Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sapphire Rehabilitation And Care Center during CMS and state inspections, most recent first.
Failure to Document and Follow Up on Bathing Refusals: A resident with severe cognitive impairment and dependence on staff for bathing/showering had repeated bath/shower refusals documented, but staff did not document reapproaches, provider notification, or whether bathing was later offered or completed. The resident’s care plan did not address the refusals until after the issue was identified, and the DON confirmed the refusal interventions were not available to floor staff before being added to the Kardex.
Infection control was not maintained during medication administration for two residents. An RN removed medications from blister packs onto her hand and then placed them into medication cups for one resident with multiple diagnoses including chronic respiratory failure and paraplegia and another resident with HTN, anxiety, and depression. The RN confirmed the practice during interview, and the facility policy states staff follow infection control procedures during med administration.
A resident with intact cognition and multiple medical diagnoses requested a COVID-19 vaccine, for which a provider order was obtained and entered. On the scheduled administration date, an LPN documented the vaccine as not available on the MAR, and the vaccine was never given. The resident reported being told the vaccine was on back order and was only offered the option to obtain it at a local pharmacy, which she declined. The ADON stated nurses are expected to confirm vaccine orders with the pharmacy, while pharmacy staff reported the vaccine was in stock but could not be released because the facility failed to submit the required vaccine request form, resulting in noncompliance with the facility’s vaccination policy.
A cognitively intact resident with multiple chronic conditions, including CHF, renal insufficiency, DM, and depression, received a 30‑day discharge notice signed by the Administrator, with discharge planned to a homeless shelter. Although the resident reported receiving the discharge letter, there was no documentation that the Office of the State Long-Term Care Ombudsman was provided a copy of the notice, and the Administrator confirmed he could not produce evidence of such notification. This failure to notify the Ombudsman regarding the resident’s discharge was identified during a complaint investigation.
The facility did not ensure food was served at appropriate temperatures, as multiple residents reported consistently receiving cold meals. Observations confirmed that food temperatures dropped significantly between the tray line and delivery to residents, with the Dietary Manager noting a lack of adequate warming carts. Resident Council minutes also reflected ongoing concerns about food temperature.
Staff did not maintain a clean kitchen environment, with about 15 ceiling tiles covered in a black dusty substance and thick dust on ceiling vents above food prep and cooking areas. The Dietary Manager confirmed the issue and stated there was no set cleaning schedule for these areas, potentially affecting all residents receiving meals.
A resident with multiple chronic conditions was unable to reliably use the call system in the bathroom due to a known malfunction, resulting in staff providing a handheld bell as an alternative. Facility staff confirmed that a specific issue with the bathroom call system prevented signals from reaching the nurses' station, and resident council minutes documented ongoing concerns about call light response.
Surveyors found that the facility failed to provide a clean, safe, and comfortable environment, with issues such as exposed drywall, exposed wires, unsanitary conditions including dried feces, and multiple areas with temperatures below the required minimum. Staff confirmed these environmental problems, and maintenance logs indicated unresolved heating issues despite previous repair attempts.
Several residents requiring assistance with ADLs did not receive timely care due to a shortage of towels and washcloths, leading families to supply their own linens. In addition, a resident with severe cognitive impairment was observed attempting to eat a foil lid from a juice container, despite staff being aware of the need to remove such lids for residents with low cognition. Staff and resident council confirmed ongoing issues with linen shortages and inadequate supervision during meals.
Surveyors found that most exterior lights were not functioning, leaving areas around the building and parking lots unlit at night. Additionally, a sitting room intended for resident use was used to store hazardous maintenance supplies, including caulk and paint stripper, with the room left unlocked and accessible. Staff confirmed these conditions, which did not meet facility policies for safety and secure storage.
A resident with multiple chronic conditions and requiring ADL assistance did not have their family's request for an electronic monitoring device in their room accommodated. The facility initiated contact with the roommate's guardian for consent but did not follow up after receiving no response, and no further action or documentation was found. Facility policy supports resident rights to electronic monitoring, but the request was not fulfilled.
A resident with severe cognitive impairment did not have access to a working bedside phone, requiring her to use the nurse's station for family calls. Staff were unaware of alternative private phone options, and the facility's policy for private phone access was not effectively communicated or implemented, resulting in a lack of privacy for the resident's phone communication.
A medication error rate of 10 percent was identified when an LPN was unable to administer three prescribed medications to a resident with multiple chronic conditions because the medications were not available in the facility. The LPN confirmed that medication unavailability is a frequent issue, resulting in missed doses and non-compliance with facility policy.
A resident with moderate cognitive impairment and multiple diagnoses was found with medications left at the bedside by an LPN, despite lacking a physician order for self-administration or for medications to be left at bedside. Facility policy requires such an order and assessment, which was not present in this instance.
A cognitively impaired resident with a history of wandering and high elopement risk left the facility twice without staff knowledge. On both occasions, the resident was found by police outside the facility, with the second incident resulting in the resident being missing for over 17 hours. Despite documented risk factors and family concerns, the care plan lacked interventions for elopement, required safety checks were not performed or documented, and incidents were not reported as required.
A resident with multiple medical and psychosocial issues, including alcohol abuse and homelessness, was discharged without evidence of a safe destination or continuity of care. The resident repeatedly left the facility unsupervised, and there was no documentation of mental health or substance abuse services being offered. Staff failed to update care plans, notify responsible parties, or coordinate with community resources, resulting in the resident being found homeless, malnourished, and expressing suicidal ideation after discharge.
Failure to Supervise Resident Outdoors and Incomplete Fall Investigation: A resident with dementia, hemiplegia, diabetes, and limited wheelchair mobility was left outside in hot weather without a way to summon staff and later developed a 106 degree F temperature, was hospitalized, and was diagnosed with heat exhaustion/dehydration-related illness. Another resident with impaired cognition, blindness, and fall risk had an unwitnessed fall with a head laceration, but the fall was not thoroughly investigated and the documentation of the resident’s location and fall interventions was conflicting and incomplete.
Failure to Address Behavioral Health Needs and Aggression Risk: A resident with anxiety, TBI, intellectual disability, and a history of self-injury became agitated during care, threw items at a CNA, and brandished a knife while threatening staff. The record showed the resident had known mood and coping issues, but the facility did not have an individualized comprehensive behavioral health care plan in place before the incident, and social services coverage was absent for part of the period leading up to the event.
Insufficient kitchen staffing led to unsanitary food service conditions and use of disposable dishware. The kitchen had food splatter, debris, unlabeled and undated foods, a dirty ice machine, dust-covered ceiling tiles, and a frozen spill that had not been cleaned. Staff reported the dietary manager had quit, cleaning had not been a priority, and only two kitchen staff were working that morning, so breakfast was served in Styrofoam containers with plastic silverware and they could not have gotten the dishes clean for lunch.
Unsanitary kitchen conditions and improperly cleaned beverage cups were observed in the LTC facility. The kitchen had food splatter on the wall behind the handwashing sink, food boxes stored on the floor, heavy debris and stains on prep and dish areas, a dirty ice machine, dusty ceiling tiles, unlabeled and undated foods, and soiled utensil drawers. On the B Unit, an MRs staff member was observed wiping beverage cups with a rag while residents were being served, and the cups still had white residue inside them.
Uncovered kitchen trash containers were observed near the handwashing station and dishwashing area, with two large trash cans filled with trash and left open with no lids or coverings. The DM confirmed the containers needed lids or covering and obtained lids at the time of discovery. Facility policy stated kitchen waste must be kept in tightly closed containers and disposed of daily.
Insufficient Surety Bond for Resident Funds: The facility failed to ensure its surety bond was large enough to cover resident personal funds deposited with the facility. Review of the bond showed $50,000.00, while the resident account balance sheet showed $59,786.08 in total resident funds across 45 accounts. The RBOM confirmed the bond was not enough to cover the current resident funds balance.
MDS assessments were inaccurate and late for multiple residents. One resident on aspirin was not coded for antiplatelet use, another resident on continuous tube feeding was not marked as receiving tube feeding, and a resident with a documented fall was not coded for a prior fall. Several quarterly MDS assessments were also signed after the required 14-day ARD window, and the MDS nurse confirmed the errors.
A facility failed to develop comprehensive care plans for three residents. One resident had TBI, intellectual disability, agitation, and a history of self-injury, but the care plan did not address those issues. Another resident repeatedly left the facility without signing out, including trips related to alcohol use, yet the care plan did not address the LOA behavior. A third resident with Alzheimer’s disease and dependence for eating had no care plan addressing hydration status or related interventions.
Missed medications, delayed treatments, and lack of ordered care: A resident with migraine, dementia, and severe glaucoma had multiple ordered meds omitted or given late, including eye drops, pain-related meds, and a monthly injection that was not administered when unavailable. Another resident with ESRD and DM missed ordered Debrox doses for ear wax, with notes repeatedly stating the drops were not in house. A resident with a head laceration had no documented monitoring or site care for several days after the injury, and another resident had ace wraps ordered for both legs but repeated observations showed the wraps were not being worn despite TAR sign-off.
Improperly labeled and stored medications were found in the facility. Multiple open insulin pens and vials for several residents were undated, a box of Cathflo was stored in the med cart despite instructions to refrigerate it, and medications for discharged residents remained in the carts. An open Tubersol vial was also found in the med refrigerator past the discard timeframe, and staff verified the labeling, storage, and disposal issues.
Dirty Floors, Walls, and Air Conditioning Units on B Unit A resident's room had brown splatters around a tube feeding pole and black sticky residue under a wheelchair, while another resident's room had brown splatters on the wall around an outlet and stains on the floor. The B unit hallway had thick sticky residue that caused shoes to stick, and two common-area AC units had dust buildup and a black mold-like substance around the vents. Housekeeping staff verified the observations and reported the floor scrubber had been down for about a month.
Failure to Honor Bathing Preferences and Keep Call Light Within Reach: The facility did not honor two residents’ stated shower preferences, as bathing records showed bed baths or mixed bathing types instead of consistent showers, and the DON confirmed the mismatch. The facility also failed to keep an alert resident’s call light within reach on repeated observations; the resident said she used it to get help, and an LPN confirmed it was out of reach.
Failure to maintain privacy during a dressing change: A resident with dementia, incontinence, and a stage 2 pressure area received wound care in a shared room where the curtain setup could not be pulled between the beds. The roommate remained in bed facing the center of the room and could see the dressing change, and the ADON confirmed the room arrangement did not provide privacy.
Failure to Timely Report Injury of Unknown Origin and Resident Altercation: The facility did not timely report an injury of unknown origin involving a resident with dementia, contractures, and hemiplegia after blistering and open areas were found on his hand with no clear cause identified. The facility also delayed reporting an altercation in which a resident with TBI, paraplegia, anxiety, and behavioral issues threw items at a CNA and brandished a knife while threatening staff, despite police involvement and multiple witnesses.
Incomplete Investigation of Resident Injury and Staff Altercation: The facility did not thoroughly investigate a resident’s unexplained hand injury or a separate incident in which a resident became agitated during care, threw objects at a CNA, and brandished a knife. The injured resident had significant neurologic impairment, contractures, and diabetes, while the other resident had TBI, paraplegia, anxiety, chronic pain, and a history of maladaptive behavior. Records showed the hand injury involved blisters, drainage, and open areas with no clear cause identified, and the altercation included verbal threats, minor injury to the CNA, and police involvement. The facility did not obtain key witness statements or fully document the events.
PASARR screening was not completed accurately for one resident and was not filed on time for another. One resident had COPD, malnutrition, anemia, alcohol abuse, and other diagnoses, but the PASARR screen incorrectly showed no mental or substance use disorders despite the resident’s alcohol abuse history. Another resident with bipolar disorder and mild cognitive impairment had no evidence of an initial PASARR submission in the record until SS later filed one after noticing it had been missed.
PASARR Not Updated After New Diagnosis: The facility failed to update a resident’s PASARR when a new diagnosis was added. The resident had mood disorder, paranoia, blindness, unspecified psychosis, and delirium, and later received a new diagnosis related to delirium and antipsychotic use. Social Service verified the PASARR should have been completed within 30 days of admission and updated when the new diagnosis was added.
Failure to provide nail care and scheduled bathing affected two residents. One resident with dementia, DM2, and CKD had long, dirty fingernails despite a care plan directing staff to check, trim, and clean nails; the resident repeatedly asked for nail care, and a UM later verified the condition. Another resident with dysphagia, anxiety, breast cancer, and DM2 was supposed to receive bathing assistance twice weekly, but documentation showed a 10-day gap without bathing, and the resident stated staff did not like to bathe residents; the DON verified the missed bathing schedule.
Failure to Offer Activities and Develop Activity Plans of Care: The facility did not ensure two residents were offered activities or had activity plans of care. One resident with dementia, depression, chronic pain, and visual impairment had documented interests in jazz, reading, and TV/movies, but there was no evidence she was offered or attended activities and her care plan did not address preferences. Another resident with Alzheimer's disease and impaired cognition was repeatedly observed alone in her room, had no activity-related care plan, and staff confirmed she had not been introduced to activities or invited to participate.
Failure to prevent pressure ulcers and follow wound orders: one resident with multiple comorbidities, limited mobility, and incontinence did not have documented turning and repositioning before developing a new unstageable mid-back pressure injury, and ordered wound treatments were missed on several days without explanation. A second resident with paraplegia and a stage 4 sacral ulcer had an outside wound practitioner order for NS cleansing and bordered foam dressing that was not transcribed or implemented, while nursing continued the older Dakin's-based treatment.
Missing Bowel Movement and Catheter Care Documentation: Two residents had documentation gaps related to bowel/bladder care. One resident with cognitive impairment and bowel/bladder continence had no recorded BM for several days, and the DON confirmed there was no bowel protocol. Another resident with an indwelling foley and orders for catheter care every shift had no documented evidence that catheter care was performed prior to the order date, which the DON verified.
Failure to Document Routine Ostomy Bag Changes: A resident with diagnoses including colostomy and ileostomy required staff help with ostomy care, but the record showed no physician order or documented evidence that the ileostomy/urostomy bag was changed routinely. Hospital records noted an ileal conduit urinary diversion and treatment for a UTI, and the DON confirmed there was no order or documentation showing routine bag changes.
Meal supervision and nutrition orders were not followed for three residents. One resident with dysphagia, dementia, contractures, and hemiplegia was observed eating breakfast alone in his room without staff present, poorly positioned, with food scattered on the tray and resident and no fluids present despite an order for close supervision, a divided plate, and nectar thick liquids. Two other residents with severe malnutrition and complex medical conditions had dietitian recommendations that were not implemented timely: one had a tube feeding increase recommended for a worsening wound, and another had a recommendation for double protein portions that was delayed.
Pain medication administration and documentation were deficient for two residents. One resident with chronic pain and migraines missed ordered fentanyl patch doses, with the MAR, narcotic counts, and progress notes showing the patch was unavailable or not given as scheduled. Another resident with paraplegia and other diagnoses had PRN oxycodone and acetaminophen given without pain parameters in place, including oxycodone administered for a pain score of zero, and nursing notes did not describe the resident’s pain when PRN meds were given.
Improper Documentation of Fentanyl Patch Disposal: A resident with chronic pain, migraines, osteoarthritis, and dementia-related diagnoses had an order for a fentanyl patch for pain control, but nursing staff repeatedly failed to properly document patch disposal on the narcotic count sheets. In several instances, disposal was signed without being witnessed, and the DON confirmed that fentanyl patch disposal should be witnessed and signed by two nurses.
A resident with multiple diagnoses, including psychosis, fractures, blindness, delirium, and DVT, was ordered Clonidine 0.1 mg transdermal patch weekly for DVT. The MAR showed the medication was given as ordered, and the DON confirmed DVT was not an appropriate diagnosis for Clonidine and that there was no documentation supporting its use.
Missed Immunosuppressant Doses for Resident With Kidney Transplant: A resident with kidney transplant status, CKD stage 3, and immunodeficiency missed multiple scheduled doses of Mycophenolate Sodium, an immunosuppressant ordered BID. The MAR and progress notes showed the medication was unavailable on several occasions, and the DON confirmed the missed doses were related to pharmacy supply issues and insurance approval delays.
Ordered Laboratory Testing Not Completed: A resident with diabetes, dementia, HTN, asthma, and other diagnoses had physician-ordered CBC, CMP, A1C, TSH, vitamin B12, and vitamin D labs that were entered into the lab system but were not collected. The chart contained no lab results or evidence the tests were obtained, and the DON confirmed the ordered testing was not completed.
Infection control procedures were not followed when a resident with a wound and PEG tube did not have ordered EBP in place, a CNA provided incontinence care for a severely cognitively impaired resident in another resident's bed, and an RN cleaned a shared BP cuff with a tissue and hand sanitizer because no approved disinfectant wipes were available. The DON and ADON confirmed the observed failures.
Topical Antibiotic Continued Past Ordered End Date: A resident with multiple chronic conditions and a hand wound was ordered Mupirocin for a limited time after hospital treatment, but the MAR showed the topical antibiotic was given for months beyond the ordered stop date. The DON confirmed the ointment was continued past when it should have been, and facility policy required medications to be administered according to the order and time frame.
The facility did not provide required written bed hold or transfer/discharge notices to three residents with complex medical needs when they were transferred to the hospital, nor did it notify the ombudsman of these discharges. The DON confirmed that documentation of these notifications was not available, and one resident reported only receiving a verbal notice about bed hold duration.
A resident with dementia and a history of wandering was physically assaulted by another resident with behavioral issues after repeatedly entering the latter's room. Despite care plans and staff redirection, the interventions in place failed to prevent the incident, resulting in facial injuries that required hospital treatment. The facility did not implement additional preventive measures until after the event, and those measures were not consistently maintained.
A resident with a tracheostomy and a history of respiratory failure experienced acute respiratory distress and did not receive appropriate emergency respiratory interventions, including suctioning, as-needed nebulizer treatment, changing the inner cannula, or Ambu bag ventilation. Staff failed to provide continuous bedside support, and no CPR was initiated prior to EMS arrival. The resident was found in cardiac arrest by EMS and was later pronounced deceased.
A resident's room was found cluttered with medical supplies and personal items, making the environment non-homelike and hindering furniture usability. The resident, with multiple medical conditions, did not require all the items present, as confirmed by their family. Facility staff acknowledged the issue, which violated the facility's policy for maintaining a homelike environment.
Failure to Document and Follow Up on Bathing Refusals
Penalty
Summary
The facility failed to properly provide bathing and shower services and oversight for a resident who was dependent on staff for care. Resident #27 was admitted with diagnoses including depression, anxiety disorder, hyperlipidemia, atherosclerotic heart disease, dementia, adult failure to thrive, hypertension, hypo-osmolality and hyponatremia, and non-traumatic intracerebral hemorrhage. Her MDS assessment showed severe cognitive impairment, and her GG section indicated she required substantial physical assistance with baths/showers. The resident’s bath and skin record documented repeated refusals of baths/showers on multiple dates, but there was no documentation that staff reapproached her later to offer bathing again, and no documentation that the provider was notified of the ongoing refusals. A bath and skin record was also started on one date without any further documentation showing whether a bath or shower was offered or completed, and there was no documentation that bathing/showering was offered after the last recorded refusal. The resident’s care plan did not include refusal of baths/showers until it was revised after the issue was brought to facility management’s attention, and the DON confirmed there was no documentation supporting reapproach attempts or that the refusal care plan and intervention had been available to floor staff before being added to the Kardex.
Infection Control Lapse During Medication Administration
Penalty
Summary
The facility failed to maintain infection prevention and control during medication administration for two residents. Resident #62 was admitted on 02/20/22 and had diagnoses including anxiety, chronic respiratory failure with hypoxia, paraplegia, neuromuscular dysfunction of the bladder, essential hypertension, and radiculopathy; the resident’s MDS dated 03/27/26 indicated cognitive intactness. During the morning medication pass observed on 05/06/26 at 9:19 A.M., RN #300 removed each of Resident #62’s medications from a blister pack onto her hand and then placed the medications in a medication cup. Resident #64 was admitted on 04/03/26 and had diagnoses including essential hypertension, anxiety, and depression; the resident’s MDS dated 04/07/26 indicated cognitive intactness. During the morning medication pass observed on 05/06/26 at 9:27 A.M., RN #300 again removed each medication from a blister pack onto her hand and then placed the medications in a medication cup. During interview on 05/06/26 at 10:10 A.M., RN #300 confirmed she opened each medication housed in a blister pack onto her hand and then placed it in a medication cup. The facility policy titled, Administering Medications dated February 2026, states staff follow established facility infection control procedures, including handwashing, aseptic technique, gloves, and isolation precautions, as applicable, for medication administration.
Failure to Provide Requested COVID-19 Vaccination Due to Breakdown in Ordering Process
Penalty
Summary
The deficiency involves the facility’s failure to administer a requested SARS-CoV-2 (COVID-19) vaccination to a cognitively intact resident after a provider order was obtained. The resident, admitted with diagnoses including asthma, malnutrition, and vertigo, had previously received four COVID-19 vaccinations, the last in late October 2024. On 12/30/25, the resident requested another COVID-19 vaccination, and the nurse practitioner issued an order on 12/31/25 for a Comirnaty 30 mcg/0.3 mL intramuscular dose. The order was entered with an end date of 01/08/26. On 01/07/26, an LPN documented the vaccine on the MAR as “Med Not Available” and did not administer it. Review of the January and February 2026 MARs showed no evidence that the vaccine was ever given. The resident later developed a cough and was transferred to the hospital after independently calling EMS; she reported being hospitalized for eight days with COVID-19 and double pneumonia. During interview, the resident stated she had been told she would receive the vaccine on 01/07/26 but did not, and was informed it was on back order, with the only alternative offered being to go to a local pharmacy, which she declined due to cold weather. The LPN unit manager did not recall the request but confirmed placing and revising the vaccine order. The LPN who signed the MAR as “Med Not Available” stated the pharmacy required paperwork before sending the vaccine and that she notified someone at the facility, though she could not recall whom. The ADON stated nurses should call the pharmacy to confirm vaccine orders and provide needed information. Pharmacy staff reported the COVID-19 vaccine was not on back order and had been available throughout the relevant months, but the facility had not submitted the required vaccine request form, so the pharmacy could not release the vaccine. Facility policy required that residents be offered influenza, pneumonia, and COVID vaccines unless contraindicated or already vaccinated.
Failure to Notify Ombudsman of Resident Discharge Notice
Penalty
Summary
The deficiency involves the facility’s failure to provide a copy of a 30‑day discharge notice to the Office of the State Long-Term Care Ombudsman for a resident being discharged. The resident, who had diagnoses including heart failure, renal insufficiency, diabetes mellitus, and depression, was cognitively intact and independent with eating, toileting, bathing, and personal hygiene per an MDS 3.0 assessment. The medical record showed the resident was admitted on an unspecified date and received a 30‑day discharge notice dated 12/29/25, with an effective discharge date of 01/28/26, signed by the Administrator. There was no documentation that the Ombudsman’s office was notified or provided a copy of this discharge notice. During an interview on 01/28/26, the resident reported receiving a letter stating she was being discharged that day to a homeless shelter, and in a separate interview the same day, the Administrator confirmed he could not provide any evidence that the Ombudsman had been notified of the discharge notice. This omission was identified as an incidental finding during a complaint investigation.
Failure to Serve Food at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to ensure that food was served at palatable and safe temperatures for all 108 residents receiving meals from the kitchen. Multiple residents reported that their food was never served hot, with several stating it was always cold. Observations during lunch meal service showed that while food temperatures on the tray line were above 165°F, the temperatures dropped significantly by the time food reached residents, with turkey at 112°F, mashed potatoes at 110°F, and vegetables at 71°F. The Dietary Manager confirmed that the food was lukewarm and attributed the issue to an insufficient number of warming food carts. Resident Council meeting minutes from the previous month also documented ongoing resident concerns about food temperature.
Unsanitary Kitchen Conditions Due to Unclean Ceiling Tiles and Vents
Penalty
Summary
Facility staff failed to maintain a clean and sanitary kitchen area, as evidenced by the presence of approximately 15 ceiling tiles covered with a black dusty substance and a thick layer of dust on the ceiling vents located above food preparation and cooking areas. During an observation with the Dietary Manager, it was confirmed that the black substance could not be removed despite attempts with a microfiber cloth, and the dust on the vents was also acknowledged. The Dietary Manager stated there was no set cleaning schedule for the ceiling or vents. Review of facility policy indicated that residents are to be provided with a safe, clean, and comfortable environment. This deficiency had the potential to affect all 108 residents who received meals from the kitchen.
Failure to Maintain Functional Call System in Resident Bathrooms
Penalty
Summary
The facility failed to ensure that resident call systems were functioning properly in bathrooms and bathing areas, as evidenced by the experience of one resident who reported that her call light was not answered on multiple occasions. The resident, who had multiple diagnoses including chronic respiratory failure, diabetes, dementia, and other serious conditions, stated that staff provided her with a handheld bell due to the malfunctioning call system. Medical record review and interviews confirmed that the resident required assistance with activities of daily living and had ongoing health concerns. Observation and interviews with facility staff, including the Administrator and Maintenance Director, revealed a known issue with the call system in double rooms with shared bathrooms. Specifically, if a metal lever or switch in the bathroom was left partially engaged, the call light above the resident's bed would illuminate but would not send a signal to the nurses' station or outside the room. Review of Resident Council meeting minutes also documented ongoing resident concerns about call light response. There was no facility policy specifically addressing call lights, though staff were expected to respond in a timely manner.
Failure to Maintain Clean, Safe, and Comfortable Environment
Penalty
Summary
Surveyors identified multiple failures by the facility to maintain a safe, clean, and homelike environment for residents, as evidenced by direct observations, resident and staff interviews, and review of maintenance logs and facility policy. Specific deficiencies included rooms with holes exposing drywall, exposed wires hanging from walls, and unsanitary conditions such as dried feces on floors, walls, and privacy curtains. Several rooms and common areas were found to be below the required minimum temperature, with one resident reporting it was freezing in her room despite the thermostat being set to a high temperature. Maintenance checks confirmed that the actual room temperature was significantly lower than the thermostat setting, and the furnace in that room was not operational. Additional temperature checks throughout the facility revealed that multiple areas, including resident rooms, hallways, and activity spaces, were below the facility's stated minimum temperature requirement. Staff interviews corroborated the environmental issues, with both maintenance and housekeeping supervisors acknowledging the problems. Maintenance logs showed that heating issues had been previously identified and marked as resolved, but subsequent observations indicated ongoing problems. Facility policy required a homelike environment with comfortable temperatures and cleanliness, but these standards were not met in the affected areas. The deficiency affected all ten residents reviewed for environmental conditions, with a total facility census of 108.
Failure to Provide Adequate ADL Assistance and Supplies
Penalty
Summary
The facility failed to ensure that residents who required assistance with activities of daily living (ADLs) received appropriate care and supervision, and did not provide staff with the necessary supplies to deliver timely ADL care. Three residents were affected by these deficiencies. One resident with dementia, chronic pain, and mobility issues reported that her family had to purchase bath towels and washcloths because the facility did not have enough linens to provide showers or baths when requested. Another resident with hemiplegia and heart failure also reported that his family had to supply towels and washcloths due to the facility's shortage, which resulted in missed showers or baths. Observations of the facility's linen storage rooms on multiple occasions revealed insufficient quantities of towels and washcloths, and both housekeeping and laundry staff confirmed that there were not enough linens to meet residents' needs in a timely manner. Resident council minutes also documented complaints about the lack of washcloths and towels, particularly on weekends. Additionally, a resident with severe cognitive impairment and a history of dementia and schizoaffective disorder was observed attempting to eat a foil lid from a juice container while in bed with a meal tray. Staff interviews confirmed that this resident required assistance with eating and that the foil lid should have been removed due to the resident's cognitive status. Despite staff education on this issue, further observation showed that the resident continued to receive meal trays with the foil lid attached. These findings demonstrate a failure to provide adequate assistance and supervision for ADLs, as well as a lack of necessary supplies to ensure timely and safe care.
Failure to Maintain Outdoor Lighting and Secure Hazardous Materials
Penalty
Summary
The facility failed to maintain adequate outdoor lighting and proper storage of hazardous maintenance equipment and supplies. Observations revealed that most exterior lights, including those around the building, employee parking lot, and visitor parking area, were not functioning, leaving large areas unlit during nighttime hours. Only two of six lights in the visitor parking area were operational, and even those had only partial illumination. Staff interviews confirmed that the lack of functioning exterior lighting was a safety issue, particularly in the dark. Additionally, a sitting room adjacent to the activity area was found to be used for storage of maintenance equipment, including hazardous materials such as caulk and paint stripper, which were labeled with warnings. The room was unlocked and propped open, making these hazardous materials easily accessible to residents. Staff confirmed that the room, originally intended as a comfortable space for residents, had become a storage area with hazardous items within reach. Facility policies required hazardous materials to be stored securely and for the environment to be safe and homelike, but these standards were not met.
Failure to Accommodate Resident Request for Electronic Monitoring Device
Penalty
Summary
The facility failed to accommodate a resident's preference to have an electronic monitoring device (camera) placed in their room. The resident, who had multiple diagnoses including chronic respiratory failure with hypoxia, type II diabetes mellitus, dementia, heart failure, depression, chronic kidney disease, weakness, and cancer, required assistance with activities of daily living. The resident's family requested the placement of an electronic monitoring device, and the facility's Social Service Designee sent an email to the guardian of the resident's roommate requesting consent for the device. However, there was no evidence of a response from the roommate's guardian, nor was there any further documented correspondence or follow-up regarding the request. Observation of the resident's room confirmed that no electronic monitoring device was present. Interviews with facility staff, including the Social Service Designee and the current Administrator, revealed that the previous Administrator had been handling the situation, but no additional documentation or communication could be found. Review of the facility's policy indicated that residents have the right to use electronic monitoring devices in their rooms, but the facility did not provide evidence that it had reasonably accommodated the resident's or family's request.
Failure to Ensure Resident Privacy and Access for Telephone Communication
Penalty
Summary
Facility staff failed to ensure that a resident had privacy and reasonable access to telephone communication. Observation revealed that the resident's bedside phone was not plugged in and the phone jack did not have service, a situation that had persisted for several months according to the roommate. The resident, who had severe cognitive impairment and was rarely understood, was unable to be interviewed, but it was confirmed that she had a guardian and a family member involved in her care. When the resident received calls from her family, she had to go to the nurse's station to communicate, as her room phone was nonfunctional and lacked a cord to connect to the outlet. Staff interviews showed inconsistent knowledge about the availability of alternative phones for private use, with some LPNs unaware of any facility-provided cell phone and unable to locate one. The Unit Manager and Administrator were not aware that the resident's phone was unusable or that not all room phones had service. Facility policy required reasonable access to phones in a private area, but staff were not aware of the designated private phone options in the Social Services or Business Office. This resulted in the resident not having private access to phone communication as required.
Medication Error Rate Exceeds Acceptable Threshold Due to Unavailable Medications
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, with three medication errors occurring out of 30 observed opportunities, resulting in a 10 percent error rate. During medication administration for one resident with diagnoses including rhabdomyolysis, type II diabetes mellitus, and hypertension, it was observed that three prescribed medications—Mucinex 600 mg, Fluticasone Propionate nasal spray, and glipizide 5 mg—were not administered as ordered due to the medications not being available in the facility. The LPN responsible for administering the medications confirmed that the medications were not given because they were not on hand and stated that this issue occurs frequently. Facility policy requires verification of the right medication, dose, time, and route before administration, but the lack of medication supply prevented compliance with these requirements.
Medications Improperly Left at Bedside Without Physician Order
Penalty
Summary
The facility failed to ensure that medications were properly stored in accordance with professional standards. During observation, a resident with vascular dementia, cerebral infarction, and hypertension was found to have several medications left in a medicine cup on his bedside table. The resident, who had moderate cognitive impairment and required minimal assistance with activities of daily living, stated he did not know how long the medications had been there and that nurses often left his medications at the bedside for him to take. Review of the medical record and physician orders confirmed there was no order for the resident to self-administer medications or for medications to be left at the bedside. An LPN acknowledged preparing and leaving the medications on the bedside table and confirmed the absence of an order for self-administration. Facility policy requires that residents may only self-administer medications if the physician and care planning team determine it is safe, which had not occurred in this case.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A cognitively impaired resident, identified as high risk for elopement, was able to leave the facility on two separate occasions without staff knowledge. The first incident occurred when the resident, who had a history of wandering, confusion, and impaired decision-making, was found by police 0.5 miles from the facility after staff were unaware of his absence until contacted by law enforcement. The resident's medical record indicated a high elopement risk score, documented episodes of wandering, and family concerns about his tendency to leave, yet no interventions or care plan addressing elopement risk were in place at the time. Following the first elopement, the resident was returned to the facility and placed on one-to-one supervision, but there was no physician order for this intervention, and the resident was returned to a non-secured unit. Documentation revealed that cognitive assessments were not completed upon his return, and the care plan still lacked interventions for elopement risk. The facility also failed to submit a Self-Reported Incident (SRI) related to this event, and the incident was not documented in the facility's incident/accident log. A second elopement occurred when the resident, who was supposed to be on 15-minute checks, left the facility again and was missing for over 17 hours before being found by police 2.6 miles away. There was no documented evidence that the required 15-minute checks were performed, and staff interviews confirmed that checks were not consistently documented or performed as ordered. The facility did not report this elopement to the state health department, and the incident was again omitted from the SRI and incident/accident log. The lack of timely and appropriate interventions, failure to follow physician orders, and inadequate documentation contributed to the deficiency.
Removal Plan
- The facility initiated a search for Resident #10.
- The facility initiated a head count, and all residents were accounted for except for Resident #10.
- The facility administrator notified the police of Resident #10's absence.
- The police requested assistance from another police department who had access to a device with thermal capabilities.
- The Bureau of Criminal Investigations was contacted and a silver alert was completed and sent out statewide.
- The Sheriff's Office was notified and assisted with the search for Resident #10.
- The facility conducted an AD HOC Quality Assurance and Performance Improvement (QAPI) meeting.
- Resident #10 was found and transported to a hospital for an evaluation.
- The facility reviewed and updated the elopement policy to reflect clearer definitions on elopement, more concise instructions to staff on reporting elopement, investigation procedures, and notification to appropriate agencies and medical staff.
- Resident #10's care plan was updated to reflect resident now resides on the secured unit.
- The facility staff completed a whole house head count as part of the facility's daily audits of residents. All residents were accounted for.
- Resident #10 was placed on the facility secured unit.
- Resident #10 was assessed by the facility nurse with no significant injuries. The assessment revealed two open areas on the right foot assessed as abrasions.
- A whole house audit of all residents was completed to ensure all residents were accurately assessed for elopement risk and no new residents were identified as being high risk for elopement. All residents who were previously identified as being high risks had their care plans reviewed for accuracy and no inaccuracies were found.
- Facility Unit Manager initiated education on the facility elopement policy which included one Registered Nurse, four Licensed Practical Nurses, and two Certified Nursing Assistants.
- The facility continued education for all staff on the facility elopement policy. Five Licensed Practical Nurses, two Certified Nursing Assistants were educated in person. Director of Nursing and the Administrator were educated on the facility Elopement Policy. Medical Director and Certified Nurse Practitioner were educated on the Elopement Policy via the telephone.
- Sixteen Licensed Practical Nurses, thirty Certified Nursing Assistants, three Activity Employees, eight Housekeepers, ten Dietary Staff, four Office Staff, twenty-one Therapists, five Speech Therapists, and one Maintenance Director were educated on the facility Elopement Policy via the telephone.
- Two Registered Nurses, eleven Licensed Practical Nurses, twenty-seven Certified Nursing Assistants, three Dietary Staff, four Housekeeping Staff, two Office Staff, seven Therapists, and one Maintenance Staff were educated in person on the facility Elopement Policy.
- All residents who were assessed as a high risk for elopement had their care plans reviewed for accuracy and updated as necessary. No inaccuracies were found.
- The facility checked the elopement binders and verified they reflected the status of the residents in the facility. No changes were identified.
- The facility reviewed the Brief Interview for Mental Status (BIMS) for residents who were deemed at high risk for elopement to ensure the assessments were accurate. There were no changes made to the resident's assessments.
- The facility completed a second check of all Elopement Risk Assessments and Elopement Care Plans for Accuracy.
- One Licensed Practical Nurse, one Certified Nursing Assistant and one Office Staff member were educated on the facility Elopement Policy.
- No staff will be permitted to work at the facility who have not received and reviewed the updated facility Elopement Policy. Facility education on the Elopement Policy will be ongoing.
- All new hired employees will be educated on the facility Elopement Policy as part of the general orientation.
- Elopement drills and head counts were completed at various times/shifts. Staff knowledge and review of the drill was completed. The Administrator reviewed and verified no actual elopements occurred.
- The facility's Interdisciplinary Team members reviewed elopement care plans to ensure interventions were in place. No identified concerns were noted.
- The facility will complete weekly elopement drills with the drills rotating between day and night shift to ensure each shift will have at least four elopement drills. Drills will be done monthly and randomly thereafter.
- The facility will conduct head counts daily as part of their midnight census procedure which ensures that all residents are accounted for daily.
- All new residents will be assessed by the facility nursing staff and follow up completed to ensure proper assessments and interventions are in place for residents deemed to be high risk for elopement.
- Telephone interviews with staff verified they all had received education on the policies/procedures for elopement. All staff had knowledge of how to respond to an elopement situation. Staff reported there had been no elopements. The LNHA verified he had continued on-going training/education/drills for all staff on elopement policies/procedures.
- Review of the audits revealed elopement drills were completed successfully and on-going monitoring continued.
- The facility denied any further elopements.
Failure to Ensure Safe Discharge and Continuity of Care for Resident with Complex Needs
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process that ensured the safety and total care needs of a resident with multiple complex medical and psychosocial issues. The resident, who had diagnoses including alcohol abuse, malnutrition, chronic illnesses, and a history of homelessness, was discharged without evidence of a safe location to go or continuity of care post-discharge. The medical record review showed repeated instances where the resident left the facility unsupervised, often without signing out, and there were no new interventions or care plan updates to address these behaviors or ensure the resident's safety during leaves of absence. Despite the resident's known risk factors, including substance abuse and mental health concerns, there was no documentation of mental health or substance abuse services being offered or provided during the resident's stay. The facility's documentation revealed that the resident frequently left the premises, sometimes being found in unsafe situations such as in the street or at bus stops, and on several occasions required staff or police intervention to return. There was no evidence of comprehensive assessment or follow-up regarding the resident's ability to safely leave the facility, nor was there documentation of communication with the resident's physician or responsible party when the resident left. The care plan for anticipated discharge was not followed, and there was no evidence of social service follow-up or coordination with community resources, even after the resident expressed uncertainty about his housing situation and demonstrated ongoing psychosocial distress. After leaving the facility, the resident was found homeless, malnourished, and expressing suicidal ideation, leading to multiple hospital admissions. Interviews with facility staff confirmed a lack of notification to appropriate authorities or support services when the resident left and did not return. The facility's own investigation was minimal, with no staff or resident statements obtained, and the documentation did not support that the resident had requested to leave against medical advice. The facility's policies regarding leave of absence and discharge were not effectively implemented, and the resident's medical and psychosocial needs were not met at the time of discharge.
Removal Plan
- LNHA and the DON were educated on the facility's discharge against medical advice (AMA) and leave of absence (LOA) policies.
- An audit was completed by LNHA of current residents with plans to discharge to the community to ensure discharge planning was in progress and discharge plans were accurately recorded in each resident's record.
- SSD and LNHA were educated by RDCS on ensuring support for residents' psychosocial well-being and providing assistance with discharge needs and requests.
- SSD will complete new admission care conferences which will include screening assessments such as the PHQ-9 depression screening tool.
- The DON provided education to the facility's interdisciplinary team (IDT) and licensed nurses on the facility's policies on discharge AMA and LOA policies.
- A Quality Assurance Performance Improvement (QAPI) meeting was held, including completion of a root cause analysis of the event and development of a plan of correction.
- MDS Nurse completed an audit of in-house residents with the diagnosis or history of substance abuse or polysubstance abuse.
- The DON provided one-on-one education to residents with a substance abuse or polysubstance abuse history on the facility's leave of absences policy.
- Ad hoc education will be provided on an ongoing basis by RDCS or Regional Nurse for any staff member who is not correctly implementing the AMA and/or LOA policies on an as-needed basis.
- Newly hired nurses will be trained on the facility's discharge AMA and LOA policies upon hire by the DON or designee.
- The DON or designee will provide education to agency staff nurses on the facility's discharge AMA and LOA procedures prior to the agency nurse being able to accept the assignment at the facility.
- LNHA or designee will audit discharges to ensure documentation supports a safe discharge, including a discharge plan that meets the residents' behavioral and psychosocial needs.
- The results of ongoing audits will be reviewed by the facility's QAPI committee to determine if additional audits or education is needed.
- At Utilization Review (UR) meetings, LNHA or designee will discuss upcoming resident discharges and safe discharge planning.
Failure to Supervise Resident Outdoors and Incomplete Fall Investigation
Penalty
Summary
The facility failed to ensure Resident #107 was adequately supervised while outside and had a way to summon staff assistance. Resident #107 had diagnoses including dysphagia, cognitive communication deficit, type 2 diabetes mellitus, cerebral infarction, vascular dementia, peripheral vascular disease, epilepsy, sickle-cell disease, contractures, and flaccid hemiplegia affecting the left side. The care plan identified deficits related to decreased mobility, use of assistive devices, staff assistance needs, impaired decision making, and safety awareness, and the resident was dependent on staff for wheelchair mobility. On 08/16/25, Resident #107 was outside by the door drinking water when staff observed dizziness, fatigue, and flushed skin. The resident was brought inside, placed in a cool shaded area, given fluids, and cooled with damp cloths. Vital signs showed a temperature of 106 degrees F, blood pressure of 109/56 mmHg, oxygen saturation of 80 percent, and heart rate of 123 beats per minute. The resident was alert and oriented to person only, oxygen was started, the physician and family were notified, and the resident was sent to the hospital. Hospital records stated the resident presented with dyspnea and hypotension, was diagnosed with acute respiratory failure and newly required supplemental oxygen, and referenced the 106 degree F temperature at the facility as likely related to heat exhaustion and dehydration from being outside. The record and interviews showed the resident had been outside in 88 degree F weather and had no way to get staff attention while outside. RN #253 stated she had been checking on the resident every 20 minutes, that he was in the shade with fluids within reach, and that it was staff responsibility to check on him because he had no way to summon help. Other residents stated Resident #107 had been brought into the courtyard by staff and left unattended on multiple occasions, and one resident reported telling staff the resident seemed too hot and that it took 15 to 20 minutes to check on him. The DON stated no further investigation was conducted because the progress note covered the incident. The facility also failed to thoroughly investigate and accurately document Resident #15's fall. Resident #15 had diagnoses including unspecified psychosis, fractures, blindness, and delirium, and the care plan identified fall risk related to history of falls, impaired balance, poor safety awareness, medication side effects, unsteady gait, and vision and hearing problems. Resident #15 used a wheelchair, required partial to moderate assistance for transfers, and had impaired cognition. On 06/08/25, the resident was found on the floor with a head laceration and blood on the gown, was sent to the emergency department, and the fall investigation documented an unwitnessed fall in the bathroom with the resident walking without assistance. However, the documentation also stated the call light was within reach but not on, the room was well lit, and the resident was wearing gripper socks, while the care plan was not updated. Later review showed conflicting documentation about where the resident had been before the fall, whether the urinal was in the designated place, and whether a mattress on the floor was part of the fall interventions. The DON verified there was a problem with the documentation and implementation of fall interventions for Resident #15.
Failure to Address Resident’s Behavioral Health Needs
Penalty
Summary
The facility failed to identify, address, and obtain appropriate behavioral health services for a resident with anxiety, intellectual disability, traumatic brain injury, paraplegia, and a history of self-injurious cutting. The resident was admitted with diagnoses including chronic pain, anxiety disorder, and TBI, and hospital records described a history of depression, anxiety, poor frustration tolerance, maladaptive coping skills, agitation, and irritability related to the TBI and baseline intellectual disability. The record also showed psychotropic medications were ordered for anxiety, depression, insomnia, and mood stabilization, and a psychotropic consent identified targeted behaviors of agitation, withdrawal, and sleep disturbance. The resident’s medical record and facility documentation did not show an individualized, comprehensive behavioral health care plan in place before the incident. The admission MDS documented the resident as cognitively intact and having no behaviors, despite hospital behavioral health records describing episodes of agitation and labile encounters with staff. Facility leadership later acknowledged there was not an individualized or comprehensive plan of care to address the resident’s behavioral and mental health needs, including poor frustration tolerance, intellectual disability, and maladaptive coping strategies. The facility also had no social services coverage from 07/19/25 through 08/10/25, and the DON stated she was not aware of the resident’s history of cutting or problems with agitation. On 08/03/25, during incontinence care, the resident became agitated during an argument with CNA #350, threw items including food, a water pitcher, and a soiled incontinence pad, and then brandished a knife. Police reports and staff statements described the resident following the CNA into the hallway while holding a butterfly knife and threatening to gut her. The police seized the knife and another knife from the resident’s room. The incident occurred before any individualized behavioral interventions had been developed or implemented to address the resident’s known behavioral health needs, and the facility later documented behavioral interventions only after the event.
Insufficient kitchen staffing and unsanitary food service conditions
Penalty
Summary
The facility failed to provide sufficient support personnel to safely and effectively carry out food and nutrition services. During observation of the kitchen, the wall behind the handwashing sink was covered in food splatter, boxes of food were stored on the floor instead of six inches off the ground, and there was a large buildup of food debris and stains on shelves in the food prep area, dishwashing area, and on the table with the griddle. The ice machine had a black or gray buildup in the back, nine ceiling tiles around a vent were covered in thick black dust with peeling wall material below, and there was a frozen orange spill in the freezer that had not been cleaned up. The kitchen also contained two open containers of sugar that were undated and unlabeled, multiple open unlabeled and undated foods in the refrigerator, and three drawers of serving utensils lined with soiled aluminum foil and containing food debris and splatters. During interview, the dietary aide and LNHA stated the dietary manager had quit the prior week and staffing was short, so cleaning had not been a priority. The dietary aide reported a food delivery had been received and had not yet been put away, and that the freezer had previously gone down and the orange material had melted before refreezing without being cleaned. The dietary aide also stated that breakfast trays were served in Styrofoam containers with plastic silverware because only two staff members were working in the kitchen that morning, and that they would not have been able to get the dishes clean for lunch with just the two of them. Review of time punches showed only two kitchen staff were present from 5:44 A.M. to 10:50 A.M., and the facility policy required the kitchen area, utensils, counters, shelves, and equipment to be kept clean.
Unsanitary Kitchen Conditions and Improperly Cleaned Beverage Cups
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen and failed to serve beverages in clean cups on the B Unit. During observation of the kitchen, the wall behind the handwashing sink was covered in food splatter, boxes of food were stored on the floor instead of being kept six inches off the ground, and multiple storage areas contained stacked boxes. Food prep tables, the dishwashing area shelf, and the table with a griddle had a large buildup of food debris and stains. The ice machine had a black or gray buildup in the back, nine ceiling tiles around a vent were covered in thick black dust with peeling wall material below, and two open containers of sugar were undated and unlabeled, with one containing a scoop. Additional kitchen findings included a frozen orange spill in the freezer, multiple open unlabeled and undated foods in the refrigerator, and three drawers of serving utensils lined with soiled aluminum foil and covered with food debris and splatters. The dietary manager had quit the prior week, and staff reported they were short staffed and cleaning had not been a priority. On the B Unit, Medical Records staff were observed wiping out beverage cups with a rag while the cups were being used to serve residents; more than half the unit had already been served while the cups were still being cleaned, and the cups had a buildup of white residue inside them. The staff member verified the cups were not appropriately cleaned and said she would return them to the kitchen.
Uncovered Kitchen Trash Containers
Penalty
Summary
Kitchen trash cans were left improperly contained during observation, with two large approximately 20-gallon trash containers filled with trash, uncovered, and open with no lids or coverings. One container was located near the handwashing station and the other near the dishwashing area. During interview, the Dietary Manager confirmed that the two containers were uncovered and needed lids or covering, and obtained lids for the trash containers at the time of discovery. Review of the facility policy Sanitization dated October 2008 stated that kitchen wastes not disposed of by mechanical means shall be kept in clean, leakproof, nonabsorbent, tightly closed containers and disposed of daily.
Insufficient Surety Bond for Resident Funds
Penalty
Summary
The facility failed to ensure that the surety bond was sufficient to cover the highest resident daily funds balance for resident personal funds deposited with the facility. Review of the surety bond dated 12/27/24 showed a bond amount of $50,000.00, while review of the Resident Fund Management Service resident balance sheet dated 09/03/25 showed total current resident account balances of $59,786.08, which was $9,786.08 higher than the bond amount. The deficiency affected 45 resident accounts managed by the facility, and the facility census was 96. During interview on 09/03/25 at 4:10 P.M., the Regional Business Office Manager confirmed that the surety bond was not enough to cover the current resident funds balance.
MDS Assessments Were Inaccurate and Completed Late
Penalty
Summary
The facility failed to ensure Minimum Data Set (MDS) assessments were completed accurately and within the required time frame for four residents. Resident #10 had diagnoses including diabetes, dementia, major depressive disorder, hypertension, asthma, and sequelae of cerebral infarction, and had an order for aspirin 81 mg daily. His quarterly MDS dated 06/11/25 indicated he could not complete the BIMS because he was rarely/never understood, required set-up assistance for eating, was independent for bed mobility, and needed supervision for transfers and ambulation, but the assessment was not marked for antiplatelet medication use and was not signed complete until 07/12/25. MDS Nurse #343 confirmed the antiplatelet coding was incorrect and that the quarterly assessment was completed more than 14 days after the ARD. Resident #64’s quarterly MDS dated 06/02/25 showed a BIMS score of 2 with severely impaired cognition and assistance needs for eating, bed mobility, and transfers, but it was not signed complete until 07/08/25. Resident #4 had diagnoses including gastrostomy, severe protein-calorie malnutrition, multiple sclerosis, stage four sacral pressure ulcer, epilepsy, cognitive communication deficit, and major depressive disorder, and had an order for continuous Osmolyte 1.2 tube feeding at 65 ml per hour; however, the comprehensive MDS did not mark tube feeding and was not completed and submitted until 07/24/25. Resident #19 had diagnoses including major depressive disorder, peripheral vascular disease, COPD, cognitive communication deficit, repeated falls, vascular dementia, mood disorder, and alcohol dependence, and a progress note documented a fall on 06/30/25, but the quarterly MDS did not indicate any prior fall. MDS Nurse #343 verified the tube feeding, fall, and timing errors, and the RAI manual stated aspirin therapy should be coded as antiplatelet medication use, quarterly MDS assessments must be completed and signed no later than 14 days after the ARD, and fall coding must include review of all available sources for any fall since the last assessment.
Incomplete Care Plans for Behavioral, LOA, and Hydration Needs
Penalty
Summary
The facility failed to develop comprehensive care plans for Residents #5, #14, and #23. For Resident #5, the record showed admission diagnoses including mood disorder, anxiety disorder, history of traumatic brain injury (TBI), and paraplegia. A behavioral health consult documented episodes of agitation and labile interactions with staff, poor frustration tolerance, maladaptive coping strategies, depression and anxiety related to the TBI, baseline intellectual disability, and a history of self-injurious cutting as recently as February 2025. Although care plans addressed psychotropic medication monitoring and later behavior related to abusive attacks on staff and/or other residents, the DON verified there was no care plan addressing the resident’s poor frustration tolerance, intellectual disability, maladaptive coping strategies, self-injurious behavior, or TBI. For Resident #23, the record documented repeated episodes of leaving the facility without signing the LOA book and leaving to go out on his own. Nursing notes described the resident leaving in a wheelchair, stating he was going to buy beer, calling the facility from offsite locations, being found by police in the street, and returning after being picked up by staff or another person. The resident was also documented as leaving to go to the mall and refusing to sign out. A care plan addressed substance-seeking behavior and noted that the resident would sign himself out to go out to drink, but the DON verified there was no care plan with interventions to address the resident leaving the facility without signing out and providing the required information when on LOA. For Resident #14, the medical record showed diagnoses including Alzheimer’s disease, major depressive disorder, unspecified mood disorder, anxiety disorder, and chronic pain. The quarterly MDS indicated the resident was rarely or never understood and required assistance with eating. Review of the care plan showed it did not address the resident’s hydration status, risk, or interventions to ensure adequate hydration. The DON verified that the care plan did not address the resident’s hydration status.
Missed medications, delayed treatments, and lack of ordered care
Penalty
Summary
The facility failed to provide medications and treatments according to physician orders for four residents. Resident #38, who had diagnoses including migraine, chronic pain syndrome, dementia, and severe bilateral open-angle glaucoma, had multiple medication omissions and delays. Aimovig was ordered for migraine but was not administered in February 2025, and the progress notes documented that it was not available with no follow-up documented. In July and August 2025, several ordered medications were missed or given late, including Refresh ointment, Rhopressa, Timolol, Dorzolamide, Famotidine, Latanoprost, and Gabapentin. On 08/23/25, multiple scheduled medications were administered at 2:55 A.M. even though they were scheduled between 8:00 P.M. and 10:00 P.M., and the resident reported she often missed her migraine injection and eye treatments because they were not available in the facility. Resident #93, who had end stage renal disease with dialysis dependence, type 2 diabetes, and a history of TIA, was ordered Debrox otic solution for ear wax. The MAR showed missed doses during July and August 2025, including doses not given on several dates and twice on some dates. Progress notes repeatedly stated that Debrox was not available in house on multiple occasions. The DON later verified the missing doses and stated the drops were always in house, but the record showed the ordered medication was not administered as scheduled. Resident #15, who had unspecified psychosis, blindness, and delirium, sustained a head laceration after being found on the floor with bleeding and two staples in place. The nursing note documented pressure being held to control bleeding and EMTs being called. However, the TAR showed no evidence of monitoring of the lacerated area and no orders for site care until several days later, when therapy reported the staples and the nurse contacted the NP for staple removal. Resident #11, who had schizoaffective disorder, Alzheimer's disease, asthma, high blood pressure, impaired cognition, and altered cardiovascular status, had an order for ace wraps to both legs and feet every morning and removal at night. Although the TAR was signed off as completed, repeated observations showed the ace wraps were not present on either leg, and the DON confirmed the resident was not wearing them as ordered.
Improperly Labeled, Stored, and Discarded Medications
Penalty
Summary
Drugs and biologicals were not labeled in accordance with accepted professional principles, and expired or improperly stored medications were found in the facility. During observation, two open Glargine insulin pens for Resident #57 were undated, and RN #850 verified they were open and undated. Two opened vials of Admelog insulin for Resident #2 were also undated. Aspart insulin for Resident #50 was open and undated, and Lispro and Glargine insulin for Resident #55 were open and undated. An unopened box of Cathflo for Resident #55 was found in the medication cart with a sticker indicating the powder must be stored in the refrigerator. Lantus for Resident #116 was dated as opened, and the resident had been admitted and later discharged. An interview with the ADON verified the medications for Residents #2, #50, and #55 were open and undated, verified Cathflo for Resident #55 was stored improperly and should have been refrigerated, and verified the medications for Residents #50, #55, and #116 should have been removed from the medication carts when those residents were discharged. In addition, an open Tubersol vial with an opened date was observed in a medication refrigerator, and LPN #345 verified the vial should have been discarded 30 days after opening.
Dirty Floors, Walls, and Air Conditioning Units on B Unit
Penalty
Summary
The facility failed to maintain the B unit floor and air conditioning units in a clean condition, and failed to keep the floor in Resident #4's room and the floor and walls of Resident #103's room clean. Observation of Resident #4's room showed brown splatters around the tube feeding pole, and the hallway floor on the B unit had a black, sticky residue throughout the hallway. On a later observation, Resident #4 again had brown splatters on the floor around the tube feeding pole and black sticky appearing residue under the wheelchair, which remained in the same spot as previously observed. Resident #103's room had brown splatters on the wall around an outlet and a variety of stains on the floor. The B unit hallway also had multiple locations with thick sticky residue that caused shoes to stick to the floor, and two air conditioning units in the common areas had dust buildup and a black mold-like substance visible around the vents. Housekeeping Aide #280 verified the observations and reported they were waiting on a part for the floor scrubber, and Housekeeping Aide #282 reported the floor scrubber had been down for about a month.
Failure to Honor Bathing Preferences and Keep Call Light Within Reach
Penalty
Summary
The facility failed to honor Resident #57’s bathing preference. Resident #57 was admitted with diagnoses including type 1 diabetes, rheumatoid arthritis, peripheral vascular disease, and hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side. The care plan identified a self-care performance deficit related to ADLs and included assistance with bathing and transfers. The resident was cognitively intact and stated she was not always getting bathed and preferred a shower. The recreational therapy referral form indicated the shower option was selected as the bathing preference, but the bathing documentation showed the resident received bed baths on multiple occasions, and the DON verified the resident was not receiving showers per her preference. The facility also failed to honor Resident #68’s bathing preference and failed to ensure Resident #12’s call light was within reach. Resident #68 was admitted with diagnoses including dysphagia, anxiety, malignant neoplasm of male breast, and type 2 diabetes. MDS assessments and the care plan indicated bathing preferences and assistance needs, and the recreational therapy referral form showed the shower option was selected. Bathing documentation showed a mix of showers and bed baths, and the resident stated he preferred showers; the DON verified he received only two showers out of five baths and was not getting showers per his preference. Resident #12 had diagnoses including dysphagia, pain, traumatic brain injury, cervical spinal stenosis, osteoarthritis, anxiety, hypertension, asthma, depression, diabetes, and cervical spondylosis, with a BIMS score of 10 and dependence for toileting hygiene. On two observations, the call light was draped across the bedside stand behind the resident and not within reach, and the resident stated she used the call light to get help; the Unit Manager LPN confirmed it was not within reach.
Failure to Maintain Privacy During Dressing Change
Penalty
Summary
The facility failed to maintain resident privacy during a routine dressing change for Resident #25, who had diagnoses including major depressive disorder, generalized anxiety disorder, constipation, vitamin D deficiency, and unspecified dementia. The resident’s annual MDS indicated the BIMS could not be completed because the resident was rarely or never understood, and the resident required supervision for eating, substantial to maximal assistance for bathing, bed mobility, and transfers, was dependent for toileting hygiene, was always incontinent of bowel and bladder, and had a stage two pressure area. During an observation of a dressing change to Resident #25’s left ischium, the room layout showed the privacy curtains could not be pulled between the beds to separate the residents. Resident #25’s roommate remained in her bed throughout the dressing change, lying on her right side facing the center of the room and Resident #25’s bed. The ADON confirmed the room was set up so the privacy curtains could not be pulled between the beds to provide privacy and that the roommate could see the dressing change and any other care the resident received.
Failure to Timely Report Injury of Unknown Origin and Resident Altercation
Penalty
Summary
The facility failed to ensure Resident #107’s injury of unknown origin was reported to the State Agency in a timely manner. Resident #107 had a history that included dysphagia, cognitive communication deficit, type 2 diabetes mellitus, cerebral infarction, vascular dementia, epilepsy, contracture of the left foot and hand, and flaccid hemiplegia affecting the left nondominant side. He also had left upper extremity paralysis with contractures. On 05/29/25, staff noted several liquid-filled blister-like areas on the back of his hand, including areas that were seeping and open, with yellowish drainage, mild odor, and pitting edema. The physician was notified and the resident was sent to the hospital. The facility investigation documented that five blisters were present, including two connected on the index finger, and the resident denied noticing them or doing anything to cause an injury. The facility noted no predisposing environmental or situational factors and listed diabetes and hyperglycemia as physiological factors. There was no further investigation or witness statements related to the injury. Hospital records described bullae and yellow crusting of the left hand with strong suspicion of bullous impetigo, along with shallow ulceration and swelling of unknown start date. The daughter expressed care concerns and stated it seemed as though the resident’s hand had been pressed against his Hoyer pad. The facility’s self-reported incidents showed the injury had not been reported, and the DON stated it had not been treated as an injury of unknown origin even though the cause could not be determined. The facility also failed to timely report an altercation involving Resident #5 and a CNA. Resident #5 had diagnoses including chronic pain, anxiety disorder, history of TBI, paraplegia, and later mood disorder; hospital records also described intellectual disability, depression, anxiety, poor frustration tolerance, maladaptive coping, and a history of self-injurious behavior. During incontinence care, Resident #5 became agitated after staff interaction, threw items at the CNA, and then brandished a switchblade-style knife while threatening her. Police were called, the knife was removed, and additional contraband was searched for in the room. Multiple staff statements and the police report described the resident throwing food, feces, and other items, causing minor injury to the CNA’s arm and hand, and moving into the hallway with the knife while other residents and staff were present. Although the facility later filed a self-reported incident, it was filed as emotional/verbal abuse by staff toward Resident #5 after the police report was obtained, rather than being reported on the day of the incident. The DON stated the facility did not file the report on the day the event occurred because of the wording in the police report describing a verbal altercation. The facility policy required allegations of abuse and injuries of unknown source to be reported immediately, with abuse allegations reported no later than two hours after the allegation was made.
Incomplete Investigation of Resident Injury and Staff Altercation
Penalty
Summary
The facility failed to thoroughly investigate a resident’s injury of unknown origin involving blistering and open areas on the back of the left hand. The resident had a history that included dysphagia, cognitive communication deficit, type 2 diabetes mellitus, cerebral infarction, vascular dementia, epilepsy, contractures of the left foot and hand, and flaccid hemiplegia affecting the left nondominant side. Occupational therapy documentation noted left upper extremity paralysis with contractures, and the resident’s MDS reflected dependence for rolling in bed and impairment to both upper and lower extremities on one side. When the hand injury was discovered, the resident had several liquid-filled blister-like areas, some seeping and some open, with yellow drainage, mild odor, and pitting edema. The resident denied noticing the injury and denied doing anything to cause it. The facility investigation documented that there were no predisposing environmental or situational factors identified, and diabetes and hyperglycemia were listed as predisposing physiological factors. However, the investigation did not include further inquiry such as witness statements or additional fact gathering related to how the injury occurred. Hospital records described bullae and yellow crusting of the left hand with strong suspicion of bullous impetigo, along with bacterial buildup between the fingers and organic debris in the partially contracted hand. The hospital also noted shallow ulceration and swelling with an unknown start date, and the resident reported the hand had been painful for over two weeks. The daughter expressed concern that the hand may have been pressed against the hoyer pad. The facility’s self-reported incidents did not include this injury, and the DON acknowledged the event had not been treated as an injury of unknown origin even though the cause could not be determined. The facility also failed to thoroughly investigate an altercation between a resident and a CNA that involved verbal threats, throwing objects, and a knife. The resident involved had diagnoses including chronic pain, anxiety disorder, history of TBI, paraplegia, and later mood disorder; hospital records also described intellectual disability, depression, anxiety, poor frustration tolerance, maladaptive coping, and a history of self-injurious behavior. Although the admission MDS described the resident as cognitively intact with no behaviors, the incident records showed escalating agitation during incontinence care. Statements and police records showed the resident became upset during care, threw items at the CNA, brandished a switchblade-style knife, and threatened the CNA while moving into the hallway. Police recovered the knife and another small knife from the resident’s room. The police report also documented that the resident threw food, feces, and miscellaneous items at the CNA, causing minor injury to her arm and hand. The facility’s investigation did not obtain a statement from the resident, did not interview the agency nurse who was providing care, and did not interview residents who were in the hallway and may have witnessed the event. The DON confirmed there was no evidence of which residents were present in the hallway and no resident interviews were completed.
PASARR Screening Not Completed Accurately or Timely
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed accurately for one resident and was not completed in a timely manner for another resident. Resident #23 was admitted, readmitted, and later discharged with diagnoses including COPD, moderate protein-calorie malnutrition, anemia, alcohol abuse, hypertensive heart disease, adult failure to thrive, chronic viral hepatitis C, osteoarthritis, a cutaneous abscess of the right lower limb, and multiple myeloma. The 5-day MDS dated [DATE] showed the resident was cognitively intact, and the PASARR identification screen dated 07/07/25 indicated no mental disorders or substance use related disorders. During interview, Social Services #312 verified that the PASARR for Resident #23 dated 07/07/25 was incorrect because the resident had a substance use disorder and a diagnosis of alcohol abuse. Resident #9 was admitted with diagnoses including bipolar disorder, COPD, hypertension, and acute kidney failure. Her MDS assessment showed a BIMS score of 12, indicating mild cognitive impairment, but the medical record contained no evidence that an initial PASARR application/form had been submitted to the state mental health agency for a determination of eligibility for additional services. Social Services #312 confirmed that a new PASARR was filed only after it was noticed that one had not previously been filed when it should have been.
PASARR Not Updated After New Diagnosis
Penalty
Summary
The facility failed to update the PASARR when Resident #15 received a new diagnosis. Review of the medical record showed the resident had a Hospital Exemption from Preadmission Screening Notification dated 02/06/25 that identified a mood disorder and paranoia, and blindness was not marked as a disability. The resident was admitted with diagnoses of unspecified psychosis, blindness, and delirium. A pharmacy recommendation dated 05/27/25 indicated a new diagnosis for Risperdal, an antipsychotic medication, was needed, and a new diagnosis of delirium due to a known physiological condition was added on 06/06/25. A PASARR completed on 08/28/25, when the hospital exemption was expiring, marked serious mental illnesses including mood disorder and delirium due to a known physiological condition, noted antipsychotic and mood stabilizing medications, and identified blindness as a related disability, with a referral for Level II evaluation. During interview, Social Service #312 verified that a PASARR should have been completed within 30 days of admission and that a new PASARR should have been completed when the new diagnosis was added in June.
Failure to Provide Nail Care and Scheduled Bathing
Penalty
Summary
The facility failed to provide nail care for a resident with dementia, type 2 diabetes, and chronic kidney disease who was dependent on staff for bathing. The care plan directed staff to check nail length and trim and clean the resident’s nails on bath day and as necessary. During an observation and interview, the resident was found to have long fingernails with a dark substance under them and stated he wanted his fingernails trimmed and cleaned. A later observation showed the same condition, and the resident again stated he wanted his fingernails trimmed and cleaned. A Unit Manager then verified the resident had long, dirty fingernails and obtained items to trim them. The facility also failed to provide bathing as scheduled for another resident with dysphagia, anxiety, malignant neoplasm of male breast, and type 2 diabetes. The resident’s MDS indicated bathing was very important to him, and the care plan identified that he required one-person assistance for bathing. Bathing documentation showed showers and bed baths on several dates, followed by a 10-day gap without bathing before the resident received another bed bath. The resident was scheduled to be bathed twice weekly on day shift, but he stated he did not get bathed because staff do not like to bathe residents and confirmed he preferred showers. The DON verified the resident was not bathed twice a week as scheduled and required staff assistance to be showered.
Failure to Offer Activities and Develop Activity Plans of Care
Penalty
Summary
The facility failed to ensure Resident #38 and Resident #11 were offered activities and had activity plans of care in place. Resident #38 was admitted with diagnoses including cognitive communication deficit, chronic pain syndrome, major depressive disorder, unspecified dementia, bilateral severe open angle glaucoma, and retinal neovascularization of the right eye. Her quarterly MDS assessment indicated intact cognition, and a recreational therapy assessment documented interests in jazz, reading, and watching television and movies. However, her plan of care did not address her activity preferences, and the record showed no evidence that she had been offered or attended activities from 07/01/25 to 08/25/25. The August 2025 activity calendar listed morning activities daily, but there were no activities scheduled after 3:30 P.M. Resident #11 was admitted with diagnoses including muscle weakness, Alzheimer's disease, depression, high blood pressure, and asthma. Her quarterly MDS showed impaired cognition with a BIMS score of 07 and need for assistance with self-care activities. Her care plan addressed psychosocial well-being and monitoring for isolation, but it did not include activity-related focus areas, goals, or interventions. Observations on multiple days showed the resident alone in her room lying in bed, and she stated she did not know of any activities happening in the facility but would like to participate if there were any. Activities Specialist #300 confirmed she had not introduced herself to Resident #11, discussed her interests, or invited her to activities, and also confirmed Resident #11 did not have an activity plan of care.
Failure to Prevent a New Pressure Ulcer and Failure to Follow Ordered Wound Treatments
Penalty
Summary
The facility failed to implement interventions to prevent pressure ulcer development for Resident #21 and failed to ensure Resident #85's pressure ulcer was treated as ordered. Resident #21 was admitted with diagnoses including obstructive and reflux uropathy, spinal stenosis, severe protein-calorie malnutrition, colostomy status, pressure ulcer of the sacral region, heart failure, and anal abscess. The Braden scale dated 07/29/25 showed moderate risk for pressure ulcers due to very limited sensory perception, very limited mobility, and friction and shearing risk. The comprehensive MDS dated 08/05/25 indicated intact cognition and that the resident was at risk for pressure ulcers, and the resident needed staff assistance with bed mobility. Resident #21's plan of care dated 08/11/25 identified an actual pressure injury with risk for delayed wound healing related to progressing comorbidities, debility, generalized weakness, decreased physical mobility, and bowel and bladder incontinence. Interventions included frequent turning and repositioning, weekly skin evaluation, wound care as ordered, nutritional supplements, preventative skin care after incontinence, and monitoring labs as ordered. However, ADL documentation from 08/01/25 through 08/18/25 did not record turning and repositioning, and there was no evidence it had been refused or offered. The DON verified there was no evidence the facility was turning and repositioning the resident as care planned or recommended before the pressure ulcer developed on 08/18/25, and the only preventative measure in place was a low air-loss mattress. Resident #21's pressure skin grid dated 08/18/25 documented a new unstageable pressure ulcer on the mid-back measuring 4 cm by 2 cm by 2 cm with moderate drainage and 100 percent slough. Physician orders dated 08/20/25 through 08/25/25 and again on 08/26/25 directed cleansing with normal saline, applying silver alginate, and covering with foam dressing daily, but the TAR showed treatments were not completed on 08/22/25, 08/23/25, and 08/29/25, with no corresponding documentation explaining why. For Resident #85, the record showed paraplegia, a stage 4 sacral pressure ulcer, and dependence on staff for bed mobility, transfers, and ambulation. An outside wound practitioner note dated 08/04/25 ordered cleansing the sacral wound with normal saline and covering it with a bordered foam dressing daily, but this order was not transcribed into the medical record or implemented by nursing staff. The TAR continued to reflect the older order for Dakin's solution, Dakin's wet-to-dry gauze, and foam dressing, and the DON stated that because the resident had refused to be seen since 08/04/25, staff should have been following those treatment orders.
Missing Bowel Movement Documentation and Catheter Care Documentation
Penalty
Summary
Resident #15, who was admitted with diagnoses including unspecified psychosis, left side rib and right lower leg fracture, blindness, and delirium, had cognitive impairment on the quarterly MDS and was documented as always continent of bowel and bladder. Review of the bowel documentation showed no recorded bowel movement from 08/07/25 through 08/16/25. During interview, the DON verified the facility did not have a bowel protocol and confirmed there was no documentation of a bowel movement for Resident #15 from 08/07/25 through 08/15/25. Resident #21 was admitted with diagnoses including obstructive and reflux uropathy, hypertension, spinal stenosis, severe protein-calorie malnutrition, systolic heart failure, colostomy status, pressure ulcer of the sacral region, heart failure, and anal abscess. The resident’s MDS showed intact cognition and an indwelling catheter, and the care plan called for catheter care every shift, monitoring for signs and symptoms of UTI, documenting output, perineal care, irrigation as needed, keeping tubing free of kinks and twists, maintaining the drainage bag below the bladder, and a privacy cover. The record also included a chronic foley catheter history and physician orders for catheter maintenance and catheter care every shift and as needed, but the medical record had no evidence that catheter care was performed prior to 08/25/25, which the DON verified.
Failure to Document Routine Ostomy Bag Changes
Penalty
Summary
The facility failed to provide documented evidence that Resident #9’s ileostomy/urostomy bag was routinely changed. Resident #9 was admitted on 03/03/25 with diagnoses including acute kidney failure, hypertension, colostomy, and ileostomy, and the quarterly MDS dated 07/24/25 indicated slightly impaired cognition and that staff assistance was required for managing the resident’s colostomy and ileostomy, including changing the bags. Review of the medical record showed no physician orders in March 2025 for ensuring the ileostomy or urostomy bag was changed, and there were no documented ileostomy or urostomy bag changes from admission until the resident was hospitalized. Hospital documentation showed the resident was hospitalized from [DATE] to 04/25/25 and was diagnosed and treated for a UTI; the hospital notes also stated the resident had a [NAME] operation in 2001, creating an ileal conduit urinary diversion. The terms urostomy and ileostomy were used interchangeably in the record. A physician order dated 04/28/25 later directed a urostomy wafer and pouch change every three days, and the DON confirmed on 09/03/25 that there was not an order or documented evidence that the resident’s ileostomy or urostomy bag was changed routinely.
Meal Supervision and Nutrition Orders Not Followed
Penalty
Summary
The facility failed to appropriately supervise and position Resident #107 during meals. Resident #107 had diagnoses including dysphagia, cognitive communication deficit, diabetes mellitus, cerebral infarction, vascular dementia, peripheral vascular disease, epilepsy, sickle-cell disease, contractures, and flaccid hemiplegia affecting the left nondominant side. His diet order required a cardiac or diabetic diet with mechanical soft texture, nectar thick liquids, a divided plate for all meals, and close supervision. During observation, he was eating breakfast in his room without staff present, his food was placed on a bedside table to the left of the bed rather than over him, he was leaning over the mattress to eat with his right hand, food was observed on the tray and on the resident, and no fluids were present. A CNA verified that he was supposed to be supervised during meals and was not positioned appropriately. The facility also failed to timely implement dietitian recommendations for Resident #4 and Resident #21. Resident #4 had diagnoses including gastrostomy, severe protein-calorie malnutrition, multiple sclerosis, stage four sacral pressure ulcer, epilepsy, cognitive communication deficit, and major depressive disorder, and received oral and enteral nutrition with poor oral intake. The dietitian recommended increasing continuous tube feeding from 65 ml per hour to 70 ml per hour because of a worsening wound, but the record showed no evidence the recommendation was addressed, and the DON verified the tube feeding was not increased as recommended. Resident #21 had diagnoses including obstructive and reflux uropathy, hypertension, spinal stenosis, severe protein-calorie malnutrition, systolic heart failure, colostomy status, pressure ulcer of the sacral region, heart failure, and anal abscess. The dietitian recommended double protein portions for dietary support, and although the order was later written, the dietitian verified the recommendation was not completed timely.
Pain Medication Administration and Documentation Deficiencies
Penalty
Summary
Safe, appropriate pain management was not provided for a resident with diagnoses including migraine, osteoarthritis, chronic pain syndrome, major depressive disorder, unspecified dementia, and severe bilateral open angle glaucoma. The resident’s care plan identified her as at risk for impaired comfort related to chronic arthritis, a wedge compression fracture, chronic pain, and migraines, and directed staff to administer pain medications as ordered and assess for signs of pain. A physician order dated 04/20/25 directed a fentanyl patch 12 mcg/hour to be applied every 72 hours and removed per schedule, but the MAR and narcotic count sheets showed the patch was not administered on 07/10/25, 08/03/25, or 08/12/25. Progress notes documented that the patch was unavailable on 07/10/25 and 08/12/25, and there was no documented reason for the missed administration on 08/03/25. The DON verified the resident had not received the fentanyl patch as ordered, and the resident stated staff had missed the patch on a few occasions and sometimes waited until the next scheduled day to apply it even when it arrived. Pain medication parameters were not in place for another resident with diagnoses including anxiety disorder, paraplegia, moderate protein-calorie malnutrition, neuromuscular dysfunction of the bladder, claustrophobia, social phobia, gout, and radiculopathy. The resident’s care plan directed staff to administer pain medication as ordered and assess for pain every shift. Orders included oxycodone 5 mg, two tablets every eight hours as needed for pain, and acetaminophen 325 mg, two tablets every six hours as needed for pain. The August 2025 MAR showed no parameters for pain medication administration, yet oxycodone was given for a pain of zero, three, five, and three, and acetaminophen was given for a pain of three. Progress notes did not describe the resident’s pain on several of those dates. The DON verified there were no parameters in place, that a pain score of zero was not appropriate for oxycodone administration, and that nursing should document the description of the resident’s pain when giving PRN medication.
Improper Documentation of Fentanyl Patch Disposal
Penalty
Summary
The facility failed to appropriately document the disposal of fentanyl patches for one resident receiving pain management services. Resident #38 was admitted with diagnoses including migraine, osteoarthritis, cognitive communication deficit, chronic pain syndrome, unspecified dementia, open angle glaucoma bilaterally and severe, and retinal neovascularization of the right eye. The resident’s Quarterly MDS assessment indicated intact cognition, and the resident was documented as having pain almost constantly, with the worst pain over the last five days rated as an eight. The care plan identified the resident as at risk for impaired comfort related to chronic arthritis, a wedge compression fracture, chronic pain, and migraines, with interventions including administering pain medications as ordered and monitoring pain characteristics. A physician order dated 04/20/25 directed that a fentanyl patch 12 micrograms per hour be applied once every 72 hours and removed per schedule. Review of the narcotic count sheets from 05/29/25 through 08/24/25 showed that nursing staff did not appropriately document disposal of the fentanyl patch on multiple dates. Disposal was not documented on 06/01/25, 06/04/25, 06/07/25, 06/10/25, 06/13/25, 06/19/25, 06/22/25, 06/25/25, 06/28/25, 07/01/25, 07/04/25, 07/07/25, 07/19/25, 07/22/25, 07/25/25, 07/28/25, 07/31/25, 08/06/25, and 08/09/25. On several occasions, the disposal was signed but unwitnessed. The DON confirmed that the nurses were not appropriately documenting fentanyl patch disposal and stated that disposal should be witnessed and signed by two nurses.
Medication Ordered With Incorrect Diagnosis
Penalty
Summary
Resident #15 was admitted with diagnoses including unspecified psychosis, left side rib and right lower leg fracture, bilateral blindness category 3, delirium, and acute embolism and thrombosis of the deep veins of the right lower extremity. Review of physician orders showed that from 04/17/25 until 09/03/25, the resident was ordered Clonidine 0.1 mg transdermal patch weekly for deep vein thrombosis, and the medication administration record showed it was administered as ordered. During interview, the DON verified that deep vein thrombosis was an incorrect diagnosis for Clonidine and stated there was no documentation to support the use of the medication.
Missed Immunosuppressant Doses for Resident With Kidney Transplant
Penalty
Summary
The facility failed to prevent Resident #8 from experiencing a significant medication error when the resident missed doses of Mycophenolate Sodium, an immunosuppressant ordered for kidney transplant status. Resident #8 was admitted with diagnoses including kidney transplant status, chronic kidney disease stage three, immunodeficiency, brief psychotic disorder, bipolar disorder, schizoaffective disorder, and unspecified mood disorder. The quarterly MDS indicated intact cognition, and the care plan identified renal insufficiency related to stage three kidney disease and immunodeficiency due to the kidney transplant, with interventions to monitor for changes in mental status, hypovolemia, acute renal failure, edema, weight gain, neck vein distension, difficulty breathing, increased heart rate or blood pressure, skin temperature, loss of consciousness, and crackles in breath sounds. The physician order dated 03/18/24 directed Mycophenolate Sodium 360 mg by mouth twice daily for kidney transplant. Review of the MAR for August 2025 showed missed evening doses on 08/08/25, 08/14/25, 08/19/25, 08/24/25, and 08/25/25, and missed morning doses on 08/15/25, 08/21/25, 08/22/25, and 08/25/25. Progress notes from 08/01/25 to 08/25/25 documented that the medication was unavailable on 08/08/25, 08/15/25, 08/19/25, 08/21/25, 08/22/25, 08/24/25, and 08/25/25. The DON verified that Resident #8 was missing doses and stated that at times the pharmacy did not have the medication and at times the facility was working with insurance to get approval.
Ordered Laboratory Testing Not Completed
Penalty
Summary
The facility failed to ensure that Resident #10’s physician-ordered laboratory testing was completed as ordered. Resident #10 was admitted on 04/18/25 and had diagnoses including diabetes, dementia, major depressive disorder, hypertension, asthma, and other sequelae of cerebral infarction. The resident’s quarterly MDS dated 06/11/25 showed the BIMS could not be completed because the resident was rarely or never understood, and the resident required set-up assistance for eating, was independent for bed mobility, and needed supervision for transfers and ambulation. The resident was also occasionally incontinent of bladder and frequently incontinent of bowel and was working with PT at the time of the assessment. A physician order dated 07/30/25 directed laboratory testing for a CBC, CMP, hemoglobin A1C, TSH, vitamin B12, and vitamin D level. A nursing progress note dated 08/01/25 stated the lab orders had been entered into the laboratory system to be drawn on 07/30/25 but were not collected, and the orders were re-entered on 08/01/25 to be collected. The medical record contained no laboratory results and no evidence that the testing had been obtained. During interview on 09/03/2025, the DON confirmed that the ordered laboratory testing was not completed.
Infection Control Failures With EBP, Shared Equipment, and Incontinence Care
Penalty
Summary
Enhanced barrier precautions were not in place for a resident with severely impaired cognition who had diagnoses including gastrostomy, severe protein-calorie malnutrition, multiple sclerosis, a stage four sacral pressure ulcer, epilepsy, and a cognitive communication deficit. The resident had a physician order for enhanced barrier precautions related to the gastrostomy tube and wound, and the care plan directed staff to wear a gown and gloves during high-contact activities. However, observations on two separate occasions showed the resident did not have enhanced barrier precautions in place, and there was no sign or PPE around the room. The DON verified that enhanced barrier precautions were not in place and should have been. In addition, infection control procedures were not followed when a CNA assisted a severely cognitively impaired male resident, who was incontinent and dependent for toileting hygiene, into the bed of two female residents and provided incontinence care there. The ADON confirmed the resident was given incontinence care in another resident's bed, and the contaminated linens were then removed. A separate observation showed an RN leaving a resident's room with a blood pressure cuff and wiping it with a facial tissue that had hand sanitizer on it because no sanitation wipes were available on the medication cart for B Hall. The RN confirmed there were no sanitation wipes available, and the regional nurse later provided sanitation wipes.
Topical Antibiotic Continued Past Ordered End Date
Penalty
Summary
The facility failed to ensure Resident #107’s topical antibiotic cream was not administered past the physician-ordered end date. Resident #107 was admitted on 07/20/17 with diagnoses including dysphagia, cognitive communication deficit, type two diabetes mellitus, cerebral infarction, vascular dementia, epilepsy, contracture of the left foot and hand, and flaccid hemiplegia affecting the left nondominant side. On 05/29/25, the resident was noted to have several liquid-filled blister-like areas on the back of the hand, with two areas seeping and two completely opened, along with yellowish drainage, a mild odor, and pitting edema; the physician was notified and the resident was sent to the hospital. The after-visit summary from 05/31/25 showed Mupirocin, a topical antibiotic, was to be applied to the hand every day through 06/03/25. A physician order dated 06/02/25 also directed Mupirocin 2% ointment to be applied to the left hand wound topically every day shift. Review of the MAR for June, July, and August 2025 showed Mupirocin was administered from 06/02/25 through 08/25/25. The DON confirmed in interview on 09/02/25 that the antibiotic ointment had been continued past when it should have been. The facility policy stated medications must be administered in accordance with the orders, including any required time frame.
Failure to Provide Required Bed Hold and Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide required bed hold notices and transfer/discharge notifications to residents or their representatives when residents were transferred to the hospital. Specifically, three residents with various medical conditions, including diabetes, chronic kidney disease, Alzheimer's disease, peripheral vascular disease, and osteomyelitis, were transferred or discharged without documentation that they or their representatives received written bed hold or transfer/discharge notices. In addition, there was no documentation that the ombudsman was notified of these transfers or discharges as required. Interviews with the Director of Nursing confirmed the absence of this documentation for all three residents reviewed. Medical record reviews revealed that one resident with severely impaired cognition and another who was cognitively intact did not receive the required notifications upon transfer to the hospital. Another resident, who was readmitted after a hospital stay, also did not receive a formal bed hold notification, despite being verbally informed of a nine-day bed hold. Facility policies reviewed indicated that written notification should be provided prior to transfers, but this was not followed in these cases.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect a resident from physical abuse, resulting in actual harm. One resident with dementia and a history of wandering into other residents' rooms was repeatedly redirected by staff but continued to enter other rooms, including that of another resident with a known behavior problem involving hitting others. Despite care plans identifying these behaviors and interventions such as redirection and staff intervention, the measures in place were not effective in preventing the incident. On the day of the incident, a resident reported to an LPN that an assault was occurring. The LPN found the resident with dementia in another resident's room, bleeding from the face after being punched. The resident who committed the assault admitted to hitting the other resident due to frustration over repeated intrusions into his room. The injured resident required hospital treatment for facial bruising and a laceration above the left eye, which required sutures. Prior to the incident, the injured resident had no facial injuries. Both residents involved had documented behavioral issues and cognitive impairments, with care plans outlining interventions to address these risks. However, the interventions were not sufficient to prevent the assault. The facility did not implement additional interventions, such as a stop sign on the door, until after the incident had occurred. Observations after the incident revealed that the stop sign intervention was not consistently maintained.
Failure to Provide Emergency Respiratory Support to Resident with Tracheostomy
Penalty
Summary
A deficiency occurred when a resident with a tracheostomy, who had a history of acute respiratory failure with hypoxia and hypercapnia, bacterial pneumonia, morbid obesity, and tracheostomy status, experienced respiratory distress and did not receive appropriate respiratory support as ordered and required by their condition. The resident was admitted with a full code status and had physician orders for tracheostomy care every shift and as needed, continuous supplemental oxygen via trach, and as-needed nebulizer treatments for shortness of breath. The care plan failed to identify a plan for respiratory or tracheostomy care. On the day of the incident, the resident requested suctioning due to difficulty clearing secretions, which was performed by a nurse with assistance from another nurse. After suctioning, the resident requested to be changed and, during repositioning, began to complain of shortness of breath and showed signs of acute respiratory distress, including labored breathing and cyanosis. The oxygen flow was increased, but the resident showed no improvement. The nurse left the room to call 911 and prepare paperwork for transfer, while another nurse was to remain at the bedside. However, when EMS arrived, the resident was found alone, without supplemental oxygen, and in cardiac arrest. No CPR was being performed by staff prior to EMS arrival, and EMS personnel immediately initiated resuscitation efforts. Interviews and documentation revealed that during the emergency, staff did not administer the as-needed nebulizer treatment, did not attempt further suctioning, did not change the inner trach cannula, and did not use an Ambu bag to provide breaths. The resident's oxygen saturation had dropped to critically low levels, and the resident ultimately lost consciousness, lost respirations, and lost pulse, and was later pronounced deceased in the emergency room. The deficiency affected one of two residents reviewed for tracheostomy care.
Failure to Maintain a Homelike Environment for a Resident
Penalty
Summary
The facility failed to maintain a homelike environment for Resident #13, as observed during a survey. Resident #13, who has multiple medical conditions including dysphasia, muscle disorder, mobility abnormalities, diabetes with a foot ulcer, respiratory failure, and dependence on renal dialysis, was found to have their room cluttered with medical supplies and personal items. During an interview and observation, it was noted that the resident's furniture was covered with medical supplies, pillows, wound vacuum care supplies, gloves, incontinence briefs, and blankets, forming a pile three feet high. The resident's family member confirmed that the resident did not have current orders for a wound vacuum and did not require the excessive number of pillows present. Further observations and interviews with a Certified Nurse Aide (CNA) and a Regional Nurse confirmed that the cluttered state of the resident's room did not appear homelike and hindered the usability of the furniture for guests. The facility's policy, dated February 2021, mandates that residents should be provided with a safe, clean, comfortable, and homelike environment, which was not adhered to in this case. This deficiency was investigated under Complaint Number OH00162784.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 769 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Columbus
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Crown Pointe Care Center | 1 mi | ★★★★★ | 1 | 0 |
| Columbus Alzheimer's Care Ctr | 1.3 mi | ★★★★★ | 0 | 0 |
| Mayfair Village Nursing Care Center | 2 mi | ★★★★★ | 19 | 0 |
| Riverview | 2.1 mi | ★★★★★ | 0 | 0 |
| Wesley Glen Health Services Corp | 2.6 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Sapphire Rehabilitation And Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.