Resident #165’s discharge. Resident #165 was admitted with diagnoses including HIV disease, psoriasis, anemia, homelessness, anxiety disorder, recurrent major depressive disorder, and noncompliance with medical treatment due to financial hardship. The record documented homelessness, unemployment, intact cognition with a BIMS score of 14, and discharge planning notes stating the resident had numerous health needs, no finances, no support system, and no housing, with discharge not considered safe. The resident later discharged after an adverse benefit determination and appeal process, and the DON confirmed the LTC Ombudsman was not notified of the discharge.
Failure to Complete PASARR After Significant Change in Mental Status
Penalty
Summary
The facility failed to ensure a new PASARR was completed when a resident had a significant change in condition. Resident #41 was admitted with diagnoses including dementia with behavioral disturbance, schizophrenia, depression, and anxiety. Nursing progress notes showed that the resident was involved in an aggressive incident in another resident's room, where she pushed a television and pushed the other resident to the ground. The physician was notified and nursing obtained an order to send her for psychiatric assessment. The resident was then discharged to a psychiatric facility, but the medical record contained no indication that a new PASARR was completed after the significant change in mental status. The Social Services Director verified that PASARR was not completed for the resident's psychiatric hospital admission and change in mental status.
Failure to Update Care Plans for Falls, Psychotropic Medication, and Hospice Needs
Penalty
Summary
The facility failed to revise care plans as needed for three residents. For Resident #56, the record showed a history of schizoaffective disorder, bipolar type, generalized anxiety disorder, depression, type 2 diabetes, dementia with mood disturbance, and chronic kidney disease stage three. An annual MDS indicated severe cognitive impairment and two or more falls since the prior assessment without injury. A physician order dated 01/20/26 directed non-slip strips be applied to the floor in front of the resident’s recliner, and a progress note dated 04/06/26 documented the interdisciplinary team reviewed the recommendation to encourage proper footwear/gripper socks and add non-skid strips in front of the recliner. However, the resident’s fall care plans initiated on 05/16/24 and 09/26/24 did not include non-skid strips in front of the recliner as an intervention, and the DON verified this omission. For Resident #81, the record showed diagnoses including dementia with other behavioral disturbance, anxiety, depression, hypertension, and hyperlipidemia, and a quarterly MDS indicated moderate cognitive impairment and disorganized thinking. A physician order dated 02/17/26 added aripiprazole 2 mg daily for schizophrenia, but the care plan initiated on 09/17/24 addressed psychotropic medication in general and included interventions focused on anti-anxiety medications rather than a specific antipsychotic plan. The DON stated she did not see a care plan specific to the resident’s antipsychotic, and the MDS/LPN who completed the care planning confirmed the available template was not specific to the antipsychotic medication. For Resident #1, the record showed chronic respiratory failure, COPD, CHF, and chronic pain, and the care plan dated 04/05/24 had not been updated to reflect hospice services or end-of-life care despite hospice enrollment for chronic respiratory failure and an MDS showing hospice services. The facility policy required care plans to be reviewed and updated at least quarterly and whenever there was a change in condition, needs, or preferences.
Missed medication monitoring and wound treatment orders
Penalty
Summary
Failure to provide treatment and care according to orders, resident preferences, and goals was identified for three residents. For one resident with schizoaffective disorder, dementia, anxiety, hypertension, and COPD, the record showed orders for Propanolol and Clonidine and a monthly vital signs order that included blood pressure, but blood pressure monitoring was not documented with the medications and monthly vital signs were missed on multiple scheduled dates. Review of the electronic record showed blood pressure was not obtained for several months across the review period, and the ADON verified that the monthly vital signs were not taken in December 2025 and April 2026 and that no blood pressures were obtained from April through September 2025. For one resident with motor and sensory neuropathy, schizoaffective disorder, diabetes mellitus, varicose veins with ulceration, and a chronic right heel ulcer, the physician ordered treatment for an abrasion to the right knee and left lower extremity with cleansing, triple antibiotic ointment, and dressing changes every evening shift. Observation showed the left lower extremity bandage remained dated 04/16/26 and had greenish-brown discharge on it, and the LPN confirmed the dressing had not been changed since 04/16/26 and was missed by staff on duty. The wound nurse also confirmed the lower leg wound was not addressed and the bandage was not changed from 04/16/26 to 04/20/26 due to an oversight. For another resident with malnutrition, cellulitis of both lower extremities, diabetes mellitus, peripheral vascular disease, failure to thrive, and chronic bilateral lower extremity ulcers, physician orders required nightly treatment to multiple areas of the lower extremities. The MAR showed treatments were signed off on some dates, but observations found the bilateral lower extremity dressings dated 04/16/26 on multiple occasions, and on one observation the wounds on the toes were not covered by a dressing. The resident stated he was unsure how often staff were changing his dressings, and the ADON later verified dressings dated 04/23/26 during another observation.
Failure to Assess and Treat a Pressure Ulcer Timely
Penalty
Summary
The facility failed to ensure skin was assessed appropriately and that a pressure ulcer was treated in a timely manner for one resident with a history of Alzheimer's disease, dementia, heart failure, hypertension, and adult failure to thrive. The resident was assessed as at moderate risk for skin breakdown, and a shower sheet documented intact skin. However, a skilled nursing assessment later stated there were no changes in skin integrity and no wound care was being performed, despite the resident subsequently being identified by the nurse practitioner as having a right lower extremity pressure ulcer to the right ankle. The nurse practitioner ordered triple antibiotic ointment, a pad and protective dressing, and an offloading boot, and directed that the right ankle be seen by the wound physician. Review of the physician orders showed nursing staff had not entered those orders for the right ankle pressure ulcer for the dressing and offloading boot. The next day, the wound physician documented a stage III pressure injury to the right lateral ankle and ordered a new treatment and heel boots while in bed. Interviews confirmed the skilled assessment noted no new skin issues, the nurse practitioner’s treatment orders were not entered into the computer, and the LPN who completed the assessment had not assessed the resident on the date in question.
Insufficient Nutrition Monitoring and Weight Management
Penalty
Summary
The facility failed to ensure sufficient interventions were in place to maintain residents’ nutritional status for three residents reviewed for nutrition services. The cited concerns involved inconsistent weight monitoring, inaccurate or unverified weights, missed ordered weights, and a lack of documented review of resident food preferences. Facility staff and the dietitian repeatedly noted significant weight loss, poor appetite, and meal refusal, but the record also showed that weights were taken by different methods, some weights were struck out as incorrect, and reweights were not consistently documented when discrepancies were identified. For one resident with dementia, adult failure to thrive, heart failure, anxiety, and suicidal ideations, the record showed weight loss after admission, repeated refusals of meals and supplements, and multiple nutrition notes documenting poor intake and significant weight loss. The resident complained about the food and refused Ensure, Hi-cal, and later Magic Cup supplements. The dietitian and NP noted weight discrepancies and questioned the accuracy of several weights because different weighing methods were used, including wheelchair, standing, and mechanical lift. The record also showed multiple meal refusals over several weeks, and staff interviews confirmed ongoing problems with weight accuracy and that resident food preferences were not being systematically maintained or reviewed. For another resident with abnormal weight loss, dysphagia, hypokalemia, secondary parkinsonism, anxiety, and paranoid schizophrenia, the record showed progressive weight loss over time, repeated meal refusals, and poor appetite. Weekly weights were ordered at different times, but some ordered weights were not available for review. The resident reported not liking the food, and the NP ordered fortified ice cream and Magic Cup supplements. Staff interviews confirmed the resident generally ate only a few bites, that weight discrepancies were ongoing, and that the facility had issues with scale calibration and inconsistent weighing methods. For a third resident with Alzheimer’s disease, dementia, dysphagia, hypertension, and adult failure to thrive, the record showed that the admission weight was taken from a hospital weight rather than an admission weight obtained by the facility, and ordered weekly weights were not completed as ordered in December 2025. The resident’s record also reflected fluctuating weights and no documented system for current food preference review.
Oxygen Tubing and Settings Not Maintained Per Orders
Penalty
Summary
The facility failed to maintain oxygen tubing in a hygienic manner and per standards of practice for three residents receiving respiratory care. Resident #11 had diagnoses including lupus, chronic respiratory failure, type 2 diabetes, depression, dementia with behavioral disturbance, and anxiety, and an annual MDS showed moderate cognitive impairment with inattention and disorganized thinking. During observation with the DON, Resident #11’s oxygen tubing was dated 03/16/26, and the DON verified it needed to be changed because it was due to be changed weekly but had not been completed. Resident #42 had diagnoses including acute and chronic respiratory failure, type 2 diabetes, peripheral vascular disease, anxiety, and schizoaffective disorder, and a quarterly MDS showed moderate cognitive impairment and rejection of care. During observation, Resident #42’s oxygen tubing was not dated, and RN #446 verified it was not dated and needed to be changed; the DON later confirmed the resident’s last oxygen order had been discontinued and that an order was needed for oxygen administration. Resident #32 had diagnoses including hemiplegia, heart failure, dementia, and COPD, and had an order for oxygen at 2 liters via nasal cannula. Observation showed the oxygen concentrator was set at 4.5 liters, and both CNA #418 and LPN #374 verified the setting was incorrect; the tubing was also not dated when it had been changed by nursing staff.
Missing Pre- and Post-Dialysis Monitoring
Penalty
Summary
The facility failed to provide comprehensive pre- and post-dialysis monitoring for a resident with end stage renal disease, COPD, mild protein-calorie malnutrition, dementia, and Alzheimer’s disease. The resident was admitted on 04/17/26 and had physician orders for dialysis, including checking the access site for bruit and thrill, checking the permacath site daily and upon return from dialysis, and applying pressure and transferring to the ER if bleeding was noted. The resident’s assessments did not include pre- and post-dialysis monitoring, and the care plan did not include pre- and post-dialysis monitoring. The resident’s nurses’ notes from 04/17/26 through 04/21/26 did not mention dialysis care and service. A dialysis report showed the resident received off-site dialysis on 04/20/26 from 7:19 A.M. to 10:17 A.M. The resident’s guardian stated the resident had been receiving dialysis for the past two years and was supposed to go Mondays, Wednesdays, and Fridays. An LPN reported receiving handoff that the resident had gone to dialysis, and the ADON stated this was the resident’s first dialysis treatment since admission. During interview, the ADON stated the resident should have had blood pressure checked before and after dialysis and confirmed that this information could not be found in the record. The DON stated staff were to obtain vitals, weight, and bruit and thrill both before and after dialysis using a dialysis communication form, but no pre- or post-dialysis assessments were located in the record and the form could not be provided for review. The DON also verified no blood pressure was recorded for the resident on 04/20/26.
Failure to Provide Adequate Social Services and Psychosocial Support
Penalty
Summary
The facility failed to ensure sufficient and appropriate social services were provided to meet the psychosocial and emotional needs of a resident with dementia with mood disturbance, generalized anxiety disorder, and impaired cognition. The resident’s record showed ongoing delusions, hallucinations, agitation, irritability, poor concentration, poor insight, and impaired judgment, along with moderate depression on MDS mood assessment. The resident was also unable to participate in BIMS testing and required substantial to total assistance with multiple activities of daily living. The record showed repeated concerns related to the resident’s emotional and psychosocial status, including not participating in activities, tearfulness during a psychiatric assessment, and a history of the resident’s husband passing away. The resident’s care plan included psychosocial and communication interventions, but the record contained no evidence of social service assessments addressing psychosocial and emotional needs after 12/02/24. The record also showed that a care plan meeting scheduled for 07/31/25 needed to be rescheduled, and there was no evidence that it was rescheduled or that a care plan meeting had been held since 04/10/25. The resident also experienced multiple injuries of unknown origin, including bruising to the arms and wrist, a hematoma, redness, swelling, and pain to the right wrist, with no documented root cause identified in the facility investigations. The facility reported some of these events as SRIs, but the investigations did not identify a root cause, and there was no evidence that emotional or social services support was provided in connection with those incidents. Interviews with the SSD and DON confirmed the resident had not had a care plan meeting since April 2025, that assessments had been delayed, and that there was no evidence the resident’s representative was notified in a timely manner about the later wrist change in condition.
Medications Not Available as Ordered for Resident
Penalty
Summary
The facility failed to ensure medications were available to administer to Resident #35 according to physician orders. Resident #35 was admitted on 06/23/17 and had diagnoses including schizoaffective disorder, dementia, anxiety, hypertension, and chronic obstructive pulmonary disease. Her orders included Latanoprost eye drops for glaucoma, Quetiapine 300 mg at bedtime, Restoril 7.5 mg at bedtime for insomnia, and Artificial Tears three times daily for irritated eyes. Review of the MAR showed missed administrations of Latanoprost, Quetiapine, Restoril, and Artificial Tears on multiple dates between October 2025 and April 2026. Nursing progress notes documented that the medications were held or unavailable, including entries stating Restoril was on hold or waiting on arrival from the pharmacy, Latanoprost eye drops were unavailable or awaiting refill, Artificial Tears were on order or recalled, and Quetiapine was on order. The notes also showed that the physician was not updated when the medications were held. During interview, the LPN/ADON verified the medications were not administered as ordered and stated the facility had over-the-counter medications in storage rooms and an emergency kit available for nursing staff use. The quarterly MDS showed Resident #35 had impaired cognition.
Failure to Provide Timely Dental Services
Penalty
Summary
Provide or obtain dental services for each resident. The facility failed to ensure timely dental services for one resident reviewed for dental services. Resident #12 was admitted with diagnoses including diabetes mellitus, hypertension, chronic pain, and unspecified protein-calorie malnutrition. The medical record showed a physician order for a dental visit shortly after admission, and later an order for Orajel for tooth and gum pain. The resident’s MDS assessment documented impaired cognition and noted obvious or likely cavities or broken natural teeth. The dental visit record showed the resident had not been seen by the dentist during the period reviewed, including after the order for dental evaluation. During interview, the resident stated she needed to see the dentist, had a loose tooth and pain at times, and required a special diet because of her dental status. The Medical Records Coordinator verified the resident had not been seen by the dentist since admission and stated the facility’s dental service did not do emergency services. The facility policy stated routine and emergency dental services were available and that social services personnel were responsible for assisting the resident or family in making dental appointments.
Failure to Coordinate Hospice Documentation and Care
Penalty
Summary
The facility failed to ensure coordination of care with hospice services for one resident receiving hospice care. The resident was admitted with diagnoses including chronic respiratory failure, COPD, CHF, and chronic pain, and the quarterly MDS indicated he was receiving hospice services. However, the resident’s care plan dated 04/05/24 had not been updated to reflect hospice services or end-of-life care, and the facility’s medical record did not contain documentation of hospice staff visits such as weekly nursing visits or three-times-weekly aide visits. The hospice enrollment form showed the resident was admitted to hospice for chronic respiratory failure, and the facility’s hospice binder contained a hospice plan of care update report dated 04/18/26 with diagnoses, orders, and care plan information. During interviews, the hospice RN stated she visited once per week and used internal notes for visits, but did not provide facility documentation and was unsure whether the notes were sent to the facility or where they were located. The hospice HHA stated she visited three times per week and also did not provide facility documentation. The DON verified that the only hospice documentation in the resident’s medical record and hospice binder was the enrollment form and plan of care, and the facility hospice policy did not address coordination of care related to hospice staff visit summaries.
Failure to Accurately Document Medication Administration and Bathing Records
Penalty
Summary
The facility failed to ensure accurate and complete documentation of medication administration and bathing records for two residents. For one resident with multiple diagnoses including diabetes, morbid obesity, and a surgical wound infection, there were several instances where the administration of IV cefepime was not signed off in the medication administration record on specific dates and times. Nursing progress notes did not address these missing entries, and the DON confirmed the omissions, attributing them in part to the lack of an IV-certified nurse on the unit and reliance on supervisors to administer the IV medication, who may have failed to document administration. For another resident with dementia, depression, and a history of strokes, bathing records over several months were found to be incomplete, with multiple shifts lacking documentation on whether a shower or bath was offered or provided. The DON verified that the bathing records were incomplete. These findings were identified during a complaint investigation and represent failures in maintaining accurate and complete medical records in accordance with professional standards.
Call Light Inaccessibility for High Fall Risk Resident
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including dementia, anxiety, depression, schizophrenia, morbid obesity, and a recent left lower leg fracture, was found unable to access the call light in her room. The resident, who had a moderate cognitive deficit and was assessed as a high fall risk with two recent falls, was observed sitting on her bed with the call light hanging from the wall and lying on the floor between the bed and the wall. The resident reported being unable to reach the call light and demonstrated her inability to do so during the observation. Further observation and interview with an LPN confirmed that the call light was indeed inaccessible, as it was stuck between the bed and the wall. The LPN had to physically crawl over the bed and stretch to retrieve the call light and make it accessible to the resident. This incident was documented as a failure to ensure that call lights were accessible to residents, as required, and was identified during an investigation under a specific complaint number.
Failure to Update Menus and Ensure Correct Portion Sizes
Penalty
Summary
The facility failed to ensure that menus were prepared in advance, updated periodically, and followed, which affected the nutritional needs of all 154 residents. The facility was using outdated menus from spring and summer 2024 instead of the current fall/winter menu. This discrepancy was confirmed by the Assistant Dietary Manager, who also reported issues with ordering and delivery that led to frequent menu changes without proper documentation. Additionally, the facility did not maintain a substitution log or track meals served, leading to inconsistencies in meal portions. Observations and interviews revealed that residents were not receiving the correct portion sizes as specified in the menu. For instance, a dietary aide used a non-measurable serving spoon to serve spaghetti, resulting in smaller portions than the prescribed eight ounces. Residents expressed concerns about incorrect meals and small portion sizes during resident council meetings, but these issues were not addressed due to the absence of the Dietary Manager. The Administrator and Director of Nursing were unaware of these concerns, and the facility had not rescheduled a canceled food committee meeting, further delaying the resolution of dietary issues.
Sanitation and Infection Control Deficiencies in Kitchen and Meal Service
Penalty
Summary
The facility failed to maintain a sanitary kitchen and food storage areas, as well as ensure proper infection control during meal service. Observations revealed that the kitchen floors were littered with torn sugar packets, old food pieces, crumbs, and sticky substances. Walls had dried liquids, and the chemical dishwasher was covered with dust, food crumbs, dirty washcloths, and a dried-up sponge. Additionally, soup bowls were placed under a light used to kill gnats. The Assistant Dietary Manager confirmed these sanitation issues, attributing them to recent staff changes and a lapse in the cleaning schedule, which was not being signed off or located. During meal service, a Dietary Aide was observed handling food with ungloved hands after adjusting her hair net, touching various surfaces, and wiping her hands on her clothing. She placed breadsticks and cheese on residents' plates with ungloved hands and picked up dropped spaghetti from the tray line, placing it back on a resident's plate. These actions were confirmed by the Assistant Dietary Manager, highlighting a failure in maintaining proper hygiene and infection control during food preparation and service. This deficiency was investigated under Complaint Numbers OH00161141 and OH00161383.
Failure to Maintain a Clean and Sanitary Environment for a Resident
Penalty
Summary
The facility failed to maintain a clean, sanitary, and homelike environment for Resident #72, who was affected by this deficiency. Resident #72 had a medical history that included diabetes mellitus type one, an acquired absence of the left leg below the knee, major depressive disorder, and noninfectious gastroenteritis. The resident required supervision and touch assistance for toileting hygiene and showering and used a motorized wheelchair. Observations revealed the resident's room was in disarray, with a strong sour smell of vomit and feces, a full urinal, a basin of vomit, scattered food, and trash, and a dead cockroach. The resident was found in a fetal position on his bed, reporting illness since the previous night and expressing a need for assistance in keeping his room clean. Interviews with facility staff, including an LPN, CNA, housekeeper, and housekeeping supervisor, revealed that the resident's room was often messy due to his frequent illness and that housekeeping was responsible for cleaning it. However, on the day of observation, the room remained uncleaned despite the resident's compliance with care. The LPN confirmed the room's condition but did not attempt to clean it. The housekeeping supervisor claimed the resident refused cleaning in the morning, but this was not reported to the LSW. The Director of Nursing confirmed that the expectation was for staff to address sanitation issues promptly if the resident was compliant, which was not done in this case.
Failure to Eradicate Cockroaches Due to Sanitation Issues
Penalty
Summary
The facility failed to eradicate cockroaches from a resident's room, affecting one resident out of three reviewed for pest control. The resident, who was admitted with diagnoses including diabetes mellitus type one, major depressive disorder, and noninfectious gastroenteritis, displayed behavioral symptoms such as defecating on the floor and in the trash can instead of using the provided bedside commode. Observations revealed unsanitary conditions in the resident's room, including a strong sour smell, a full urinal, a basin of vomit, scattered food, and a dead cockroach on a glue trap. Interviews and pest control service reports indicated that the room was treated for cockroaches on multiple occasions, but the presence of personal items and clothing throughout the room hindered thorough pest control efforts. The pest control company noted sanitation issues in the room, which contributed to the ongoing presence of cockroaches. The facility's administrator confirmed that the resident's sanitation issues were a factor in the failure to completely eradicate the cockroaches.
Improper Preparation of Cinnamon Rolls
Penalty
Summary
The facility failed to ensure that cinnamon rolls were properly prepared, resulting in them being unpalatable and unappetizing. Observations and interviews revealed that the cinnamon rolls served were approximately the size of a 50-cent piece, hard, and crunchy. Multiple residents, including Resident #6 and Resident #7, complained that the cinnamon rolls were too hard to eat. Resident #6 had eaten only 10% of his lunch tray, and Resident #7 described the cinnamon roll as very hard and gross. Staff members, including a State tested Nursing Assistant (STNA) and a Registered Nurse (RN), confirmed the residents' complaints about the cinnamon rolls' texture and appearance. The Dietary Manager (DM) acknowledged that the cinnamon rolls served on the specified date were not properly prepared. The DM explained that a dietary cook failed to place the tray of cinnamon rolls over a steam table to allow the dough to rise before baking, resulting in the small size and hard texture. The DM confirmed that the cinnamon rolls were not palatable or appetizing and should not have been served to the residents. The dietary cook responsible for the preparation error was subsequently educated on the proper preparation of cinnamon rolls.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 543 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Canton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hall Of Fame Rehabilitation And Nursing Center | 1.6 mi | ★★★★★ | 26 | 0 |
| Canton Christian Home | 1.9 mi | ★★★★★ | 14 | 0 |
| The Pines Healthcare Center | 2.1 mi | ★★★★★ | 4 | 0 |
| Astoria Skilled Nursing And Rehabilitation | 2.1 mi | ★★★★★ | 2 | 1 |
| Bethany Nursing Home, Inc | 2.6 mi | ★★★★★ | 52 | 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.