Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at New Dawn Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with CHF, CKD stage 4, anxiety, and a thoracic vertebral fracture had hospice pain orders for scheduled oxycodone every 4 hours plus PRN oxycodone, but the facility transcribed only the PRN order. As a result, the resident missed scheduled doses overnight and had documented pain, including crying and reporting severe back pain; the clinical manager verified the order was transcribed incorrectly.
A resident with dementia, reduced mobility, and wheelchair use reported that staff had dropped her while she was being changed and developed left knee pain and swelling. An LPN gave PRN acetaminophen, but the provider was not notified right away despite ongoing pain, swelling, and later documentation that the resident was yelling in agony with movement. An x-ray was delayed until later and showed a comminuted distal femur fracture, after which the resident was sent to the ED for further evaluation.
Insufficient nursing staffing led to delayed call light response and resident care delays. Multiple residents and a resident representative reported that staffing was short on all shifts, call lights were not answered timely, and residents waited a long time for toileting, incontinence care, and showers. One resident’s call light was observed unanswered for about 22 minutes, and the resident stated delays sometimes resulted in incontinence and extra linen and clothing changes. A CNA confirmed the facility used agency CNA and nursing staff to help cover staffing needs.
Failure to Provide Education and Informed Consent for Psychotropic Medications: The facility did not document that residents receiving psychotropic meds were educated on the risks and benefits before treatment. Residents with diagnoses including depression, dementia, anxiety, schizoaffective disorder, PTSD, and insomnia were ordered meds such as Zoloft, Remeron, Ativan, risperidone, clonazepam, alprazolam, and quetiapine, but the record lacked evidence of informed consent. The DON confirmed the facility had no evidence of this education or consent process for these residents.
The facility failed to maintain a comprehensive infection prevention and control program and failed to ensure staff were knowledgeable on handling infectious linens. The infection control log was not trended, was incomplete, and did not consistently identify infection types, organisms, or isolation details for multiple residents, while an LPN/IP confirmed the log was not being reviewed for trends and a vaginal infection trend was not investigated. In addition, a Laundry Attendant stated staff did not know the type of isolation or infection for red-bagged linens and that isolation items may not always be kept separate from regular linen during laundering.
Failure to Maintain an Effective Antibiotic Stewardship Program: The facility did not have an effective system to monitor antibiotic use, document the indication, dose, and duration of antibiotics, or consistently apply McGeer’s criteria. An LPN/IP and the DON reported gaps in oversight and staff education. One resident received doxycycline for a respiratory concern despite a negative chest x-ray and no documented criteria for treatment, and another resident received ceftriaxone for UTI despite no documented signs or symptoms and no evidence that McGeer’s criteria were met.
Excessive lint buildup was found in two laundry dryers during an observation of the laundry room. Both lint traps were entirely covered in thick white lint, and lint had also built up on the bottom of each dryer. An LNA confirmed the buildup was excessive and appeared to be from more than one day.
Unsafe and Unsanitary Resident Environment: The facility failed to maintain a clean, sanitary environment for multiple residents. One resident’s room had urine odors, urine on the floor, and bowel movement smears on the toilet and walls, with the family reporting ongoing dirty linens and odors; another resident’s bathroom had a strong urine odor, an uncovered bed pan on the toilet, and damaged wall surfaces; a third resident’s bathroom contained soiled briefs in an unlined trash can with a strong urine odor. Staff also confirmed ongoing odor concerns and that soiled briefs were sometimes discarded in trash cans without liners.
Advance directive records were inaccurate or missing for multiple residents. One resident had no documented code status in the paper chart, EMR, or emergency binder, while others had conflicting documentation between signed directives, orders, care plans, and the emergency binder. LPNs confirmed the emergency binder was the first place staff should check for code status, but it did not consistently contain the residents’ advance directives.
Pureed diet food was not prepared to the proper consistency for five residents on ordered pureed diets. During observation, an LPN-like dietary process was not involved; instead, Dietary Staff blended chicken and dumplings, but the item still contained gritty chicken and larger noodle/dumpling pieces when tasted by the surveyor. The DON-equivalent dietary manager confirmed pureed items should be smooth with no chunks and stated the food could have been blended longer.
A resident who was dependent on staff for bathing and required a Hoyer lift did not receive documented shower assistance as scheduled. Bathing sheets and progress notes showed multiple days with no record that a shower was provided or even offered, while the resident stated she went without showers on several days after returning from the hospital. An LPN, CNA, and DON confirmed the resident was supposed to be offered a shower daily and that the documentation did not support that this occurred.
Failure to assess and manage urinary incontinence: A resident with dementia, CKD, recurrent UTI, and obstructive/reflux uropathy was frequently incontinent of bowel and urine, but the facility did not determine the type of urinary incontinence or implement an effective toileting plan. The record lacked evidence of timely incontinence care on multiple occasions, and the DON confirmed there was no urinary toileting trial/program and no clear identification of the incontinence type.
A resident with dementia, CKD, metabolic encephalopathy, subarachnoid hemorrhage, and other diagnoses had a nutrition risk care plan that included monitoring meal intakes, but the record lacked evidence of multiple meal intake entries. The resident required assistance with eating, lost 10.43% of body weight in 29 days, had a mini-nutritional assessment score indicating malnutrition risk, and there was no evidence that nutritional interventions were developed and implemented. The resident’s representative said the resident could not feed herself and was unsure staff were consistently helping, while a CNA stated, “I absolutely will not feed her,” and the DON confirmed the lack of meal intake evidence.
Failure to Report Injury of Unknown Origin: A resident with dementia and moderate cognitive impairment complained of severe left knee pain after saying staff had dropped her while changing her. Nursing notes documented swelling, limited movement, and later imaging showed a comminuted distal femur fracture with displacement and effusion. The facility’s investigation could not confirm the cause of the injury, yet the Administrator confirmed it was not reported to the State Survey Agency.
A resident’s quarterly MDS was not coded accurately because depression was omitted from the active diagnoses even though the resident was receiving antidepressants, including Zoloft for depression and Remeron as an appetite stimulant. The MAR showed both medications were given during the assessment period, and the DON confirmed the MDS should have included depression as an active diagnosis.
Incomplete PASARR Assessments and Missing PASARR Care Plans: The facility failed to keep PASARRs accurate and failed to carry out PASARR recommendations for two residents with significant psychiatric diagnoses. One resident’s PASARR omitted delusional disorder despite psychotropic use and related care planning, while another resident’s PASARR and MDS did not reflect documented delusions, anxiety, paranoid personality disorder, or Level II PASARR findings. The second resident also had no PASARR plan of care or safety plan, even though Level II recommendations called for psychiatric review, neuro exams, counseling, behavioral interventions, therapy, and activities.
Failure to Include Constipation in the Care Plan: A resident with CHF, DM, muscle weakness, and difficulty walking was receiving scheduled Colace for constipation, but the comprehensive care plan did not address constipation. The DON confirmed the omission and acknowledged the resident should have had a care plan for this issue.
Failure to Hold Quarterly Care Planning Conference: A resident with chronic respiratory failure, ventilator dependence, and other significant diagnoses did not have a quarterly care planning conference after admission, and there was no evidence that she or her family were invited to participate. The resident said she had not been included in any care planning meetings, the LSW confirmed no quarterly conference had been completed, and the Activity Director stated she was responsible for scheduling but relied on the SW to identify which residents needed conferences.
A resident with multiple chronic conditions, including DM2, ESRD on dialysis, and adult failure to thrive, had a mid-spine skin injury that was ordered for treatment, but no comprehensive skin assessment was documented on admission or when the alteration was first noted. Staff were unsure whether the area was pressure-related, described it as a scratch, and later observed an open area with scant drainage under a dressing; the wound team had not evaluated the resident, and the DON and wound nurse confirmed the assessment had not been completed.
Failure to assess and monitor a resident's AV fistula. A resident with ESRD and dialysis dependence had an AV fistula documented in hospital records and dialysis orders for M/W/F, but the baseline care plan and admission assessments did not identify the fistula, and there were no orders or evidence that staff were assessing or monitoring it. An LPN confirmed the lack of orders and monitoring, and the DON confirmed there was no dialysis care plan or order to remove the dressing placed after dialysis.
Improper bedside storage and administration of medications: Two residents had medications left in pill cups on their bedside tables without orders or indications for bedside storage or self-administration. One resident with DM and other chronic conditions kept several meds at the bedside because she waited to take them after meals, and another resident with cancer, anemia, AFib, GERD, and DM had chemo capsules left at the bedside by the nurse. An RN stated meds must be observed as taken before documentation, and a CNA reported seeing meds left at residents’ bedsides.
The facility failed to ensure antibiotic use was necessary for two residents. One resident had no documented UTI signs or symptoms, yet the NP ordered ceftriaxone after a urine culture grew bacteria, while the IP stated she was unsure the resident met treatment criteria and had not completed infection tracking. Another resident with significant cognitive impairment received an extra dose of cephalexin before it was on the MAR, and the DON confirmed it was given without a provider order or notification.
Undated COVID-19 consent and missing education documentation: The facility failed to document a resident or representative signature and date on a COVID immunization consent form and had no evidence that education on the risks and benefits of the vaccine was provided. The affected resident had CHF, dementia, OA, CKD, Afib, and HTN, and the DON confirmed the missing documentation; the facility policy required education and documentation of vaccination status.
Surveyors found multiple failures to follow infection prevention and control practices, including Enhanced Barrier Precautions (EBP), wound care, glucometer disinfection, and catheter care. An LPN administered IV antibiotics through a PICC line for a resident on EBP without wearing a gown, despite posted EBP signage and a policy requiring gown and gloves for high-contact device care. An RN performed a dressing change on a resident’s toe wound under an EBP care plan using only gloves and no gown, even though the door sign indicated EBP for the wounds. Another LPN used a shared glucometer for a resident’s blood glucose check, placed the glucometer and test strip container on the bed and then on the med cart, and did not clean or disinfect the equipment between residents, contrary to facility policy. In addition, a CNA provided catheter care to a resident and then continued to handle the call light, bed controls, bedding, and the urinary drainage bag without removing the contaminated gloves.
Staff failed to consistently monitor a resident’s blood pressure before administering antihypertensive medications. An RN gave lisinopril and metoprolol succinate, then checked the resident’s blood pressure afterward, despite acknowledging it should have been taken beforehand. Review of the MAR showed no specific hold parameters for these drugs, though there was a section to document BP and pulse with metoprolol tartrate, and multiple prior low BP readings had led to doses being withheld. The DON confirmed that BP should ideally be checked before giving medications that can lower BP, particularly for residents with a history of low readings.
A resident with dementia, repeated falls, generalized muscle weakness, gait difficulty, incontinence, and multiple medications (including diabetic, BP, narcotic, and psychotropic drugs) was care-planned and had MD orders for Dycem/non-skid material on the wheelchair as a fall-prevention intervention. A fall risk assessment identified the resident as high risk for falls and continued the Dycem intervention. During surveyor observation, the resident was found sitting in a wheelchair without the Dycem or other non-skid material in place, and an LPN confirmed its absence, resulting in a cited failure to implement the ordered fall-prevention measure.
A resident with multiple medical conditions, including a wrist fracture and CHF, was assessed as needing catheter care, which was scheduled every shift but documented as completed on only a few shifts, with the DON attributing the lack of entries to documentation issues. The resident’s skin was initially documented as intact with no wounds, yet later skilled evaluations recorded skin concerns and dressings as dry and intact on several occasions, while no wound assessments could be found. During interviews, an RN, a CNA, and the DON all denied the presence of wounds or dressings beyond a wrist cast and stated that the skin remained intact, creating discrepancies that showed the medical record was incomplete and inaccurate.
The facility failed to implement its antibiotic stewardship program for two residents who were documented in the infection control log as having in-house UTIs and were treated with antibiotics, despite no recorded UTI signs or symptoms in their medical records. For both residents, who had intact cognition and were dependent for ADLs, the infection control log indicated that McGeer’s criteria were met, yet there was no supporting clinical documentation or completed McGeer’s assessments. The DON confirmed the absence of documented UTI symptoms and assessments, even though the facility’s antibiotic stewardship policy required the infection control nurse or designee to review antibiotic utilization to ensure appropriate prescribing and use.
Surveyors found that staff failed to keep call lights within reach for two cognitively impaired, ADL-dependent residents who were care planned as fall risks. In one case, a resident seated in a Broda chair had the call light lying on the floor beside the bed, despite a care plan requiring it to be within reach and a sign to prompt use; a CNA confirmed it was not accessible and noted a loop on the cord intended for the resident’s wrist due to blindness. In another case, a resident lying in bed had the call light positioned behind a refrigerator, also out of reach, which a CNA verified. These observations showed the facility did not follow its own policy requiring call lights to be easily reachable when residents are in bed or confined to a chair.
A CNA failed to follow infection control protocols during incontinence care for a resident with multiple comorbidities, including diabetes and morbid obesity. The CNA reused washcloths for different body areas, did not follow the required front-to-back cleaning method, and did not use separate cloths as outlined in facility policy. The CNA acknowledged not following proper infection control procedures during the care.
A resident with type 1 diabetes and multiple comorbidities experienced critically high blood glucose readings that exceeded the prescribed insulin sliding scale. Despite facility policy requiring physician notification for such elevated levels, documentation showed only that a supervisor was notified, with no evidence that a physician or on-call provider was contacted for follow-up orders.
A facility failed to administer medications according to physician orders and manufacturer directions, resulting in a 10.8% error rate. An LPN gave medications to a resident with a heart rate below the prescribed threshold, and another LPN used an undated Lantus vial and rubbed the injection site against instructions. The DON confirmed the errors.
A resident with a complex medical history was administered Gleevec beyond the ordered duration due to the facility's failure to document and follow orders to hold the medication. Despite instructions from a hematology/oncology consultant and hospital discharge orders, the facility resumed the medication, leading to adverse symptoms and a significant medication error.
A resident's MAR was found incomplete, with missing documentation for lidocaine patch application and removal, blood glucose monitoring, and clindamycin administration. The DON confirmed the MARs were incomplete, and the facility's policy required documentation of medication administration.
A resident with diabetes and a leg amputation experienced a delay in receiving care after repeatedly requesting a snack and drink to manage low blood sugar. Despite using the call light multiple times, the resident's needs were not promptly addressed by a CNA, leading to frustration and a call to 911. The facility's investigation did not adequately address the timeline of events or the delay in meeting the resident's needs.
The facility failed to prevent the misappropriation of controlled medications, affecting 11 residents on the 200 hall. Inconsistencies in the Controlled Medication Shift Change Log led to discrepancies in medication counts, with missing Morphine not properly documented or located. Staff interviews confirmed the lack of adherence to procedures for handling discontinued or expired medications, and the facility's policy did not adequately address narcotics reconciliation.
The facility failed to accurately reconcile controlled medications for 33 residents, as revealed by discrepancies in the Controlled Medication Shift Change Logs. Interviews with LPNs indicated inconsistent documentation, particularly by agency nurses, leading to potential discrepancies in medication counts. The facility's policy did not adequately address the reconciliation process, contributing to the deficiency.
A resident with diabetic foot ulcers did not receive proper wound care as prescribed, with missed dressing changes on multiple occasions. The resident reported pain and uncompleted dressing changes, while an LPN admitted to not performing a change and incorrectly signing off the treatment sheet. The DON confirmed lapses in documentation and care.
A facility failed to provide proper care for a resident with a Stage IV pressure ulcer, as evidenced by missed dressing changes and incorrect mattress settings. Despite orders for Enhanced Barrier Precautions, LPNs only used gloves during wound care. The resident's care plan was not adequately followed, leading to this deficiency.
The facility failed to adequately monitor and document the administration of narcotic pain medications for two residents. One resident received Oxycodone without proper documentation on the MAR, and another had Tramadol removed from the controlled substance drawer without corresponding records. The Director of Nursing confirmed the discrepancies and lack of comprehensive pain assessments, violating the facility's Pain Management Policy.
The facility failed to label narcotic medications according to professional standards, affecting two residents. One resident's Tramadol label included conflicting orders, causing confusion about administration frequency. Another resident's Tramadol was labeled for routine dosing despite an as-needed order, leading to administration errors. LPNs confirmed these discrepancies.
The facility failed to maintain accurate medical records for two residents, with discrepancies in the administration of controlled substances. A nurse signed out multiple doses of morphine and oxycodone without explanation or proper documentation, violating the facility's policies. The Director of Nursing confirmed the lack of documentation for excess medication.
A facility failed to follow infection control measures during a dressing change for a resident with a Stage IV pressure ulcer. Despite orders for Enhanced Barrier Precautions, two LPNs only used gloves and did not wear masks or gowns as required. The facility's policy aimed at preventing multidrug-resistant organism transmission was not adhered to, and the oversight was confirmed in an interview with one of the LPNs.
The facility did not ensure food was served at palatable temperatures, affecting all residents who ate meals prepared in the kitchen. Interviews with residents revealed concerns about food often being cold. An observation showed that while food on the steam table was initially hot, it cooled significantly by the time it was served. A test tray revealed BBQ ribs at 98°F and sweet potato fries at 94.3°F, both cool to the touch and lukewarm in taste.
The facility failed to properly sanitize dishes and utensils as the dish machine did not reach the required temperature for sanitization. Observations showed temperatures between 145-147°F, below the necessary 180°F. Staff were not instructed on handling inadequate temperatures, and the issue was linked to a faulty hot water tank. The problem persisted from April to June 2024, with no proper sanitization process in place until the deficiency was identified.
The facility failed to provide facial protection for staff handling soiled linens and did not implement its water management program for legionella prevention. Observations revealed no facial shields in the laundry room, and the Maintenance Director was unaware of key plan components. Additionally, the TB risk assessment was outdated, using data from 2021 despite more current information being available.
The facility failed to secure and discard expired medications, affecting three residents and potentially impacting all 25 residents on the 200 unit. An LPN verified expired insulin for two residents, while another resident had medications without a physician's order. Expired over-the-counter medications were also found in the storage room, violating facility policies.
The facility failed to forward the personal funds of two deceased residents to their estates within 30 days. One resident, with altered mental status, diabetes, and hypertension, passed away, but her funds were not dispersed until months later due to contact issues with her representative. Similarly, another resident with congestive heart failure, diabetes, and hypertension experienced a delay in fund disbursement for the same reason. In both cases, the funds were eventually used to settle outstanding balances with the facility.
A facility failed to document a resident's wish for CPR in the medical record. The resident initially had a DNRCCA-DNI order, but later signed an Advance Directive Questionnaire indicating a desire for CPR. A social service note also documented the resident's request for full measures, but this was not immediately updated in the medical record. The discrepancy was later addressed by the DON, who clarified and updated the resident's code status.
The facility failed to establish comprehensive care plans for two residents. One resident with anxiety was prescribed Vistaril, but their care plan did not address the anxiety diagnosis or medication use. Another resident, who fell and sustained fractures, had a care plan that addressed only one of the fractures. These deficiencies were confirmed by the DON.
Incorrect transcription of pain medication orders led to missed doses
Penalty
Summary
The facility failed to correctly transcribe a resident’s pain medication orders, resulting in missed doses and documented pain. Resident #81 was admitted with diagnoses including heart failure, chronic kidney disease stage four, anxiety disorder, and an unspecified fracture of the fourth thoracic vertebra. Hospice medication orders dated 07/09/26 included Oxycodone 5 mg by mouth every four hours for pain and Oxycodone 5 mg by mouth every four hours as needed for pain, but the facility admission orders dated 07/10/26 only included Oxycodone 5 mg by mouth every four hours as needed for pain and did not transcribe the scheduled every-four-hour order. Medication administration records and narcotic sign-off sheets showed the resident received Oxycodone 5 mg on 07/10/26 at 3:31 P.M. and not again until 07/11/26 at 7:45 A.M. Pain assessments documented pain levels of 9 and 10 on 07/10/26, with no documented pain assessment after 6:09 P.M. that day until 5:59 P.M. the next day. Nursing notes stated the resident was crying and reported back pain of 10 at 7:45 A.M. on 07/11/26, and the hospice RN later confirmed the intended orders were Oxycodone 5 mg every four hours and Oxycodone 5 mg as needed for breakthrough pain every four hours. The clinical manager verified the medication was transcribed incorrectly, resulting in missed doses during the night.
Delayed provider notification and treatment after reported injury
Penalty
Summary
The facility failed to provide necessary and timely treatment after a resident reported a possible injury and left knee pain. The resident had a history that included dementia, unsteadiness on feet, difficulty walking, reduced mobility, muscle weakness, and use of a manual wheelchair. On the day the concern was first documented, the resident told staff that someone had dropped her while she was being changed, and her left knee was swollen and she could only slightly lift it. An LPN gave PRN acetaminophen, but there was no documented evidence that the medical provider was notified at that time of the reported fall, the pain, or the change in condition. The resident continued to have pain and swelling over the next two days. Documentation showed the resident remained symptomatic, including a shower sheet note stating she was yelling in agony with the slightest movement and that staff had dropped her, yet there was still no documented provider notification tied to that change in condition. The medical provider was not notified until later, when an x-ray was ordered. The x-ray confirmed a comminuted impacted fracture of the distal femur with displacement, articular surface involvement, a large joint effusion, and soft tissue swelling. The resident was then sent to the emergency department for further evaluation. Facility records and staff statements showed inconsistent accounts of the event and delayed communication among staff. One CNA stated the resident had reported being dropped, another stated the resident’s foot kept falling during wheelchair transport, and an LPN later documented that the resident said she had been dropped while being changed. The facility’s investigation and interviews confirmed there was a delay in notifying the provider beginning when the resident first reported pain and swelling, and that the provider was not notified until several days later. The facility policy required incidents, accidents, and changes in condition to be recorded in the medical record.
Insufficient Nursing Staffing and Delayed Call Light Response
Penalty
Summary
The facility failed to ensure sufficient nursing staff were available to provide nursing and related services to meet resident needs and maintain resident safety and well-being for all 68 residents in the building. During interviews, multiple residents and a resident representative reported that staffing was consistently inadequate across all shifts and days, call lights were not answered in a timely manner, and residents often had to wait a long time for assistance with toileting, incontinence care, and showers. One resident representative stated that call lights were always going off and were not answered timely, and another reported having to search the halls for staff to obtain assistance because staff were not attentive to residents. An observation showed Resident #34 activated the call light at approximately 8:58 A.M., and staff did not respond until 9:20 A.M. In interview, Resident #34 stated the delay occurred when she needed to use the bathroom and that waiting too long sometimes led to incontinence, bed and clothing changes, and additional work for staff. Resident #34 also stated the staff were very nice but there were not enough of them. During interview, a CNA confirmed the facility used agency CNA and nursing staff to help staff the building. The facility policy on answering call lights stated residents' requests and needs should be responded to as soon as possible.
Failure to Provide Education and Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure residents receiving psychotropic medications were provided education on the risks and benefits of those medications so that the resident or resident representative could give informed consent. Based on record review and interviews, there was no documented evidence that residents #3, #53, #9, #8, and #76, or their representatives, were educated about the risks and benefits of the psychotropic medications they were receiving before or during treatment. Resident #3 had diagnoses including depression and anhedonia and was ordered Zoloft 75 mg daily and Remeron 15 mg daily. The medical record did not show that the resident or representative received education on the risks and benefits of these medications. The DON confirmed there was no evidence of informed consent for Zoloft or Remeron and stated the facility had not been obtaining informed consents for psychotropic medications. Resident #53 had diagnoses including unspecified dementia, major depressive disorder, and generalized anxiety disorder and was ordered Zoloft 25 mg daily, with no evidence of education or informed consent in the record. Resident #9 had diagnoses including mood disorder, dementia, schizoaffective disorder, PTSD, hallucinations, delusions, anxiety, and depression and was ordered Ativan 0.5 mg twice daily and risperidone 0.5 mg daily and 1 mg at bedtime, with no documented education or informed consent. Resident #8 had diagnoses including Alzheimer's disease, dementia, depressive episode, osteoarthritis, femur fracture, hypertension, anxiety, major depressive disorder, and myocardial infarction and was ordered clonazepam 0.5 mg twice daily, with no documented education or informed consent. Resident #76 had diagnoses including depression, anxiety, and insomnia and received alprazolam 0.25 mg twice daily, Remeron 7.5 mg at bedtime, and quetiapine 50 mg twice daily, with no evidence that the resident or representative was educated on the risks and benefits. The facility policy required review of non-pharmacological alternatives, indications, risks and benefits, and the resident's or representative's right to accept or decline treatment before initiating or changing psychotropic medications.
Infection Control Log and Laundry Handling Deficiencies
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. Review of the infection control log from 06/2025 to 06/2026 showed no evidence of trending infections, and there was no infection control log for 06/2026. The April 2026 log was not comprehensive because it did not include infection types and microorganisms for all residents; for example, one resident’s infection type was listed as labs and the microorganism as elevated white blood cells, five residents were listed with urinary infections with the microorganism recorded as UTI, and 24 residents were listed on isolation without identifying the type of isolation or the organism/type of infection. The May 2026 log had similar issues, including two urinary tract infections with the microorganism listed as UTI, one resident’s infection type listed as labs with elevated white blood cells, nine residents on isolation without the type or organism identified, and seven residents treated for a vaginal infection. The LPN/IP confirmed the facility had not trended infections, had not started the June 2026 log timely, and had not investigated the vaginal infection trend to determine the cause. The facility also failed to ensure staff were knowledgeable on the laundry process for infectious linens. During interview, the Laundry Attendant stated CNA staff collect dirty linen and place isolation linen in red bags in the dirty/soiled room, after which housekeeping/laundry collects it and brings it to the laundry room. The Laundry Attendant stated staff do not know what type of isolation or infection the resident has and simply place any isolation linen in a red biohazard bag. The Laundry Attendant also stated that when washing linen, whether from red biohazard bags or regular linen, staff use the laundry formula chart on the wall for wash settings, and that items in red bags may or may not be kept separate from regular linen depending on how soiled they are. Facility policies reviewed stated soiled laundry and bedding are to be handled, transported, and processed according to best practices for infection prevention and control, and contaminated linens and personal items are to be laundered separately and stored in biohazard bags and/or a designated area prior to laundering.
Failure to Maintain an Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain an effective antibiotic stewardship program for all 68 residents. Review of the infection control program for 06/2025 to 06/2026 showed no evidence of a stewardship program that documented the indication, dose, and duration of antibiotics, reviewed laboratory reports to determine whether antibiotics were indicated or needed adjustment, used an infection assessment tool or management algorithm when prescribing, or maintained a system to monitor antibiotic use. The LPN/Infection Preventionist reported she had recently taken over the infection control program, was still learning, and confirmed there was no documented evidence from 06/2025 to 06/2026 to determine whether residents met criteria for treatment. She also stated the facility used McGeer’s criteria but she did not complete the forms or document whether residents met criteria anywhere, and she did not always know when antibiotics were ordered until it was too late. The DON stated she had not provided education to nursing staff regarding McGeer’s criteria. Resident #12 was admitted with diagnoses including diabetes, obstructive and reflux uropathy, and benign prostatic hyperplasia with lower urinary tract symptoms. The infection control log showed the resident was treated with doxycycline for an upper respiratory infection, but the chest x-ray was negative. The record contained no evidence that the resident met criteria for antibiotic treatment, no dosage or strength documentation, and no justification for antibiotic use. The order was for a chest x-ray due to a harsh cough and rhonchi, and the chest x-ray showed no acute disease process. The MAR showed doxycycline 100 mg twice daily was administered for several days. The LPN/Infection Preventionist later reviewed the record and stated the resident did not meet McGeer’s criteria for antibiotic treatment. Resident #6 had diagnoses including UTI, hypothyroidism, diabetes mellitus, hypercholesterolemia, hypertension, bilateral osteoarthritis of the knee, benign prostatic hyperplasia with lower urinary tract symptoms, and a history of venous thrombosis and embolism. The resident was incontinent of bladder and bowel, was not on a toileting program, and progress notes from 05/2026 to 06/10/26 showed no evidence of signs or symptoms of UTI. A urine culture collected for hydronephrosis of the right kidney grew greater than 100,000 cfu of E. coli and Klebsiella pneumoniae, and ceftriaxone was sensitive to both organisms. The urine results were faxed to urology, no new orders were given from urology, and later the facility NP reviewed the culture and ordered ceftriaxone 1 gram IM daily for 7 days for UTI. The resident stated he had no pain or new urinary symptoms before the antibiotic was started, and the LPN/Infection Preventionist later confirmed there was no documented evidence that the resident had signs or symptoms of UTI or met McGeer’s criteria for antibiotic treatment.
Excessive Lint Buildup in Laundry Dryers
Penalty
Summary
The facility failed to provide a safe environment when the laundry room dryers were not maintained. During observation of the facility laundry room, two dryers were found with lint traps that were entirely covered in a thick layer of white lint, and lint was also built up on the bottom of each dryer. The amount of lint in each trap was described as excessive, and the buildup appeared to be from more than one day. Laundry Attendant #105 confirmed the excessive lint buildup in both dryers during interview.
Unsafe and Unsanitary Resident Environment
Penalty
Summary
The facility failed to ensure a safe and sanitary environment for residents, affecting three residents. Resident #39 was admitted with congestive heart failure, Alzheimer's disease, and dementia, and her quarterly MDS showed she was not on a toileting program, was frequently incontinent of urine, and was continent of bowel. During observations, the 400 hallway smelled of urine, and Resident #39’s room had a yellow ring on the bed sheet, urine dried on the floor around the toilet, and bowel movement smeared on the toilet seat and rails. The resident’s daughter reported the room had ongoing urine odors, dirty sheets, and bowel movements smeared in the bathroom by the roommate, and provided dated photos showing bowel movements on the walls and toilet, urine on the floor, and dirty sheets that were not cleaned for several days over the prior months. Resident #7’s bathroom had a strong urine odor, and a bed pan was sitting over the toilet on the toilet seat without a bag when not in use; the resident also reported the wall by the door was scuffed, gouged, and in need of repair. Resident #2’s bathroom contained several soiled briefs in a small trash can with no liner and a strong urine odor. Staff interviews confirmed the odor concerns on the hall and in resident rooms, and one staff member stated the urine odor may have been caused by soiled briefs being left in trash cans and that some staff throw briefs into trash cans even when there is no liner inside.
Advance directive records were inconsistent or missing across multiple resident charts
Penalty
Summary
The facility failed to ensure resident advance directives were accurate in all records for four residents reviewed. Resident #76, admitted with diagnoses including COPD, HTN, anemia, type 2 DM, depression, anxiety, ESRD, and dependence on renal dialysis, had no evidence of an advance directive in the paper chart, electronic record, or emergency binder. During interview, LPNs confirmed there was no documented code status in the resident’s record or emergency binder and stated staff should first check the emergency binder, then the paper chart, then the electronic medical record. Resident #10 had a signed advance directive changing code status to DNR comfort care, and this was reflected in the orders and care plan, but the emergency binder did not contain the advance directive. Resident #6 was documented as full code in the care plan, current orders, and paper record, but the emergency binder had no evidence of code status. Resident #2 had conflicting documentation, with an electronic order for full code status while the paper record contained a signed advance directive for DNR comfort care and the care plan identified the resident as DNRCC; an LPN confirmed the electronic and paper records did not match and was unsure of the resident’s current code status.
Pureed Diet Food Not Prepared to Proper Consistency
Penalty
Summary
Food prepared for residents on ordered pureed diets was not consistently prepared in the proper consistency. Based on menu review, observation, interview, and policy review, the facility failed to ensure food was prepared in a form designed to meet individual needs when pureed food items were not smooth and contained chunks. This affected five residents (#13, #5, #37, #54, and #58) of five residents reviewed for ordered pureed diets, with a census of 68. On 06/10/26, the lunch menu included chicken and dumplings, green peas, a dinner roll, and a chocolate chip bar. During observation at 11:30 A.M., Dietary Staff #48 placed chicken and a dumpling/noodle item into the robot coupe and blended the food, checked the consistency, scraped the sides, blended again, and added 4 ounces of chicken gravy before placing the food into a serving bowl. At 11:31 A.M., Surveyor #51519 tasted the item and found gritty pieces of chicken and larger pieces of noodle/dumpling. Dietary Staff #48 did not orally check the consistency before placing a lid on the bowl and putting it in the warmer. Dietary Manager #62 stated pureed items should be smooth with no chunks, no skin, and nothing left over, and later confirmed the chicken and dumplings could have been pureed longer to ensure proper consistency.
Failure to Provide Scheduled Shower Assistance
Penalty
Summary
The facility failed to ensure a resident who was dependent on staff for personal care received showers as scheduled. Resident #78 had diagnoses including reduced mobility, muscle weakness, major depressive disorder, paranoid schizophrenia, bipolar disorder, anxiety disorder, stroke, muscle spasms, difficulty walking, dependence on a wheelchair, and repeated falls. Her MDS indicated she was cognitively intact, had no communication issues, did not display behaviors or reject care during the assessment period, and required substantial to maximum assistance with showers and bathing. Her care plan stated she was dependent on staff for showers/bathing and required a Hoyer lift and staff assistance for transfers. The shower schedule for the resident’s hall listed her to be showered as requested, and the facility’s shower sheet process required documentation even if a shower was refused. Review of bathing sheets after her return from the hospital showed showers documented only on three days, with no documentation that a shower was provided or offered on several other days. For two of the days, the bathing sheets showed the resident was offered a shower and refused, but there was no documentation for the remaining days in question. Progress notes for that period also did not document showers being offered and refused on those dates. During interview, the resident stated she had not been showered on six different days since returning from the hospital and said staff told her they did not have time to do it because she required a Hoyer lift and two staff members. An LPN stated the resident was to be offered a shower daily and that the resident liked daily showers, while a CNA stated some staff may have relied on the resident to request a shower instead of offering one, even though the resident needed staff to ask her daily. The DON confirmed the resident reported going without a shower for six days and that the documentation supported that report, with only one additional bathing sheet found showing a shower offer and refusal.
Failure to Assess and Manage Urinary Incontinence
Penalty
Summary
The facility failed to complete a comprehensive assessment to determine the type of urinary incontinence for Resident #54 and failed to implement an effective treatment plan to address the resident’s incontinence. Resident #54 was admitted with diagnoses including urinary tract infections, subarachnoid hemorrhage, metabolic encephalopathy, dementia, chronic kidney disease, and obstructive and reflux uropathy. The admission MDS showed the resident could not complete the brief interview for mental status and required assistance with multiple activities of daily living, including toileting hygiene, mobility, and transfers. The care plan identified incontinence related to weakness, age-related changes, and obstructive/reflux uropathy, and the resident was frequently incontinent of bowel and urine. The medical record did not show documented incontinence care on several dates, and on multiple other dates the resident had incontinence care documented only once per day. The resident’s representative reported concerns that incontinence care was not being provided in a timely or adequate manner and stated they could smell urine and see the brief soaked, sometimes including the resident’s pants. The DON confirmed there was a lack of evidence that incontinence care had been completed and stated the resident was not on a urinary toileting trial or program and that the facility did not know the type of urinary incontinence the resident had.
Failure to Monitor Meal Intake and Assess Significant Weight Loss
Penalty
Summary
The facility failed to ensure Resident #54’s meal intakes were monitored and failed to comprehensively assess the resident’s weight loss. Resident #54 was admitted with diagnoses including left rib fracture, urinary tract infections, subarachnoid hemorrhage, metabolic encephalopathy, dementia, chronic kidney disease, and obstructive and reflux uropathy. The care plan identified nutrition risk related to the resident’s medical conditions and included monitoring meal intakes. The admission MDS showed the resident required set up or clean up assistance for eating and had an ordered therapeutic diet. The resident’s orders included a no added salt diet, pureed texture, and thin liquids. Record review showed Resident #54 lost weight from 127.2 lbs. to 115.8 lbs. in 29 days, a 10.43% loss, and there was no evidence that nutritional interventions were developed and implemented for the weight loss. The mini-nutritional assessment score was 8, indicating risk of malnutrition. The medical record also lacked evidence of meal intake documentation for multiple breakfasts, lunches, and dinners on several dates. The resident’s representative stated the resident could not physically feed herself and was unsure staff were consistently helping her eat during every meal. During observation, CNA #75 stated, “I absolutely will not feed her.” The DON confirmed there was a lack of evidence for the resident’s meal intakes and that the resident was dependent on staff for dining and eating.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the state survey agency for one resident. Resident #10 had diagnoses including dementia, unsteadiness on feet, difficulty walking, abnormal posture, reduced mobility, muscle weakness, history of TIA, anemia, depression, anxiety, bipolar disorder, and paranoid personality disorder. The resident’s MDS showed moderate cognitive impairment with a BIMS score of 11, and the resident was able to speak clearly and understand others and self. The resident complained of left knee pain after stating to aides that they had dropped her while changing her the prior night. Nursing documentation described swelling of the left knee, no redness, intact skin, and limited movement due to pain. A shower sheet documented that the resident was given a bed bath because of the knee pain and that she said night shift had dropped her while changing her. Additional nursing documentation later noted new orders for a left knee x-ray due to increased pain and swelling. The x-ray showed a comminuted impacted fracture of the distal femur with displacement, articular surface involvement, joint effusion, and soft tissue swelling. The facility’s investigation stated the fall/incident occurred when the resident was being transported in a wheelchair and her left leg/heel touched the floor and was jarred, but staff could not confirm what actually caused the fracture. The DON and LPN confirmed the injury was of unknown origin, and the Administrator confirmed the injury was not reported to the State Survey Agency. The facility policy stated unexplained injuries must be investigated and reported to the Administrator and State Agency.
Inaccurate MDS Assessment Failed to Include Depression
Penalty
Summary
The facility failed to ensure a resident’s quarterly MDS assessment was completed accurately to reflect all known active medical diagnoses. Resident #3 was admitted with diagnoses including congestive heart failure, adult-onset diabetes mellitus, hypertension, muscle weakness, and difficulty walking. The resident also had physician orders for Remeron 15 mg by mouth daily as an appetite stimulant and Zoloft 75 mg by mouth daily for depression and anhedonia. The quarterly MDS assessment did not code depression in Section I as an active diagnosis, even though the resident was receiving antidepressant medications at the time the assessment was completed. The MDS did indicate in Section N that the resident received an antidepressant during the assessment reference period, and the April 2026 MAR confirmed Remeron and Zoloft were administered during that period. The MAR’s listed medical conditions did not include depression, despite Zoloft being used for that diagnosis. During interview, the DON confirmed the quarterly MDS was not coded accurately and that depression should have been included as an active diagnosis.
Incomplete PASARR Assessments and Missing PASARR Care Plans
Penalty
Summary
The facility failed to ensure Preadmission Screening and Resident Review (PASARR) assessments were complete and failed to ensure PASARR recommendations were implemented for two residents reviewed. One resident was admitted with multiple psychiatric and neurologic diagnoses, including mood disorder, dementia, schizoaffective disorder, PTSD, visual hallucinations, delusions, mild cognitive impairment, anxiety, major depressive disorder, hemiplegia, hypertension, transient ischemic attack, cerebral infarction, and osteoarthritis. The resident’s orders included lorazepam 0.5 mg by mouth twice daily for delusional disorders, and the care plan noted psychotropic medication use related to dementia, anxiety, delusional disorder, and schizoaffective disorder. However, the resident’s PASARR did not document the diagnosis of delusional disorder, and the Social Service Designee confirmed this omission during interview. A second resident’s PASARR did not reflect delusions, anxiety, or paranoid personality disorder, even though the resident was admitted with schizoaffective disorder bipolar type, delusional disorders, bipolar disorder, major depression, anxiety, and paranoid personality disorder. The annual MDS also stated the resident was not considered by the State Level II PASARR process to have a serious mental illness and/or intellectual disability or related concern, despite triggering for Level II evaluation due to schizoaffective disorder, bipolar disorder, dementia with behavioral disturbance, and delusional disorder. The Level II recommendations included ongoing psychiatric medication review, neurological exams, mental health counseling, a safety plan, a behavioral-based treatment plan, therapy, activities, and medication as ordered, but the current plan of care contained no PASARR plan of care or safety plan. The SSD and MDS Nurse both confirmed the PASARR and MDS were inaccurate and that no PASARR plan of care or safety plan was in place.
Failure to Include Constipation in the Comprehensive Care Plan
Penalty
Summary
The facility failed to ensure a comprehensive care plan was developed to address constipation for a resident receiving Colace on a scheduled basis. Resident #3 was admitted with diagnoses including congestive heart failure, adult-onset diabetes mellitus, muscle weakness, and difficulty walking. The resident had a physician order for Colace 100 mg, two capsules by mouth twice a day for constipation, and the order had been in place since 01/11/26. Review of the resident’s active care plans showed no care plan addressing constipation. During an interview on 06/09/26 at 4:15 P.M., the DON confirmed that the comprehensive care plans did not include constipation and acknowledged the resident was receiving Colace twice daily for constipation and should have had a care plan for it.
Failure to Hold Quarterly Care Planning Conference
Penalty
Summary
The facility failed to ensure Resident #7’s quarterly care planning conference was scheduled and that the resident and/or family had the opportunity to participate in the care planning process. Resident #7 was admitted to the facility with diagnoses including chronic respiratory failure, dependence on a respiratory ventilator, hypertension, lymphedema, peripheral vascular disease, depression, anxiety disorder, muscle weakness, and abnormalities of gait and mobility. Her quarterly MDS assessment showed she had no communication issues, was cognitively intact, had a functional limitation in range of motion of one lower extremity, and used a wheelchair for mobility. The resident’s record showed an initial care conference was held on 02/18/26, but there was no evidence of any quarterly care planning conference after admission. The resident stated she had not been invited to attend any quarterly care planning conferences and did not recall any meetings involving herself, her husband, and facility disciplines to review her care, orders, or goals. The LSW confirmed there was no evidence a quarterly care conference had been completed and calculated that one should have been held in May 2026. The Activity Director stated she was responsible for scheduling care planning conferences, sending letters to families, and notifying management, but also stated she did not feel she was the best person to track when conferences were due and relied on the social worker to identify residents who would remain in the facility long enough to require one. The facility policy stated residents and family members were to be invited to participate in assessment and care planning conferences, and that care conferences were to be held upon admission, quarterly, and as needed or upon request.
Failure to Timely Assess Mid-Spine Pressure Ulcer
Penalty
Summary
The facility failed to timely and comprehensively assess a pressure ulcer for Resident #76, who was admitted with chronic pulmonary disease, adult failure to thrive, anemia, type 2 diabetes, heart disease, fibromyalgia, rheumatoid arthritis, a history of TIA, end stage renal disease, dialysis dependence, and a wedge compression fracture of L1. The baseline plan of care identified the resident as at risk for skin breakdown and directed staff to monitor and document the location, size, and treatment of any skin injury. Orders were entered for cleansing the mid-spine area with normal saline, applying skin prep, and covering it with a border foam dressing three times weekly and as needed, but the medical record showed no evidence that a comprehensive skin assessment was completed on admission or on the mid-spine area when treatment was started. The wound progress note stated the resident was not evaluated by the wound team because the resident was anxious and had behaviors during the visit, and the team planned to re-attempt the next visit. During observation, an LPN confirmed there were no skin assessments in the record and no assessment of the mid-spine area. The LPN was unsure whether the area was pressure-related or non-pressure-related and reported unit managers said it was a scratch. When the dressing was removed, there was scant serosanguinous drainage and an open area on the mid-spine; the resident stated the area had been present for some time and was caused by lying in bed. The DON and another LPN/wound nurse later confirmed there was no skin assessment completed on admission or after the skin alteration was noted, and the wound nurse stated the wound NP only comes on Monday and Thursday and had not seen the resident because the resident was at dialysis and then sent to the hospital.
Failure to Assess and Monitor Dialysis AV Fistula
Penalty
Summary
The facility failed to ensure a resident's dialysis port was assessed and monitored. Resident #76 was admitted with diagnoses including anemia, type 2 diabetes, end stage renal failure, and dependence on renal dialysis. Hospital records showed the resident had an AV fistula, and the nursing note documented that the resident had dialysis with 500 ml removed and that a fistula was present in the left arm. However, the baseline plan of care contained no dialysis plan of care, and the admission assessments contained no evidence that the resident had an AV fistula. The resident's orders included dialysis on Monday, Wednesday, and Friday, but there were no orders for staff to assess or monitor the AV fistula and no evidence in the medical record that staff were doing so. During interview, an LPN confirmed there were no orders or evidence that the AV fistula was being assessed or monitored and stated she had not assessed it yet. During observation, the resident had a dressing on the right arm, reported receiving dialysis for over a year, and stated the dialysis nurse had placed the dressing on the fistula after treatment. The resident also stated she did not know how to check the AV fistula to ensure it was functioning. The LPN confirmed there were no orders to remove the dressing, and the DON later confirmed there was no baseline dialysis plan of care, no orders to assess and monitor the AV fistula, and no orders to remove the dressing.
Improper bedside storage and administration of medications
Penalty
Summary
The facility failed to properly store and administer medications for two residents. Resident #42, who had diagnoses including type 2 diabetes, cellulitis of the left lower limb, polyneuropathy, glaucoma, insomnia, peripheral vascular disease, and hypertension, had no order or indication in the medical record to keep medications at the bedside or to self-administer medications. During observation, a pill cup containing several different medications was found on the resident’s bedside table, and the resident confirmed the medications were there because she waited to take them since taking them close to meals upset her stomach. Resident #22, who had diagnoses including cancer, anemia, atrial fibrillation, GERD, and diabetes mellitus, also had no order or indication to keep medications at the bedside or to self-administer. During observation, the resident was sitting in her room with a pill cup containing three white capsules on the bedside table, and she confirmed her chemo medication had been placed there by the nurse. An RN stated medications cannot be left at the bedside and must be observed as taken before documentation, and a CNA reported seeing medications left in pill cups at residents’ bedsides. Facility policy stated medications must be administered safely, timely, and in accordance with prescribed orders, with documentation completed after administration.
Unnecessary antibiotic treatment and unauthorized medication administration
Penalty
Summary
The facility failed to ensure that residents received only necessary antibiotic treatment. For one resident admitted with diagnoses including urinary tract infection, hypothyroidism, diabetes mellitus, hypercholesterolemia, hypertension, bilateral osteoarthritis of the knee, benign prostatic hyperplasia with lower urinary tract symptoms, and a history of venous thrombosis and embolism, the record showed no documented signs or symptoms of a UTI in progress notes from May through June 2026. Although a urine culture collected for hydronephrosis of the right kidney grew greater than 100,000 CFU of E. coli and Klebsiella pneumoniae, the resident reported no pain or new urinary symptoms before the antibiotic was started, and staff interviews confirmed there was no documented evidence that the resident met McGeer criteria for treatment. Despite the lack of documented symptoms, the facility’s NP reviewed the urine culture and ordered ceftriaxone 1 gram IM daily for seven days for UTI. The resident’s antibiotic therapy plan of care was initiated, and the MAR showed ceftriaxone began the next day. The infection control log for June 2026 was not available, and the LPN/Infection Preventionist stated she did not have a log or trending map for that month, was unsure whether the resident met treatment criteria, and did not complete the infection control log or forms to verify criteria were met. Another LPN stated the urologist did not want the urine treated, but the facility NP later ordered treatment without documented rationale. A second resident with vascular dementia, rhabdomyolysis, CHF, anxiety, reflux uropathy, urinary retention, hypertension, pacemaker, atrial fibrillation, heart failure, and diabetes was also treated for UTI. The record showed an RN gave the first dose of cephalexin from the medication machine before it was listed on the MAR, and the nurse wanted the antibiotic started as soon as possible. The order was for cephalexin 500 mg by mouth daily for seven days. The DON confirmed the resident received an additional dose of cephalexin without a provider order or provider notification, and the medication administration policy required medications to be given as prescribed and documented in the MAR.
Undated COVID-19 Consent and Missing Education Documentation
Penalty
Summary
The facility failed to ensure COVID-19 immunization consent forms were dated and failed to maintain documented evidence that education was provided to residents and/or their representatives regarding the risks and benefits of the COVID-19 immunization. This deficiency affected one resident, Resident #53, out of five residents reviewed for immunizations in a facility with a census of 68. Record review showed Resident #53 was admitted with diagnoses including congestive heart failure, dementia, osteoarthritis, chronic kidney disease, atrial fibrillation, and hypertension. The resident’s medical record contained no evidence of documentation that the resident and/or representative consented to or declined the COVID immunization. An LPN confirmed the consent form lacked a resident or representative signature and date, and the DON confirmed there was no evidence that the resident and/or representative had been educated on the risks or benefits of the COVID immunization. The facility policy stated that education on the benefits, risks, and potential side effects must be provided before offering the vaccine and that documentation of education and vaccination status must be maintained.
Failure to Implement Infection Control Practices for EBP, Device Care, Wound Care, and Shared Equipment
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), device and wound care practices, and cleaning and disinfection of shared equipment. For a resident with type 2 diabetes mellitus and a urinary tract infection receiving IV meropenem via a PICC line, an LPN administered the medication without donning a gown, despite an EBP sign on the door and a facility policy requiring gown and gloves for high-contact care involving central lines. The LPN confirmed she had not implemented EBP and stated she had never been told it was required. The facility’s EBP policy, revised March 2024, required gown and glove use for high-contact resident care activities, including device care such as central lines, and indicated EBP for residents with indwelling medical devices regardless of multidrug-resistant organism colonization. Another deficiency occurred during wound care for a resident with peripheral vascular disease and chronic obstructive pulmonary disease who had wounds on the left toe and coccyx and a care plan intervention for EBP, including wearing a gown and gloves when providing care. A physician’s order directed daily and as-needed dressing changes to the left third toe wound. During an observed dressing change to the lateral aspect of the third toe, an RN wore gloves but did not don a gown, despite an EBP sign posted on the door. The RN verified that the EBP sign was related to the resident’s wounds and acknowledged she had not worn a gown during the wound care. The same EBP policy requiring gown and glove use for high-contact resident care activities applied in this situation. Additional infection control failures involved shared equipment and catheter care. For a resident with type 2 diabetes mellitus requiring daily blood glucose monitoring, an LPN used a shared glucometer, placed the glucometer and test strip container on the resident’s bed, then later on the medication cart and mouse pad, and did not clean or disinfect the glucometer or container after use before proceeding to administer medications to another resident. The LPN gave inconsistent answers about cleaning frequency and confirmed she had not cleaned the items after use, contrary to the facility’s policy requiring reusable items to be cleaned and disinfected between residents. In a separate observation, a CNA provided urinary catheter care to a resident with congestive heart failure, vascular dementia, and obstructive and reflux uropathy, then failed to remove gloves afterward and continued to handle the call light, bed controls, bedding, and the urinary collection bag and cover with the same contaminated gloves. The CNA confirmed she had not removed the gloves used for catheter care before touching these items.
Failure to Monitor Blood Pressure Before Administering Antihypertensive Medications
Penalty
Summary
Staff failed to monitor a resident’s blood pressure prior to administering antihypertensive medications. On 02/25/26 between 8:55 A.M. and 9:05 A.M., an RN administered lisinopril 20 mg and metoprolol succinate 50 mg to Resident #18 and obtained the resident’s blood pressure only after giving the medications. In a subsequent interview, the RN confirmed that the resident’s blood pressure should have been taken before administering these medications. Review of the February 2026 MAR for this resident showed no specific parameters for holding lisinopril or metoprolol tartrate, although there was a designated area to document blood pressure and pulse with metoprolol tartrate administration. The MAR indicated five instances when metoprolol tartrate was not administered due to low blood pressure readings, including 90/67, 93/51, 95/61, and 105/90 on various mornings, and additional readings of 99/63 and 98/52 on other dates. In an interview, the DON stated that blood pressures should ideally be monitored prior to giving medications that could affect blood pressure, especially for residents with a history of low readings. This deficiency was investigated under Complaint Number 2706361.
Failure to Implement Ordered Non-Slip Wheelchair Intervention for High Fall-Risk Resident
Penalty
Summary
Surveyors found that the facility failed to implement a care-planned fall intervention for a resident assessed as high risk for falls. The resident had dementia, repeated falls, generalized muscle weakness, difficulty walking, incontinence, and multiple co-morbidities, and was taking diabetic, blood pressure, narcotic, and psychotropic medications. A fall risk plan of care initiated on 11/11/22 identified the resident as at risk for falls related to weakness, co-morbidities, incontinence, and medication use, and an intervention dated 11/16/23 specified placing Dycem, a non-slip material, on the resident’s wheelchair. A physician order dated 11/05/23 also directed use of a non-skid sheet on the wheelchair. A fall risk evaluation dated 11/04/25 again identified the resident as high risk for falls, with risk factors including multiple recent falls, memory problems, frequent incontinence, behavioral issues, confinement to a chair, loss of balance when standing, need for hands-on assistance for mobility, use of an assistive device, and decreased muscle coordination, and it continued the intervention of Dycem to the wheelchair. During an observation and interview on 02/25/26 at 1:25 P.M., the resident was observed sitting in a wheelchair without Dycem or a non-skid sheet in place, despite the ongoing care plan and physician orders requiring this intervention. An LPN present at the time confirmed that the resident was in the wheelchair and that there was no Dycem present. This failure to implement the ordered and care-planned non-slip wheelchair intervention for a high fall-risk resident constituted the cited deficiency.
Incomplete and Inaccurate Medical Record for Resident Catheter Care and Skin Status
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident with multiple diagnoses, including a non-displaced left wrist fracture, depression, bipolar disorder, malignant melanoma of the trunk, and congestive heart failure. An admission nursing assessment documented that the resident was alert but confused and indicated that catheter care was to be provided by nursing assistants. The nursing assistant task bar showed catheter care scheduled every shift from late December through late January, but there was no documentation that this care was completed except for three day shifts in January. The urinary catheter was discontinued on 01/22/25. The DON stated there was no catheter care documentation in December because the task did not appear on the aide task bar until the baseline care plan evaluation was completed and acknowledged that only three days in January showed completion, characterizing the issue as a documentation problem rather than a failure to provide care. The resident’s admission assessment and a wound nurse practitioner note shortly after admission both documented intact skin with no open wounds. However, multiple skilled evaluations later documented skin concerns and dressings as dry and intact on several dates in January, yet no corresponding skin or wound assessments could be located in the medical record. During interviews, an RN and a CNA both denied that the resident had any wounds or dressing changes, stating they were only aware of a wrist cast. The DON also reported that the resident’s skin remained intact throughout the stay and stated that the skilled evaluations indicating skin concerns and dressings were incorrect. These inconsistencies between clinical documentation, staff interviews, and the absence of wound assessments demonstrated that the resident’s medical record was not complete or accurate.
Failure to Implement Antibiotic Stewardship for Suspected UTIs
Penalty
Summary
The deficiency involves the facility’s failure to implement its antibiotic stewardship program to ensure appropriate use of antibiotics, specifically related to urinary tract infection (UTI) management. For one resident admitted in December 2024 and readmitted in September 2025 with diagnoses including heart failure, COPD, and diabetes mellitus, record review showed no documentation of any UTI signs or symptoms in the medical record. Despite this, the infection control log for January 2026 listed the resident as having acquired an in-house UTI and receiving antibiotics from January 27, 2026, to February 3, 2026, and indicated that McGeer’s criteria were met. The DON confirmed there was no documentation of UTI signs or symptoms, and although a urinalysis was ordered on January 19, 2026, there was no documentation of signs and symptoms or a completed McGeer’s assessment for UTI. A second resident, admitted in August 2023 and readmitted in March 2024 with diagnoses including chronic kidney disease, major depressive disorder, and anxiety disorder, similarly had no documentation of UTI signs or symptoms in the medical record. The quarterly MDS showed this resident had intact cognition and was dependent on staff for ADLs. The facility’s infection control log for February 2026 recorded that this resident acquired an in-house UTI and was on antibiotics from February 1, 2026, to February 6, 2026, and again indicated that McGeer’s criteria were met. The DON verified there was no documentation of UTI signs or symptoms and no McGeer’s assessment completed for this UTI. Review of the facility’s undated Antibiotic Stewardship Program policy showed that the infection control nurse or designee was responsible for infection control line listing and review of antibiotic utilization to ensure appropriate prescribing and use of antibiotics, which was not carried out as required in these cases.
Failure to Ensure Call Lights Were Accessible to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain a call light system that was readily accessible to residents in accordance with its policy requiring call lights to be within easy reach when residents are in bed or confined to a chair. For one resident with Alzheimer’s disease, schizophrenia, and major depressive disorder, the care plan identified a risk for falls and included interventions to ensure the call light was within reach and a sign was in place to remind the resident to use the call light for assistance. The quarterly MDS showed this resident was moderately cognitively impaired and dependent on staff for ADLs. On two separate observations the resident was seated in a Broda chair next to the bed while the call light was found on the floor beside the bed, not within reach. A CNA confirmed the call light was not accessible and explained that a loop was placed around the call light cord to go around the resident’s wrist because the resident was blind. A second resident, admitted with dementia, chronic kidney disease, and diabetes mellitus, also had a care plan identifying fall risk with an intervention to ensure the call light was within reach. The quarterly MDS indicated this resident was severely cognitively impaired and dependent on staff for ADLs. During observation, this resident was lying in bed while the call light was located behind the refrigerator, out of the resident’s reach. A CNA verified that the call light was not accessible to the resident. These findings were identified during the course of a complaint investigation and showed that, for two of three residents reviewed for call light accessibility, the facility did not ensure call lights were positioned so residents could use them as required by facility policy and care plan interventions.
Failure to Maintain Infection Control During Incontinence Care
Penalty
Summary
A deficiency was identified when a Certified Nurse's Aide (CNA) failed to maintain proper infection control procedures during incontinence care for a resident with multiple diagnoses, including congestive heart failure, morbid obesity, diabetes, and erythema intertrigo. The resident was dependent on staff for most activities of daily living and was always incontinent of bowel and occasionally incontinent of urine. During observed care, the CNA placed soiled washcloths and towels directly on the bed, reused washcloths for different areas, and did not follow the facility's perineal care policy, which requires separate cloths and specific cleaning directions to prevent cross-contamination. The CNA was observed removing gloves, washing hands over the washcloths in the sink, and then reapplying gloves multiple times throughout the care process, but continued to use the same washcloths for different body areas. The CNA confirmed in an interview that proper infection control procedures were not followed. The facility's policy specifically instructs not to use the same cloth or water to clean the urethra or labia and to follow a front-to-back cleaning method, which was not adhered to during the observed care.
Failure to Notify Physician of Critically High Blood Glucose Levels
Penalty
Summary
The facility failed to ensure physician notification occurred when a resident experienced significantly elevated blood glucose levels. The resident, who had multiple diagnoses including type 1 diabetes, end stage renal disease, malnutrition, and cognitive impairment, had blood glucose readings of 578 and 537 on consecutive checks. Despite these readings exceeding the highest range of the prescribed sliding scale for insulin administration, there was no documentation that a physician or on-call provider was notified to provide follow-up orders. Review of the resident's care plan and medication orders confirmed that insulin was to be administered according to a sliding scale, with specific instructions for blood glucose levels up to 450. Facility policy, as described by an LPN, required staff to notify the on-call provider for blood glucose readings over 450. However, progress notes only indicated that the end of the scale was given and a supervisor was notified, with no evidence of physician notification for the elevated readings. This deficiency was identified during a complaint investigation.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure medications were administered in accordance with physician orders and drug manufacturer directions, resulting in a 10.8% medication error rate. One incident involved a Licensed Practical Nurse (LPN) administering medications to a resident with a heart rate of 55, despite physician orders specifying that the medications should be withheld if the heart rate was less than 60. The medications involved were amlodipine, hydralazine, and metoprolol succinate. The Director of Nursing (DON) confirmed that the orders required withholding the medications under these conditions. Another incident involved an LPN administering Lantus insulin to a resident without noting the date the vial was opened, contrary to the facility's policy requiring the date to be recorded. The Lantus vial was delivered over a month prior, and manufacturer instructions indicated it should be discarded after 28 days. Additionally, the LPN rubbed the injection site post-administration, which was against the manufacturer's instructions. The DON verified the need for dating insulin vials and acknowledged the manufacturer's instructions regarding the injection site.
Medication Management Error with Anti-Neoplastic Drug
Penalty
Summary
The facility failed to properly manage the medication orders for a resident, leading to the administration of an anti-neoplastic medication, Gleevec, beyond the ordered duration. The resident, who had a complex medical history including pleural effusion, pneumonia, and leukemia, was initially prescribed Gleevec by a hematologist. However, the facility did not document the order to hold the medication as instructed by the hematology/oncology consultant and the hospital discharge instructions. This oversight resulted in the continued administration of Gleevec, which was not authorized by the attending physician upon the resident's return to the facility. The resident experienced adverse symptoms, including coughing up blood, which prompted communication with the hematology/oncology office. Despite instructions to hold the medication until a follow-up appointment, the facility resumed administering Gleevec. Laboratory results indicated a significant decrease in hemoglobin and platelet levels, which were attributed to the continued use of the medication. The resident's condition worsened, leading to further medical evaluations and hospital admissions. Interviews with the resident's physician and the hematology/oncology office confirmed that the continued administration of Gleevec was a medication error. The physician was unaware of the orders to hold or discontinue the medication and stated that he would not have contradicted a specialist's orders. The facility's failure to properly document and communicate medication orders resulted in a significant medication error, affecting the resident's health and requiring additional medical intervention.
Incomplete Medication Administration Records
Penalty
Summary
The facility failed to maintain accurate and complete medication administration records for a resident with multiple diagnoses, including hypertension, type two diabetes mellitus with diabetic neuropathy, intervertebral disc disorders, and arthropathies of the right shoulder. The resident's January 2025 Medication Administration Record (MAR) showed missing documentation for the application and removal of a prescribed lidocaine patch on several dates. Additionally, there were missing blood glucose monitoring results, which were necessary to determine the administration of sliding scale insulin. These omissions made it unclear whether the insulin should have been administered. In February 2025, further discrepancies were noted in the MAR, including the lack of documentation for the administration of clindamycin and missing blood sugar recordings. The Director of Nursing confirmed the incompleteness of the MARs and acknowledged that any reasons for not administering medication should have been documented. The facility's policy required the individual administering medication to document it in the MAR, which was not adhered to in these instances.
Resident's Needs Unmet, Calls 911 for Assistance
Penalty
Summary
The facility failed to provide timely care and services to Resident #72, who had a history of diabetes mellitus type two, depression, and a right below-the-knee amputation. The resident, who was cognitively intact, experienced a delay in receiving assistance after repeatedly requesting a snack and drink to manage his blood sugar levels. Despite using the call light multiple times, the resident's needs were not addressed promptly by CNA #100, leading to frustration and the resident calling 911 for help. On the evening of the incident, Resident #72 activated the call light around 7:30 P.M. and requested a peanut butter and jelly sandwich, two sodas, and assistance from the nurse, as he felt his blood sugar was low. CNA #100 responded but did not fulfill the request, stating she was busy with rounds. The resident's repeated requests over the next few hours were similarly unmet, leading to increased agitation. Eventually, the resident crawled to the hallway to seek help, where he encountered CNA #100 and LPN #150, who did not provide immediate assistance. The situation escalated when Resident #72 called 911, prompting LPN #200 to intervene. The facility's investigation into the incident did not adequately address the timeline of events or the delay in meeting the resident's needs. The Clinical Manager and Administrator acknowledged the failure to provide timely care, with expectations that the resident's requests should have been met within a reasonable timeframe. This deficiency was investigated under Complaint Number OH00161322.
Misappropriation of Controlled Medications
Penalty
Summary
The facility failed to prevent the misappropriation of controlled medications, specifically narcotics, affecting 11 residents on the 200 hall. The Controlled Medication Shift Change Log revealed inconsistencies in documenting the number of medications and signature sheets counted during shift changes. Medications were removed from the controlled medication drawer without proper documentation, leading to discrepancies in the medication count. Interviews with staff, including LPNs and the Director of Nursing (DON), confirmed these discrepancies, and the DON was unable to locate completed signature sheets or the missing medications. The investigation revealed that Resident #71 had expired, and there were missing cards of Morphine that were not accounted for in the log. Staff interviews indicated that the usual procedures for handling discontinued or expired medications were not followed, as the DON did not receive any medications or signature sheets for destruction from the 200 hall. The facility's Controlled Substance policy did not adequately address the reconciliation process for narcotics, contributing to the lack of proper documentation and oversight. The facility's Administrator and DON confirmed that a Self Reported Incident and a Police Report were filed regarding the misappropriation. The facility's Pharmacy Policy required immediate reporting of suspected theft or loss of drugs, but the policy lacked specific procedures for documenting and reconciling controlled substances. The investigation led to the resignation of an RN involved in the medication count discrepancies, and the missing Morphine was not located.
Inaccurate Reconciliation of Controlled Medications
Penalty
Summary
The facility failed to ensure accurate reconciliation of controlled medications, affecting 33 residents who were prescribed controlled medications. The deficiency was identified through a review of medical records, facility policy, and staff interviews. The Controlled Medication Shift Change Logs for various halls revealed discrepancies in the recording of medication counts, with fluctuations in the number of medication cards and signature sheets without corresponding entries of medications being added or removed. This lack of documentation made it difficult to track the controlled medications accurately. Interviews with Licensed Practical Nurses (LPNs) highlighted that the process of counting controlled substances was not consistently recorded, leading to potential discrepancies in medication counts. Agency nurses were sometimes involved, and they did not always sign the logs or know the proper way to record controlled medications. This inconsistency in documentation meant that staff could not verify if medications were missing, as the check and balance step of tracking all controlled medications was not being followed. The Director of Nursing (DON) and the facility's Controlled Substance policy were also reviewed. The policy did not address the specific reconciliation process used by the facility, nor did it include procedures for documenting when medications were added or removed from the locked drawer. The policy required controlled substances to be stored in a locked container in the medication room, but the facility stored them in a locked drawer of a medication cart in the hall. The deficiency was investigated under a Master Complaint Number, indicating non-compliance with regulations related to handling, storage, disposal, and documentation of controlled substances.
Failure to Provide Proper Wound Care for Diabetic Foot Ulcers
Penalty
Summary
The facility failed to ensure proper care and treatment for diabetic foot ulcers for a resident, leading to a deficiency. The resident, who was admitted with multiple medical conditions including type 2 diabetes and diabetic foot ulcers, had specific physician orders for wound care. These orders included cleansing the wounds with normal saline, applying bacitracin, and covering with a dry dressing or Band-Aid daily. However, there were documented instances where the dressings were not changed as required, specifically on 10/18/24, 10/27/24, and 11/06/24. Additionally, on 11/11/24, the resident reported that the nurse left the dressings in the room but did not return to change them, despite the treatment record being signed off as completed. Interviews with the resident and staff revealed discrepancies in the documentation and actual care provided. The resident expressed that his right foot was in pain and that he did not receive the necessary dressing changes. An LPN admitted to not performing the dressing change on 11/11/24 due to being occupied with an admission and incorrectly signing off the treatment sheet. The Director of Nursing confirmed that there were days when the foot dressings were not signed off as completed, indicating a lapse in the facility's adherence to the prescribed treatment plan for the resident's diabetic foot ulcers.
Failure to Provide Proper Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care and treatment for pressure ulcers in accordance with professional standards, affecting a resident with multiple medical conditions, including a Stage IV pressure ulcer on the sacrum. The resident, who was moderately impaired in daily decision-making and required substantial assistance to move, had a history of osteomyelitis, MRSA infection, and multiple pressure ulcers. Despite physician orders for specific wound care and the use of a low air loss mattress set according to the resident's weight, there were lapses in care. The treatment record showed that the sacral dressing was not changed on several occasions, and the mattress was set incorrectly at a higher weight than the resident's actual weight. During an observation, it was noted that the resident's sacral wound dressing change was conducted by LPNs who only used gloves as PPE, despite an order for Enhanced Barrier Precautions, which required additional protective equipment. An interview with one of the LPNs confirmed the incorrect mattress setting and the failure to adhere to the PPE requirements during the dressing change. The facility's policy on pressure ulcer prevention emphasized reviewing the resident's care plan for special needs, which was not adequately followed, leading to the deficiency.
Inadequate Monitoring and Documentation of Narcotic Administration
Penalty
Summary
The facility failed to ensure adequate monitoring and documentation of narcotic pain medication administration for two residents. Resident #8, admitted with multiple diagnoses including a fractured neck of the right femur and chronic lymphocytic leukemia, had an order for Oxycodone 5 mg to be administered as needed for pain. However, there were discrepancies in the medication administration records, with 13 doses of Oxycodone removed from the controlled substance drawer without corresponding documentation on the Medication Administration Record (MAR). Additionally, there was no evidence of comprehensive pain assessments being conducted to justify the use of the narcotic, as required by the facility's Pain Management Policy. Similarly, Resident #26, readmitted with conditions such as sepsis, myocardial infarction, and chronic kidney disease, had an order for Tramadol HCL 50 mg for pain management. The records indicated that six doses of Tramadol were removed from the controlled substance drawer without documentation on the MAR. Like Resident #8, there was a lack of pain assessments to support the administration of the narcotic medication, and the necessary details such as date, time, drug, and dosage were not recorded. Interviews with the Director of Nursing (DON) confirmed the discrepancies in medication administration and the lack of adequate monitoring for both residents. The facility's undated Pain Management Policy mandates that pain assessments be conducted prior to administering pain medication, with documentation of the drug, dose, and route on the Pain Management Flow Sheet and MAR. The absence of such documentation and assessments for the narcotic medications administered to Residents #8 and #26 represents a deficiency in compliance with the facility's policies and procedures.
Medication Labeling Deficiency for Controlled Substances
Penalty
Summary
The facility failed to ensure that narcotic medications were labeled according to professional standards, affecting two residents. For one resident, the controlled medication shift change log and signature sheets revealed a prescription for Tramadol with a label that included two different orders: one for a single daily dose and another for as-needed administration. This discrepancy led to confusion about the correct administration schedule, as confirmed by an LPN who noted that the resident was receiving the medication only as needed, not daily. For another resident, the medical record indicated a readmission with multiple diagnoses, including sepsis and heart failure. The physician's order specified Tramadol to be administered every eight hours as needed, but the medication label incorrectly stated it should be given three times daily. This error was not flagged to alert staff of the dosage change, resulting in the medication being administered as needed from a mislabeled card. An LPN verified the inconsistency between the label and the actual administration practice.
Medication Administration and Record-Keeping Deficiencies
Penalty
Summary
The facility failed to ensure accurate medical records for two residents, which was identified through a review of medical records, interviews, and policy review. Resident #71's medical record showed discrepancies in the administration of Morphine Sulfate. On multiple occasions, Registered Nurse (RN) #174 signed out two doses of morphine instead of one without providing an explanation. Additionally, there was no evidence of proper documentation or witness verification for wasted medication, as required by the facility's policy. The Director of Nursing confirmed that excess medication was signed out without proper documentation. Similarly, Resident #16's medical record revealed issues with the administration of Oxycodone. RN #174 signed out two doses of Oxycodone instead of one on two separate occasions, again without explanation. The Director of Nursing verified that excess medication was signed out without documentation of its disposition. These findings were part of an investigation under a master complaint number, indicating non-compliance with the facility's medication management policies.
Infection Control Breach During Dressing Change
Penalty
Summary
The facility failed to adhere to infection control measures during a dressing change for a resident with a Stage IV pressure ulcer. The resident, who was admitted with multiple diagnoses including hyperkalemia, congestive heart failure, and dementia, had a chronic sacral pressure ulcer that required specific dressing changes. Physician orders included Enhanced Barrier Precautions (EBP) for wounds, which mandated the use of gowns and gloves during high-contact care activities. However, during an observed dressing change, two LPNs only used gloves and did not wear masks or gowns as required by the EBP policy. The facility's EBP policy, implemented to prevent the transmission of multidrug-resistant organisms, was not followed. The policy required gowns and gloves to be used during wound care, and face protection if there was a risk of splash or spray. Despite the presence of a sign indicating EBP at the resident's door, the LPNs did not comply with the necessary precautions. An interview with one of the LPNs confirmed the oversight and acknowledged that the dressing changes were not consistently documented.
Food Served at Inadequate Temperatures
Penalty
Summary
The facility failed to ensure that food was served at palatable temperatures, potentially affecting all 59 residents who consumed meals prepared in the kitchen. Interviews conducted on July 1, 2024, with several residents revealed concerns about the palatability of food, specifically noting that it was often served cold. An observation on July 2, 2024, showed that while food temperatures on the steam table were above 165 degrees Fahrenheit, a test tray plated at 12:22 P.M. and delivered to the floor at 12:31 P.M. had significantly cooled by the time it was served. By 12:43 P.M., the BBQ ribs on the test tray measured 98 degrees Fahrenheit, and the sweet potato fries were 94.3 degrees Fahrenheit, both of which were verified by a staff member. The food was described as cool to the touch and lukewarm in taste.
Inadequate Dish Sanitization Due to Low Temperature
Penalty
Summary
The facility failed to ensure proper sanitization of dishes and eating utensils due to the high-temperature dish machine not reaching the required temperature for sanitization. Observations revealed that the dish machine's temperature ranged between 145-147 degrees Fahrenheit, below the required 180 degrees Fahrenheit for sanitization. The kitchen staff was using a rinse aid that was not intended for sanitization, and there was no sanitizing solution in the bus tubs used for rinsing dishes. Interviews with staff indicated that the dish machine's temperature was inconsistent, and there were no instructions provided on what to do when the temperature was inadequate for sanitization. The issue was compounded by the facility's hot water tank needing replacement, which affected the dish machine's performance. The maintenance staff was uncertain about how long the dish machine had been failing to reach the appropriate temperature. The dietary staff was not observed sanitizing items after they were run through the dish machine, contrary to what the Administrator was informed. Additionally, the Registered Dietitian initially used incorrect test strips for chlorine levels, and the proper sanitization process using bleach was only initiated after the deficiency was identified. The dish machine temperature logs from April to June 2024 showed consistently low temperatures, indicating a prolonged period of inadequate sanitization.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were in place, as evidenced by the lack of facial protection in areas where staff handled soiled linens. During an observation in the laundry room, it was noted that no facial shields were available to prevent splatter from soiled linens. Housekeeping staff confirmed that soiled laundry was sent back to the floor for aides to rinse, yet no facial shields were available in the utility rooms where this rinsing occurred. The facility's policy required protective gloves and other appropriate protective equipment when handling soiled laundry, which was not adhered to. Additionally, the facility did not implement its water management program for legionella prevention effectively. The Maintenance Director was unaware of key components of the plan, such as the meaning of TMV, and could not provide evidence of monthly checks or other required actions. There was no documentation of shower heads being descaled, cleaned, and disinfected quarterly, nor were records kept of hot water tank maintenance. Furthermore, the facility's tuberculosis risk assessment was outdated, using data from 2021 despite more current information being available. The Administrator acknowledged that the TB risk assessment had not been updated with the latest data, which was available from the Ohio Department of Health.
Medication Management Deficiencies
Penalty
Summary
The facility failed to ensure that medications were properly secured and discarded when expired, affecting three residents and potentially impacting all 25 residents on the 200 unit. For Resident #21, a bottle of Lantus insulin was found to be expired, as it was opened beyond the 28-day limit. Similarly, Resident #37 had an expired bottle of Insulin Aspart, which was also not discarded after 28 days. Both instances were verified by the respective LPNs, who acknowledged the oversight in checking expiration dates prior to medication administration. Additionally, Resident #36 was found to have Tums and Preparation H at her bedside without a physician's order, which was confirmed by an LPN. The facility's medication storage room contained expired over-the-counter medications, including Loratadine, Naproxen Sodium, and Melatonin, which were not discarded as required. These lapses were in violation of the facility's policies on administering and storing medications, which mandate checking expiration dates and ensuring medications are administered according to physician orders.
Delayed Disbursement of Deceased Residents' Personal Funds
Penalty
Summary
The facility failed to ensure that the personal funds of two deceased residents were forwarded to their estates within the required 30-day period. Resident #227, who had diagnoses including altered mental status, diabetes mellitus, and hypertension, passed away on December 8, 2023. Despite this, her personal funds, amounting to $50.15, were not dispersed until July 1, 2024, when the facility debited her account and made a check out to itself. The delay was attributed to the facility's inability to contact the resident's representative until June 2024, at which point the representative agreed to use the funds to settle the resident's outstanding balance with the facility. Similarly, Resident #228, who had diagnoses including congestive heart failure, diabetes mellitus, and hypertension, passed away on February 20, 2024. Her personal funds, totaling $100.22, were not dispersed until June 30, 2024, when the facility debited her account and issued a check to itself. The facility also cited difficulties in reaching the resident's representative until June 2024, who then agreed to apply the funds towards the resident's outstanding balance. These actions resulted in a failure to comply with the requirement to forward personal funds to the residents' estates within 30 days of their passing.
Failure to Document Resident's CPR Wishes
Penalty
Summary
The facility failed to ensure that a resident's wish for cardiopulmonary resuscitation (CPR) was clearly documented in the medical record. The resident, identified as Resident #128, had an initial order for Do Not Resuscitate - Comfort Care - Arrest - Do Not Intubate (DNRCCA - DNI) upon admission. However, an Advance Directive Questionnaire signed by the resident indicated a desire for CPR. A social service progress note later documented the resident's request to change her advance directive to full measures, but this change was not immediately reflected in the medical record. Interviews revealed that the Licensed Social Worker (LSW) responsible for the admission paperwork left the documents with the resident and forgot to retrieve them until later. Upon discovering the resident's signed full code status, the LSW informed a floor nurse but failed to notify the Director of Nursing (DON). The discrepancy between the resident's wishes and the medical record was eventually discussed with the DON, who clarified the resident's code status and updated the medical record accordingly. The facility's Advance Directives policy requires that residents be informed of their rights to make medical decisions, and that their care plans align with their documented preferences.
Failure to Establish Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to ensure comprehensive care plans were established for two residents, leading to deficiencies in their care. Resident #14, who was admitted with diagnoses including congestive heart failure, depression, and chronic kidney disease, was prescribed Vistaril for anxiety. However, the care plan did not address the anxiety diagnosis or the use of anti-anxiety medication. This was confirmed by the Director of Nursing during an interview. Resident #54, admitted with conditions such as a fracture of the left femur, dementia, adult failure to thrive, and difficulty in walking, experienced a fall after self-ambulating without a necessary mobility device. This resulted in an intertrochanteric fracture and a humeral fracture. While the care plan addressed the intertrochanteric fracture, it failed to include the humeral fracture, as confirmed by the Director of Nursing.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 487 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Dover
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Country Club Center I | 0 mi | ★★★★★ | 44 | 1 |
| Amberwood Manor | 1.9 mi | ★★★★★ | 0 | 0 |
| Park Village Health Care Center Inc | 2.2 mi | ★★★★★ | 9 | 0 |
| Hennis Care Centre Of Dover | 2.3 mi | ★★★★★ | 0 | 0 |
| Park Village Hc Np Llc | 3.6 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.