Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Stellar Care Center during CMS and state inspections, most recent first.
Food Stored in Unsanitary Refrigerator Conditions: A walk-in white refrigerator in the kitchen had a foul odor, and inspection revealed a rotten apple, an old onion, an open cheese slice, and an unidentifiable rotted item under a shelf. The Dietary Manager confirmed the findings, and the facility policy stated food must be stored in a clean, dry area free from contaminants.
Failure to Document Updated COVID-19 Vaccine Offers: The facility did not document offering the updated COVID-19 vaccine to four residents who had been in the facility for over a year. Records showed offers of other vaccines, including influenza and pneumococcal, but no evidence of a COVID-19 vaccine offer for residents with conditions such as COPD, dementia, CHF, HTN, and DM. The interim DON confirmed there was no documented evidence that the updated COVID-19 vaccine had been offered or provided.
A resident with a PICC line for IV cefepime therapy and multiple comorbidities received IV medication from an LPN who attached IV tubing directly to the open end of the PICC line without a needleless connector, after cleaning only the open hub. The LPN stated that PICC lines do not have valves, despite reporting prior IV therapy training. Facility leadership and HR reported they did not maintain competency or training records for agency staff, and one agency only verified licensure while another provided a self-assessment showing the LPN rated IV skills as limited and requiring supervision, even though the facility’s contract assigned responsibility for orientation, education, and competency of agency staff to the facility.
Failure to document advance directives was identified for a resident with stroke, AFib, bilateral AKA, HTN, anxiety, depression, schizophrenia, DM, and CHF. The EMR had no current code status order, while a discontinued full-code order was found in the chart history and a paper chart note still showed FULL CODE. An LPN and CNA both confirmed the code status was not listed where they expected it in the EMR.
The facility failed to obtain resident or representative signatures on NOMNC and SNF ABN forms for two residents when Medicare Part A skilled services were ending. The notices were signed only by facility staff, with no documented evidence that the residents or their representatives acknowledged receipt or were notified that PT/OT and other skilled services were ending and Medicare coverage would stop.
Two residents with dementia received Seroquel without an adequate indication for use. One resident was on Seroquel for dementia with agitation despite no documented psychosis and no GDRs after admission, while the other received Seroquel for depressive disorder and agitation even though psych notes showed no psychosis, hallucinations, or aggression. Staff interviews and record review showed limited behavior documentation, and the family’s refusal of med changes was allowed to drive continued use.
Failure to Provide Transfer and Bed Hold Notices: A resident with stroke, acute respiratory failure, and pneumonitis was found unresponsive by a nurse, prompting transfer to the ER after the DON was notified. The facility had no evidence that a written transfer notice or a bed hold notice was provided at the time of transfer, and the Administrator confirmed the notices were not given as required; the facility had only been issuing bed hold notices to residents with Medicaid payer status.
Inaccurate MDS coding affected two residents. One resident receiving hospice services was not coded as hospice on the annual MDS, despite records and staff confirmation showing hospice involvement. Another resident with dementia and insomnia was coded as receiving a hypnotic on the admission MDS even though the MAR showed only Melatonin 10 mg PO at HS, which the MDS nurse confirmed is a supplement and not a hypnotic under the RAI manual.
The facility failed to ensure two residents received ordered treatment. One resident with multiple chronic conditions missed three doses of doxycycline for a finger infection when the antibiotic was unavailable from pharmacy and the E-kit, and the course was not adjusted to make up the missed doses. Another resident with morbid obesity had an order for Zepbound for weight loss, but the medication was documented as unavailable and there was no record that the ordered dose was administered.
A resident with an indwelling urinary catheter had no documented catheter care, and staff observed sediment and dark-colored tubing. Another resident with an indwelling catheter had missing shift output documentation despite an order to record output and notify the provider for low output. A third resident with dementia and recurrent UTIs received only 9 of 10 ordered Macrobid doses, with the MAR and LPN review confirming the incomplete antibiotic course.
Failure to Provide Adequate Hydration: A resident with dementia, contractures, and significant dependence for care was repeatedly observed without fluids or two-handled cups within reach despite orders for increased fluids and two-handled cups at meals. Staff had to provide drinks intermittently, and the resident was seen asking for water and needing assistance to drink during meals and while resting in the hallway.
Failure to provide and document ordered oxygen therapy for two residents. One resident with CHF, dementia, and other diagnoses had PRN O2 orders, but the record lacked evidence of tubing changes, oxygen titration, and ongoing SpO2 monitoring, even though the resident was observed on O2 via NC. Another resident with COPD had a continuous O2 order and tubing-change order, but the care plan did not reflect continuous oxygen therapy, despite the resident being observed wearing O2 at all times.
Pharmacy recommendations from monthly med regimen reviews were not consistently addressed for two residents receiving Seroquel. For one resident with dementia, the pharmacist questioned the antipsychotic use and requested a diagnosis supporting it, but the NP responded over a month later and did not provide the requested diagnosis; a later recommendation was also answered over a month later. For another resident with dementia and mood disturbance, the consulting pharmacist did not identify any irregularities or note the lack of an appropriate diagnosis to support Seroquel use.
Ordered CBC w/diff and LFT monitoring for a resident on methotrexate was not consistently completed or reported to the provider. The resident had RA, CHF, AFib, contractures, and dementia with significant cognitive impairment. The record showed missed lab monitoring, including no evidence of ordered labs being obtained at one point and incomplete follow-through on later CBC/LFT orders, with the resident left off the lab list.
Infection control practices were not followed for a resident receiving IV antibiotics through a PICC line and for another resident on TBP for COVID-19. An LPN administered IV cefepime through an open-ended PICC without a needleless connector/valve, contrary to facility policy, and a regional RN confirmed the connector was missing. In a separate event, an activity director entered a COVID-positive resident’s room wearing a surgical mask instead of an N95 respirator and without proper eye protection, despite the resident being on TBP and posted PPE instructions.
A resident was admitted on Levofloxacin for a UTI, but the facility did not ensure the antibiotic was reviewed under its antibiotic stewardship program to confirm lab support and McGeer criteria were met. The infection log and McGeer checklist both indicated the resident did not meet criteria for UTI treatment, yet the antibiotic continued, and the DON acknowledged there was no evidence of IP review or follow-up on the final urine culture, which later showed low organism counts of unclear significance.
A resident with a suprapubic catheter did not receive comprehensive and individualized catheter care as ordered, including missed catheter changes and inadequate documentation. Staff were unaware of or misunderstood physician orders, and catheter care was not consistently performed due to staffing shortages and lack of training. These failures led to the resident developing a severe UTI, sepsis, and acute kidney injury, requiring hospitalization and intensive care.
The facility did not pay multiple vendor and utility bills on time, resulting in overdue accounts, shut-off notices for water and electricity, and delayed payments to the medical director. Staff reported supply delays and concerns about payroll, while the business office manager repeatedly forwarded unpaid bills to corporate accounts payable with limited resolution. All residents, who have complex medical needs, were at risk due to the facility's failure to maintain financial solvency and ensure uninterrupted essential services.
The facility did not adequately assess or provide for the activity needs of all residents, resulting in repetitive and limited programming, lack of specialized activities for memory care residents, and widespread dissatisfaction among both residents and staff. Observations and interviews revealed that scheduled activities were often not meaningful or engaging, and that some residents, including those with mental health conditions, were left without appropriate opportunities for socialization and stimulation.
The facility did not maintain adequate nursing staff, resulting in delayed or missed care such as bathing, feeding, and incontinence care. Staff and residents reported long wait times for assistance, unsafe transfers, and unmet personal care preferences. Facility records and leadership confirmed that current staffing levels were insufficient to meet the needs of residents requiring assistance with ADLs.
The facility did not provide specialized memory care services as advertised, with residents on the memory care unit receiving the same activities as the rest of the facility and lacking individualized programming. Observations and staff interviews revealed minimal engagement, no separate activity calendar, and inadequate staffing, resulting in periods of unsupervised residents and unmet psychosocial needs. Families and staff expressed concerns about the lack of stimulation, safety, and the absence of meaningful activities tailored to residents with dementia.
The facility did not manage its resources effectively, resulting in overdue utility and vendor bills, delayed payments to the Medical Director, and insufficient dietary staffing as outlined in the facility assessment. Administrative staff were often absent or unresponsive, and the dietary department was understaffed, causing delays in meal preparation and requiring CNAs to assist with kitchen duties, impacting all residents.
A facility-wide assessment failed to accurately account for the number of residents dependent on staff for ADLs such as toileting, dressing, bathing, and transferring, resulting in staffing levels that did not meet the actual needs of the resident population. Interviews with the DON, Administrator, and Dietary Director confirmed that both direct care and dietary staffing were insufficient compared to the requirements outlined in the assessment, leading to inadequate care coverage during both routine operations and emergencies.
Multiple residents did not receive prescribed treatments, such as wound care and nutritional supplements, and there were repeated failures to document care or notify providers of significant changes, including missed skin assessments and unreported rapid weight gain in a resident with CHF. Staff interviews confirmed lapses in following care protocols and physician orders, resulting in unaddressed changes in condition and incomplete care documentation.
Two residents did not receive required fall prevention interventions or post-fall assessments, as one lacked a care planned floor mat and another did not have a post-fall assessment documented after an unwitnessed fall. Additionally, hazardous chemicals were left unsecured and accessible to all residents on the memory care unit while staff were not present, as confirmed by an LPN. These deficiencies were identified through observation, interviews, and record reviews.
A resident with multiple chronic conditions was discharged home without comprehensive discharge instructions or documentation of a discharge note in the medical record. The discharge summary lacked evidence of education on diet or activities, and the DON confirmed the documentation was incomplete.
Two residents admitted with complex medical conditions did not have complete baseline care plans developed within 48 hours of admission. Only partial care plans, such as dietary or nutrition/hydration risk, were initiated, while other required care plans were delayed. Facility leadership confirmed that care plans were not completed in accordance with policy, and care conference documentation was incomplete.
Two residents who were dependent on staff for bathing, due to conditions such as Alzheimer's disease and mobility impairments, did not receive showers according to their preferences and scheduled times. Documentation and staff interviews confirmed that multiple showers were missed, and in some cases, behavioral challenges were cited as reasons for not providing care. The facility's policy allowed residents to choose the frequency and timing of bathing, but this was not followed.
A resident with multiple chronic conditions was admitted and continued to receive oxygen therapy at 2 LPM via nasal cannula, but there was no physician order for this treatment. Both the DON and Administrator confirmed that an order was required, and facility policy mandates physician orders for oxygen administration except in emergencies.
A resident with multiple serious conditions experienced moderate to severe pain over several days due to a delay in receiving ordered Tramadol. During this period, there was no documentation of alternative pain management interventions, despite ongoing pain reports and facility policy requiring appropriate pain assessment and treatment.
A resident with a history of depression, anxiety, and alcohol dependence was unable to attend AA meetings due to a broken facility van, and no alternative support or social services were provided during this period. The resident, who relied on AA for social interaction and emotional support, did not receive follow-up or in-house interventions from the social worker or other staff, despite clear care plan directives and facility policy requirements.
Two residents did not receive prescribed medications as ordered due to delays in pharmacy delivery and issues with the facility's medication ordering process. One resident missed several days of an ear wax removal treatment, while another experienced unmanaged pain due to a week-long delay in receiving Tramadol. Staff and nursing interviews confirmed ongoing problems with obtaining both prescription and OTC medications, and the facility did not notify physicians when medications were unavailable.
Two residents with special dietary needs received meals that were unpalatable, lacking flavor, and had poor texture, as confirmed by dietary staff and resident feedback. One resident on a pureed diet received food that was stringy, lumpy, and watery, while another resident reported their meal had no flavor. These deficiencies were observed and verified during meal preparation and service.
Two residents did not receive food prepared in the required texture for their prescribed diets. One was served a whole hot dog instead of a mechanical soft diet, and another received pureed foods that were stringy, lumpy, and lacked flavor, despite orders for a pureed diet. Dietary staff and the dietary director confirmed the food did not meet required consistency standards.
A resident with a suprapubic catheter had monthly catheter changes documented as completed by LPNs, but interviews revealed that the procedure was never actually performed. Staff misunderstood the order, believing it referred to changing the catheter bag, and some lacked training on the procedure. The physician was not notified of the missed catheter changes, and the DON confirmed the inaccurate documentation.
A resident with an indwelling catheter and severe cognitive impairment was observed multiple times with their catheter bag lying on the floor while resting in bed. An LPN confirmed the observation, indicating a failure to follow infection prevention and control practices for catheter care.
A resident with multiple comorbidities and an unstageable pressure ulcer did not receive wound care in accordance with infection control protocols. An LPN and the ADON entered the room without donning gowns as required by enhanced barrier precautions, and the LPN used improper wound cleaning techniques and failed to clean equipment between uses. Staff interviews confirmed that infection control policies were not followed during the procedure.
Medication and treatment carts were left unlocked and unattended at the nurses' station while an LPN was off the unit and a CNA was serving breakfast in the dining room. Several cognitively impaired residents, all able to ambulate independently and known to wander, had access to the area. Facility policy required carts to be locked when unattended, but this was not followed.
A resident with complex medical conditions did not receive all required components of their comprehensive MDS assessments. Specifically, the annual MDS was missing the Cognitive Pattern: Brief Interview for Mental Status and Pain Assessment interview, and the quarterly MDS lacked the Pain Assessment interview. These assessment omissions were verified by the ADON.
Two residents with complex medical needs did not have comprehensive care plans or discharge plans developed, despite being cognitively intact and expressing goals to return to the community. Both lacked documented referrals and active discharge planning, and one resident did not have a pain management care plan, even though pain was regularly assessed and treated.
A resident with significant medical needs developed new pressure ulcers and did not receive the prescribed silver alginate wound treatment, instead receiving calcium alginate for an extended period. During a dressing change, an LPN and the ADON failed to follow infection control protocols, including not using required PPE and reusing contaminated instruments, contrary to facility policy.
Two residents with colostomies did not consistently receive ostomy care as ordered by their physicians, as documented in the TAR and confirmed by the ADON. Both residents were cognitively intact and had care plans specifying the need for regular ostomy care, but records showed multiple missed care opportunities.
Two residents experienced medication administration errors, including late administration, incorrect dosages, and wrong medication forms, resulting in a medication error rate of 26.9%. Nursing staff acknowledged the errors, which occurred despite facility policy requiring timely and accurate medication administration.
The facility failed to implement a comprehensive pressure ulcer prevention program for two residents, resulting in the development of Stage II pressure ulcers. Both residents were at risk due to impaired mobility and incontinence, but care plans were not adequately followed. Incontinence care was not provided every two hours, and required pressure-relieving devices were not in place. Staff shortages contributed to the inability to provide necessary care, as confirmed by staff interviews and observations.
The facility failed to maintain sanitary conditions in food storage and preparation, affecting all residents receiving food. Expired and undated food items were found, and a staff member did not follow proper hand hygiene when changing gloves during food preparation. The dishwasher also failed to reach the required rinse temperature.
The facility failed to maintain a clean and safe environment, with issues such as discolored tile and grout, rusty air vents, torn walls, and sticky floors. A resident's room was particularly unkempt, with soiled bedding, cluttered window sills, and flies present. Staff confirmed the lack of maintenance and cleaning, noting the absence of a maintenance person for over a month and the facility's quarterly exterminator contract not addressing flies.
The facility failed to ensure proper documentation of advanced directives for two residents. One resident lacked an order for code status upon admission, while another had conflicting code status orders in electronic and paper records. The DON confirmed these discrepancies, which violate the facility's policy requiring clear display of advanced directives in medical records.
A facility failed to accurately document a resident's psychiatric diagnoses in the PASRR, despite the resident having major depressive disorder and unspecified psychosis. The PASRR did not reflect these conditions, although the resident's care plan and MDS indicated active diagnoses and antidepressant use. The DON confirmed the oversight, and the facility's policy required a review for unrecognized serious mental illness, which was not conducted.
The facility failed to develop comprehensive care plans for three residents, affecting their diagnoses, medications, and ADLs. A resident with dementia, depression, hallucinations, insomnia, and diabetes lacked care plans for these conditions and medications. Another resident with cerebral infarction and heart disease had no care plans for anticoagulation and bleeding risks. A third resident with dementia and other conditions lacked an ADL care plan. The facility's policy required care plans within seven days of the MDS assessment, which was not followed.
A resident with dementia and Alzheimer's disease did not receive consistent assistance with bathing, shaving, and oral care, despite requiring substantial help. The resident experienced gaps of up to ten days between showers, was often unshaven, and lacked access to oral care supplies. Staff interviews revealed that personal hygiene supplies were out of reach, and there was no follow-up after shower refusals. The facility's policy did not address handling refusals, leading to inadequate care.
Food Stored in Unsanitary Refrigerator Conditions
Penalty
Summary
Food was not stored under sanitary conditions in the facility kitchen. During an initial tour of the kitchen, a walk-in white refrigerator was observed to have a foul odor upon entry. Inspection under the shelf in the right corner of the refrigerator revealed a rotten apple, an old onion, an open cheese slice, and an unidentifiable rotted item. The Dietary Manager later confirmed the foul odor and the presence of these items in the refrigerator. Review of the facility's undated Food Storage policy stated that food will be stored in an area that is clean, dry, and free from contaminants, and that all refrigerator units should be kept clean and in good working condition at all times.
Failure to Document Offering Updated COVID-19 Vaccine
Penalty
Summary
The facility failed to ensure that residents who had lived there for over a year were offered the updated COVID-19 vaccine for the 2025-2026 respiratory season. Four of five residents reviewed for vaccination status—Resident #4, Resident #5, Resident #33, and Resident #36—had documentation showing they were offered other vaccines such as influenza, pneumococcal, shingles, RSV, and hepatitis B, but there was no documented evidence that the updated COVID-19 vaccine was offered to them. Resident #4 had diagnoses including COPD, morbid obesity, adult-onset diabetes mellitus, nicotine dependence, and hypertension. Resident #5 had unspecified dementia, hypertension, and hyperlipidemia, and his records showed influenza and pneumococcal vaccine offers, with influenza accepted and pneumococcal refused, but no COVID-19 vaccine offer documented. Resident #33 had unspecified dementia, hypertension, adult-onset diabetes mellitus, hypercholesterolemia, and bronchitis, and her records showed offers of influenza and pneumococcal vaccines, both declined, with no evidence of a COVID-19 vaccine offer. Resident #36 had atrial fibrillation, morbid obesity, congestive heart failure, hypertension, and unspecified dementia, and her vaccination consent form listed several vaccines but did not include the updated COVID-19 vaccine. On interview, the interim DON stated there was no evidence that the updated COVID-19 vaccine had been offered or provided to these residents for the 2025-2026 respiratory illness season and that documentation for residents residing in the facility for over a year could not be located.
Failure to Ensure Competent IV Therapy Administration by Agency LPN
Penalty
Summary
The deficiency involves the facility’s failure to ensure that an IV medication was administered by a competent licensed nurse and to verify and document IV therapy competencies for an agency LPN. A resident was admitted with a postoperative wound infection, a PICC line placed in the right upper arm for long-term IV antibiotic therapy, and multiple comorbidities including diabetes, liver disease, hypertension, anemia, depression, and a history of stroke. The resident had an order for IV cefepime 2 g in 100 ml normal saline to be given three times daily via the PICC line. On observation, the PICC line had a flesh-colored bandage wrapped around the base, obscuring the insertion site, and the external catheter had a purple open-ended hub labeled “5 ml” with no needleless connector/valve attached. During administration of IV cefepime, the LPN cleaned the open end of the external PICC with an alcohol swab, flushed with normal saline, and then attached the IV tubing directly to the open end of the PICC line without a needleless connector device. When questioned, the LPN stated that PICC lines she worked with never had valves and that this was how PICC lines are, despite reporting that she had IV therapy training and certification. Licensure review showed the LPN had been licensed less than a year and, per the Ohio Board of Nursing, IV certification is no longer listed on LPN licenses for those licensed after a certain date, making IV training and competency verification the employer’s responsibility. The Human Resource Director reported she did not maintain personnel files, licensure checks, or competency records for agency staff, and the interim DON reported having no education or competency documentation for the LPN other than IV training provided after the issue was identified, stating that the agency would have competency records. The Administrator reported that one staffing agency only verified licensure and did not check competencies, and that another agency provided only a self-assessment skills checklist on which the LPN rated her IV therapy skills as limited and requiring supervision. The facility’s contract with that agency specified that the facility was responsible for orientation, education, training, and competency of agency staff.
Advance Directive Not Documented
Penalty
Summary
Failure to document advance directives was identified for one resident. The resident was admitted with diagnoses including stroke with left side paralysis, atrial fibrillation, bilateral above-the-knee amputations, hypertension, anxiety and depression, schizophrenia, diabetes, and congestive heart failure. Review of the medical record showed no current code status order, although a discontinued order indicated full-code status had been discontinued on 10/27/25. During interview, an LPN stated the resident’s code status should appear in the EMR orders screen and confirmed there was no current code status order. The LPN then found a green paper in the front of the paper chart with FULL CODE written on it and stated the paper charts were being phased out. A CNA reported code status could be found in the Kardex section of the EMR but could not locate it for the resident. Review of the facility’s Advance Directives Policy stated resident wishes are to be communicated to staff via the care plan and to the resident physician.
Failure to Obtain Resident or Representative Acknowledgement of Medicare Skilled Service Termination Notices
Penalty
Summary
The facility failed to ensure residents and/or their representatives signed liability notices acknowledging when skilled services were ending and when Medicare Part A coverage would no longer apply. For Resident #2, the record showed the last covered day for Medicare Part A skilled services was 09/05/25, and a NOMNC and SNF ABN were dated 08/25/25. Both forms included spaces for the resident or representative to acknowledge receipt, but only facility employees signed them; there was no documented signature from the resident or representative, and there was no documented evidence that the resident or representative had been notified that skilled services were ending or that Medicare Part A coverage would stop. The SNF ABN also indicated physical therapy and occupational therapy were ending, and option #3 was selected to opt out of continuing those services. For Resident #36, the record showed the last covered day for Medicare Part A skilled services was 08/27/25, with a NOMNC and SNF ABN dated 08/15/25. As with Resident #2, both forms were signed only by facility employees and not by the resident or representative, and there was no documented evidence on the notices that the resident or representative had been notified that skilled services were ending or that Medicare Part A coverage would end. The SNF ABN also identified physical therapy and occupational therapy as ending and had option #3 selected. During interview, the Administrator acknowledged the notices were not signed by the residents or their representatives, stated Resident #2 was not physically able to sign, and confirmed there was no documentation supporting that Resident #36's representative had been notified when skilled services and Medicare Part A coverage ended.
Inadequate Indication for Antipsychotic Use
Penalty
Summary
The facility failed to ensure that two residents with dementia received antipsychotic medication only with an adequate indication for use. Resident #5 had diagnoses including unspecified dementia with agitation and depression and was receiving Seroquel 50 mg twice daily for unspecified dementia with agitation. The resident’s more recent psychoactive medication consent did not identify a diagnosis or specific target behaviors supporting the medication, and the chart did not show any gradual dose reduction attempts after admission to the nursing facility. A pharmacy review flagged the medication for evaluation under psychotropic drug guidelines, and the prescriber agreed a dose reduction would be attempted, but the resident’s sister/POA refused changes. During the investigation, staff and the psychiatric CNP acknowledged that dementia with agitation was not an appropriate diagnosis for Seroquel, and the CNP stated the resident did not display psychosis or a disturbance in perception at the time of the psychiatric follow-up. Resident #5’s record also showed that the only behavior documented in the active care plan was crawling on the floor, while observations during multiple on-site visits showed the resident lying in bed or in a recliner with eyes closed and no behaviors observed. A CNA familiar with the resident described occasional yelling out, usually in the afternoon or evening, but denied aggressive behaviors toward staff or other residents. The CNP stated she had attempted to reduce the Seroquel while the resident was on the assisted living side, but the POA declined those attempts, and she could not identify whether behavior management, environmental changes, or other person-centered approaches had been used in place of the antipsychotic. Resident #33 was also receiving Seroquel without an adequate indication. Her diagnoses included unspecified dementia with mood disturbance and depression, and her orders included Seroquel 25 mg three times daily for depressive disorder and 50 mg at bedtime for agitation, along with Zoloft for depression. Psychiatric notes showed no suicidal or homicidal ideation, delusions, hallucinations, psychosis, or disturbance in perception, and the resident was described as redirectable with no reports of aggression. The CNP noted a plan to discuss a gradual dose reduction with the family, but the record did not show that the medication was being tapered because it lacked an appropriate diagnosis for use. During observations, Resident #33 was seen pleasant, smiling, and sitting in common areas, with no negative or aggressive interactions with staff or other residents. Staff interviews indicated the facility could not find an adequate indication for Seroquel, and the DON stated the resident’s daughter had previously opposed medication changes. A CNA described occasional overstimulation, restlessness, and a need for quiet time, which improved when the resident was taken to her room with a magazine or television, but denied other behaviors or agitation toward others. The CNP stated that mood disturbance was not typically an adequate indication for Seroquel and that she was working on a gradual dose reduction, but she did not document an intent to taper the medication to discontinuation because the resident lacked an appropriate diagnosis for its use.
Failure to Provide Transfer and Bed Hold Notices
Penalty
Summary
The facility failed to ensure that a resident and/or the resident’s representative was provided a written transfer notice and a bed hold notice at the time the resident was transferred to the hospital. Resident #1 was admitted with diagnoses including stroke, acute respiratory failure, and pneumonitis due to inhalation of food and vomit into the lungs. On 09/11/25 at 9:40 A.M., a nurse found the resident unable to be aroused while attempting to administer medications; the resident did not respond to tactile stimuli and remained unresponsive. The DON was notified, and the decision was made to send the resident to the emergency room, where he was transported by squad at 10:05 A.M. When asked to provide documentation showing that a transfer notice and bed hold notice had been given at or around the time of transfer, the facility produced only a bed hold notice that had been electronically signed by the resident on 09/10/25 during admission paperwork. There was no evidence that a transfer notice was provided to the resident or his representative when he was sent to the hospital, and there was no documented evidence that a bed hold notice was provided at the time of transfer to give the resident the option to hold a bed. The Administrator confirmed on 01/26/26 that the facility had no evidence of a written transfer notice and no evidence of a bed hold notice at transfer, and stated the facility had only been providing bed hold notices to residents with Medicaid payer status, while this resident had private insurance.
Inaccurate MDS Coding for Hospice Status and Medication Classification
Penalty
Summary
The facility failed to ensure accurate MDS assessments for two residents. Resident #3 was admitted with diagnoses including CHF, atrial fibrillation, a cardiac pacemaker, type 2 diabetes, HTN, and GERD. Her record showed an order to admit her to hospice active 11/20/24, and her care plan stated she was receiving hospice services with goals focused on comfort and dignity through end-of-life services. However, her annual MDS completed on 01/01/26 showed a BIMS score of 04 and did not document that she was receiving hospice care and services or that she had a life expectancy of six months or less. The Regional MDS nurse confirmed the MDS was inaccurately coded to reflect hospice status, and the admissions director confirmed the resident did receive hospice care and services. Resident #33 was admitted with unspecified dementia, moderate, with mood disturbance and insomnia. Her physician orders showed Melatonin 10 mg PO at bedtime for insomnia, and the medication had been ordered since 11/02/25 and administered nightly as ordered. Her admission MDS assessment dated 11/10/25 indicated the resident received a hypnotic during the seven-day assessment period and that it had an indication for use. Review of the CMS RAI Manual stated medications in Item N0415 are to be coded by therapeutic category and/or pharmacological classification, not by how they are used. The MDS nurse confirmed the assessment was not coded accurately because Melatonin is a supplement and not a hypnotic, and she acknowledged it had been coded as a hypnotic medication.
Missed antibiotic doses and unadministered weight loss medication
Penalty
Summary
The facility failed to ensure Resident #3 received complete treatment for a left index finger infection. The resident, who had diagnoses including congestive heart failure, atrial fibrillation, a cardiac pacemaker, type 2 diabetes, hypertension, and gastroesophageal reflux disease, had orders to clean the finger, apply triple antibiotic ointment, and cover it daily until resolved, along with an order for doxycycline hyclate 100 mg by mouth twice daily for seven days for infection. Review of the January 2026 MAR showed three missed doses of doxycycline, including both doses on 01/08/26 and the morning dose on 01/09/26. Progress notes documented that the medication was awaiting arrival from pharmacy and that it was unavailable from the E-kit, but there was no documentation that the antibiotic course was adjusted to make up for the missed doses, and the resident received 11 of 14 ordered doses. The facility also failed to ensure Resident #17 received physician-prescribed weight loss treatment. The resident had diagnoses including necrotizing fasciitis, chronic obstructive pulmonary disease, hyperlipidemia, insomnia, morbid obesity, and depression. The record showed an order for Zepbound 10 mg/0.5 mL subcutaneous injection every Saturday for weight loss, ordered on 12/27/25 and discontinued on 01/05/26. A progress note stated the medication was not available and was reordered from pharmacy, but the record contained no documentation that Resident #17 received the ordered January dose. The MAR also showed no documentation of administration of Zepbound for weight loss.
Missing catheter care, urinary output documentation, and incomplete antibiotic administration
Penalty
Summary
Catheter care was not documented for a resident with an indwelling urinary catheter. The resident was admitted with diagnoses including necrotizing fasciitis, COPD, hyperlipidemia, insomnia, morbid obesity, and depression. The MDS showed the resident had an indwelling urinary catheter, and the orders required a 16 French catheter with a 10 mL balloon to be maintained and changed every 30 days as needed to maintain patency. The care plan identified the resident as at risk for complications related to catheter use and included monitoring and documenting for pain, discomfort, and signs and symptoms of UTI. Review of the record, including orders, MAR, TAR, and tasks, revealed no documentation that indwelling urinary catheter care had been completed. During observation, the catheter tubing contained sediment and appeared dark in color. The DON and ADON confirmed there was no documentation in the medical record showing catheter care had been completed. Urinary output monitoring was also not documented as ordered for another resident with an indwelling catheter. That resident had diagnoses including Parkinson's disease, diabetes, obstructive and reflux uropathy, urinary retention, Alzheimer's disease, dementia, and chronic kidney disease. The order required indwelling urinary output to be recorded every shift and the provider notified if output was less than 400 mL per shift, but the TAR showed multiple dates with no documented output and several entries marked "see nurses notes" with no corresponding nursing notes found. In addition, a third resident with dementia and a history of frequent UTIs received only 9 of 10 prescribed doses of Macrobid for a UTI; the MAR showed one dose on the first day and two doses daily thereafter through the end of the order, and an LPN found two doses remaining after the order was considered complete. The RNN verified the resident had received only nine doses and notified the provider.
Failure to Provide Adequate Hydration
Penalty
Summary
The facility failed to provide adequate hydration for Resident #36. The resident was admitted with diagnoses including atrial fibrillation, congestive heart failure, contractures of both hands and knees, rheumatoid arthritis, and dementia. The quarterly MDS showed the resident required set-up assistance and supervision with meals, was dependent in several areas of care, used a specialized wheelchair, and had a BIMS score of 3/15 indicating significant cognitive impairment. Provider orders included increasing fluids by offering at least one large glass of water every two hours, offering cranberry juice, avoiding bladder-irritating drinks, and providing two-handled cups at every meal. Survey observations showed multiple times when Resident #36 was seated in the hallway or in bed without fluids or two-handled cups within reach. On several occasions, the resident was observed with eyes closed and covered with a blanket in the main hallway near the lounge, with no staff continuously present in the immediate area and no fluids or two-handled cups available. During breakfast, the resident was observed eating in bed without a divided plate or two-handled cups, and a nurse gave the resident a small 4-ounce plastic cup for medications; the resident used a pincer grasp because of contractured hands to drink the water. At the noon meal, the resident was observed with a divided plate, soup, and two two-handled cups containing coffee and orange Kool-Aid. The resident was slouched in the wheelchair with eyes closed and contractured hands resting on the upper chest. A nurse had to encourage the resident to eat, and the resident asked for drinks while being fed. The CNA reported the resident had already consumed two glasses of orange Kool-Aid before the nurse assisted. Later observations again found the resident without fluids or two-handled cups within reach, and when the resident asked for water, CNA #77 confirmed there was no water available and stated the resident sometimes did not receive a two-handled cup with meals.
Failure to Provide and Document Ordered Oxygen Therapy
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for two residents who had oxygen orders and were receiving oxygen therapy. Resident #10 was admitted with diagnoses including dementia, metabolic encephalopathy, type 2 diabetes, heart failure, hypertension, and acute kidney failure. The resident had an order for oxygen at 2-4 liters via nasal cannula to maintain oxygen saturation above 90% as needed for shortness of breath and low oxygen saturations, and the care plan directed staff to give oxygen as ordered. However, the record showed no evidence that the resident’s nasal cannula tubing was changed, no evidence that oxygen was initiated or titrated as ordered when the resident was wearing oxygen, and no documented oxygen saturation monitoring after the last recorded check. The resident was observed lying in bed with oxygen at 3 liters via nasal cannula, and the tubing had no date on it. Resident #17 was admitted with diagnoses including necrotizing fasciitis, COPD, hyperlipidemia, insomnia, and depression. The resident had an active order for oxygen at 2 liters per minute via nasal cannula continuously to keep oxygen saturation above 90%, along with an order to change oxygen tubing, cannula, or mask weekly and as needed. The record contained no evidence that the resident’s care plan reflected continuous oxygen therapy. The resident was observed with oxygen via nasal cannula at 2 liters and confirmed wearing oxygen at all times. Facility policy required documentation of the initial and ongoing assessment for oxygen therapy, the resident’s response to oxygen, and care plan interventions based on the oxygen orders, including delivery system, timing, flow rates, and monitoring of oxygen saturation and complications.
Pharmacy Recommendations Not Timely Addressed or Identified
Penalty
Summary
The facility failed to ensure that pharmacy recommendations from monthly drug regimen reviews were appropriately addressed by the prescriber and responded to in a timely manner for two residents reviewed for unnecessary medications. Resident #5, who was admitted with unspecified dementia with agitation and depression, had monthly medication regimen reviews in which irregularities were identified for Seroquel. On 04/17/25, the pharmacist requested that the physician provide an allowed diagnosis supporting the antipsychotic use under the applicable regulations, but the nurse practitioner did not respond until 05/19/25 and did not provide the requested diagnosis. Instead, she stated she would like a gradual dose reduction attempt if agreed to by the family. A later pharmacy recommendation on 08/17/25 again questioned the continued use of Seroquel under psychotropic drug therapy guidelines, and the nurse practitioner did not respond until 09/24/25, again over a month later, and again only agreed to a dose reduction attempt if the family agreed. Resident #33 was admitted with unspecified dementia with mood disturbance and was receiving Seroquel 25 mg three times daily for depressive disorder and 50 mg at bedtime for agitation. Her monthly medication regimen reviews on 11/21/25 and 12/18/25 did not identify any irregularities, and the consulting pharmacist did not note that the resident lacked an appropriate diagnosis to support the use of Seroquel or make any related recommendation. Regional Nurse #90 confirmed that the pharmacist reviewed the resident’s medication regimen twice since admission and did not identify the missing diagnosis support for the antipsychotic use.
Ordered Lab Monitoring for Methotrexate Not Completed
Penalty
Summary
The facility failed to obtain ordered laboratory tests and failed to report results to the ordering practitioner for one resident receiving methotrexate for rheumatoid arthritis. The resident was admitted with diagnoses including atrial fibrillation, congestive heart failure, contractures of the bilateral hands and knees, rheumatoid arthritis, and dementia. The quarterly MDS showed the resident was dependent in several areas of care and had a BIMS score of 3/15, indicating significant cognitive impairment. Provider orders included methotrexate 2.5 mg by mouth weekly and, later, CBC with differential and LFT every four weeks while on the methotrexate regimen. The record showed CBC with diff and LFT were obtained in August and September 2025, but there was no evidence of CBC with diff or LFT being obtained in October 2025. A CBC with diff was obtained in November 2025 and again in December 2025, but there was no evidence of an LFT with either of those labs. There was also no CBC with diff or LFT obtained in January 2026. The regional RN verified the facility did not obtain the ordered labs on January 13, 2026 and that the resident had been left off the laboratory list; the omission of the October 2025 labs was also verified by email communication with the Administrator.
Infection Control Failures With PICC Line Care and COVID-19 Precautions
Penalty
Summary
The facility failed to follow infection control practices to prevent the spread of infection for a resident receiving IV antibiotic therapy through a PICC line. The resident was admitted with diagnoses including post operative wound infection, diabetes, liver disease, high blood pressure, anemia, depression, and a history of stroke. The medical record showed an order for cefepime 2 grams in 100 mL normal saline to be given intravenously three times a day through 02/20/26, and the PICC had been placed in the resident’s right upper arm before admission for long-term antibiotic use. During observation, the resident’s PICC line had a flesh-colored bandage wrapped around the base of the line that prevented view of the insertion site. The exposed external catheter had a purple open-ended hub with the writing of 5 mL on it, and there was no needleless connector device or valve attached to the end of the external catheter. The LPN administering the IV cefepime cleaned the open end of the PICC with an alcohol swab, attached a 10 mL syringe of normal saline to flush the catheter, and then attached the IV cefepime tubing directly to the open end of the PICC without a needleless connector or valve present. The LPN stated that PICC lines she works with never have valves on the end and that is how PICC lines are. The facility regional RN confirmed the resident did not have a needleless connector attached to the open end of the PICC line and stated she would obtain one and attach it, along with changing the PICC dressing. The facility policy for IV therapy stated all lumens of catheters will have a needleless connection device on the hub to prevent intake of air embolus and/or outward blood flow, and that needleless connector devices are also used to help prevent catheter associated infections. The report also identified a separate infection control failure involving a resident on transmission-based precautions for COVID-19, where an activity director entered the resident’s room wearing a surgical mask instead of an N95 respirator and did not don eye protection over her prescription glasses, despite the resident being in TBP’s and signage indicating required PPE procedures.
Antibiotic Use Not Reviewed Against UTI Criteria
Penalty
Summary
The facility failed to ensure a resident admitted on an antibiotic for a urinary tract infection was reviewed under its antibiotic stewardship program to confirm there were laboratory results supporting the treatment and that the resident met criteria for continued antibiotic use. Resident #48 was admitted with diagnoses including hemiplegia and hemiparesis following a stroke, adult onset diabetes mellitus, and a UTI. Hospital records showed an AVS diagnosing acute cystitis without hematuria and ordering Levofloxacin 500 mg by mouth daily for 7 days. The hospital urinalysis collected before admission showed cloudy urine, a large amount of leukocytes, and negative nitrites, while the final urine culture was still pending at the time of admission. The resident received the full antibiotic course in the facility from 11/06/25 through 11/13/25, with the scheduled 11/14/25 dose not given because the resident was in the hospital. The facility’s infection log listed the resident as admitted with a UTI, noted that no organism had been identified, and indicated the resident did not meet McGeer’s criteria for UTI treatment, yet the antibiotic treatment continued. A McGeer’s Criteria checklist completed by the facility’s infection preventionist also indicated the resident did not meet criteria for treatment. The interim DON acknowledged there was no evidence the infection preventionist reviewed the resident’s antibiotic use for the UTI and stated no one had followed up to obtain the final urine culture results, which later showed less than 100,000 CFU/ml with low numbers of organisms of unclear significance and recommended repeat collection if clinically indicated.
Failure to Provide Comprehensive Suprapubic Catheter Care Resulting in Sepsis and Hospitalization
Penalty
Summary
A deficiency occurred when facility staff failed to develop and implement comprehensive and individualized care and interventions for a resident with a suprapubic catheter. The resident, who had a history of neurogenic bladder, diabetes, hypertension, and other chronic conditions, had a physician order for suprapubic catheter care every shift and monthly catheter changes. Despite these orders, there was no evidence that a care plan was developed at the time of catheter placement, and documentation showed repeated missed catheter care and tubing checks across several months. Staff interviews revealed that catheter care was not consistently performed due to staffing shortages, and some staff were unaware of or misunderstood the physician's orders regarding catheter changes, with some believing the order referred only to the catheter bag rather than the catheter itself. The resident's medical records indicated that catheter care and monthly changes were not documented as completed on multiple occasions, and there was no documentation of the resident refusing care or of the physician being notified about missed catheter changes. Additionally, there was no monitoring or documentation of urinary output or urine appearance prior to the resident's acute change in condition. Staff interviews confirmed that the suprapubic catheter had not been changed as ordered, and some staff admitted to not having received training on how to perform the procedure. The resident's care plan addressing the suprapubic catheter was not initiated until several months after placement, and interventions to monitor for complications were not implemented in a timely manner. As a result of these failures, the resident developed a severe urinary tract infection that progressed to sepsis and acute kidney injury, requiring hospitalization and intensive care. Hospital records documented grossly purulent urine, obstructive kidney stones, and the need for surgical intervention, including catheter exchange and stent placement. The lack of adherence to physician orders, inadequate documentation, and insufficient staff knowledge and training directly contributed to the resident's acute medical deterioration.
Removal Plan
- Resident #05 was transferred to the hospital and remained in the hospital.
- An audit of all current residents was completed by the DON for any residents with a suprapubic catheter. No other residents noted with a suprapubic catheter. Resident #09 was identified to have an order for an indwelling urinary catheter (Foley). Resident #09 was seen by the Nurse Practitioner.
- An investigation was completed by the DON of why this error occurred in order to implement corrective actions.
- RDCO #1022 reviewed facility policies including the Physician Order policy, Catheter Care policy, Suprapubic Catheter Replacement and Suprapubic Care procedures to ensure they were comprehensive, and no changes were needed prior to staff education.
- RDCO #1022 provided education to the DON on Physician Orders policy, Suprapubic Cath Care and Suprapubic Cath Replacement procedures.
- Education was provided in person or via phone to all current licensed nurses by the Director of Nursing (DON) and Assistant Director of Nursing (ADON). The education included following physician orders regarding catheters including catheter care (video was given on steps for suprapubic catheter replacement), along with the suprapubic catheter care and replacement procedure. In addition, staff were educated if they were unable to complete this task for the day as ordered, they were to report to the DON/ADON and they would assist on how to get the task completed. The DON followed up with the nurses after the education to ensure there were no unanswered questions related to the education.
- All current Certified Nurses Assistants (CNAs) were educated by the DON on catheter care for Foley catheters using the facility Catheter Care policy. A video was provided on how to do catheter care. The CNA staff were educated if they were unable to complete this task as ordered for the day they were to report to the DON/ADON and they would assist in how to get the task completed. The DON followed up with CNAs after the education to ensure there were no unanswered questions related to the education.
- The Medical Director was notified by the DON of the Immediate Jeopardy (IJ) concern involving Resident #05. An Ad-hoc Quality Assessment and Performance Improvement (QAPI) meeting was held with Medical Director, DON, Administrator, and RDCO #1022. The IJ was reviewed, the reason for the IJ, and the facility abatement plan.
- The Administrator provided contracted staffing agencies education related to catheter care. Education would be added for the staff to review prior to picking up a shift. The DON/designee would ensure agency staff reviewed education by contacting them once they had arrived at the facility and getting a verbal acknowledgement they have reviewed.
- The facility implemented a plan for all new staff to be verbally educated on Physician Order policy, Catheter Care policy, Suprapubic Catheter Replacement and Suprapubic Care procedures, what to do if you do not know how to change a catheter, following physician orders by the DON/designee during new hire orientation.
- The DON/ADON would review physician orders daily and would ensure if there were any new suprapubic catheter orders that the care and changing orders were in place and being followed. The DON/ADON would review residents with suprapubic catheters and would review catheter orders to ensure they were accurately documented when completed by going in and checking if the care and or catheter had been changed per order.
Failure to Ensure Timely Payment of Essential Services and Vendor Bills
Penalty
Summary
The facility failed to ensure timely payment of bills and invoices, resulting in multiple overdue accounts and shut-off notices for essential services such as water and electricity. Review of financial records and interviews revealed that invoices from the State Fire Marshal, local hardware store, and utility companies were not paid on time, with some accounts receiving final collection notices and threats of service interruption. The business office manager consistently forwarded overdue bills and shut-off notices to corporate accounts payable, but payments were often delayed or only partially made, leaving outstanding balances. Staff interviews confirmed that the facility was experiencing financial difficulties, with some supplies delayed and concerns expressed about payroll and the overall financial health of the facility. The medical director reported not being paid for several months, and the State Fire Marshal's office confirmed outstanding survey fees dating back to the previous year. The corporate representative acknowledged that some utility accounts exceeded autopay limits and that bills were sometimes only paid after shut-off notices were received, citing cash flow issues and the need to avoid bounced checks. The facility assessment indicated that all 35 residents were clinically complex, with multiple chronic or comorbid conditions, making uninterrupted services critical to their care. Despite the absence of actual service shut-offs at the time of the investigation, the ongoing risk of interruption due to unpaid bills was evident. The administrator's job description included responsibilities for financial oversight, but the system in place failed to ensure timely payment of essential services, potentially affecting all residents.
Failure to Assess and Meet Resident Activity Needs
Penalty
Summary
The facility failed to assess and meet the activity needs of all 35 residents, as evidenced by record review, observation, interviews, and review of the activity calendar and job descriptions. The activity calendar showed repetitive and limited activities, such as beverage cart and sit and chat, with only one main activity per day, and little to no evening programming. Observations and staff interviews confirmed that beverage cart and sit and chat were not considered meaningful activities by staff or residents, and that activities were often not conducted as scheduled. Residents and staff reported dissatisfaction with the lack of variety, frequency, and engagement in the activities provided, with some residents expressing boredom and a desire for more options. The memory care unit was particularly affected, with no specialized programming or activities provided for its residents. Observations revealed long periods with no activities, and staff confirmed that activity assessments had not been completed for memory care residents. Residents in this unit were often left without stimulation or opportunities to participate in group activities, and staff noted that when memory care residents were able to leave the unit for activities such as church, their mood improved significantly. However, such opportunities were rare, and the activity staff did not regularly provide or invite memory care residents to participate in activities. One resident with a history of major depression, anxiety disorder, and alcohol dependence in remission was specifically noted to have a care plan that included goals and interventions for activity participation, but reported that there were not enough activities to meet his needs. The activity director confirmed that she was the only member of the activity department, with limited time and resources to provide a variety of activities, and that the activity room was not accessible to residents outside of her working hours. The job description for the activity director outlined responsibilities for providing a comprehensive activity program, but these were not being met, as evidenced by the lack of assessments, limited programming, and resident and staff dissatisfaction.
Failure to Provide Sufficient Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple staff and resident interviews, observations, and review of facility records. Staff reported frequent instances where Certified Nursing Assistants (CNAs) were left alone on the floor, especially during weekends and night shifts, resulting in delayed or missed care such as bathing, oral care, feeding assistance, and incontinence care. Staff also described situations where tasks requiring two staff members, such as Hoyer lift transfers, were performed by a single staff member due to inadequate staffing. Observations confirmed that call lights often went unanswered for extended periods, and residents expressed frustration with long wait times for assistance, sometimes exceeding an hour. Residents reported feeling unsafe, particularly during night shifts, and described incidents where they were not assisted with mobility aids, leading to fear of falls and actual accidents. Several residents stated that their personal care preferences, such as timely showers and the ability to choose their clothing, were not being met due to staff rushing through care. Staff interviews further revealed that the lack of adequate staffing led to poor quality and untimely care, with some residents not receiving regular incontinence care, turning, or repositioning as required. Staff also reported that nurses were often pulled away from medication passes to assist with resident care, causing further delays. A review of the facility's assessment tool indicated that the number of full-time and part-time nursing staff employed was insufficient to meet the needs of the current resident population, particularly those who were fully dependent on staff for activities of daily living (ADLs) such as dressing, bathing, transferring, and toileting. The Director of Nursing and Facility Administrator confirmed that, based on the facility assessment, the current staffing levels were not adequate to provide timely and quality care to residents. The deficiency was substantiated through direct observation, staff and resident interviews, and review of facility documentation.
Failure to Provide Specialized Memory Care Services and Activities
Penalty
Summary
The facility failed to provide specialized memory care services as advertised for all residents residing on the memory care unit. Record review showed that multiple residents with diagnoses such as dementia, Alzheimer's disease, depression, and other cognitive impairments were admitted to the unit. Despite facility brochures and fliers promoting a specialized memory care program, interviews with staff and observations revealed that no specific memory care program or specialized activities were implemented. The activities provided to memory care residents were the same as those offered to the rest of the facility, and there was no separate activity calendar or tailored programming for the memory care unit. Observations on the memory care unit showed a lack of engagement and stimulation for residents, with minimal activities occurring and residents often left sitting in common areas or in their rooms without interaction. Staff interviews confirmed that the activity director was unable to provide activities for the memory care unit due to other responsibilities, and activity assessments for these residents were not completed until after they were requested by surveyors. The only activities listed, such as beverage cart and sit and chat, were not consistently provided, and staff did not consider them meaningful activities. Residents were not routinely invited to participate in facility-wide activities, and the activity room was locked when the activity director was not present. Staffing on the memory care unit was consistently reported as inadequate, with only one aide assigned per shift, leading to periods when residents were left unsupervised while staff attended to individual care needs. Staff and family interviews expressed concerns about resident safety and the lack of engagement, stimulation, and supervision. Families reported not being informed about the benefits of memory care and expressed expectations for more specialized activities and higher staffing levels. The facility's own policies and job descriptions outlined requirements for individualized activity programming and assessments, which were not met for the memory care residents.
Failure to Administer Facility Resources and Maintain Adequate Dietary Staffing
Penalty
Summary
The facility failed to administer its operations in a manner that enabled effective and efficient use of resources, impacting all 35 residents. Multiple invoices and shut-off notices from utility companies and the Fire Marshal's office were overdue, with some accounts at risk of service interruption. The Business Office Manager consistently forwarded these notices to corporate accounts payable, but payments were often delayed or only partially made. Staff interviews revealed concerns about delayed supplies, financial instability, and lack of responsiveness from administration and corporate leadership. The Medical Director also experienced delayed payments, and the Fire Marshal's office confirmed outstanding bills dating back to the previous year. Administrative staff, including the Administrator, were frequently absent or inaccessible, with several staff members reporting that the Administrator was rarely present and did not engage with staff or residents. Concerns raised by staff were often ignored, and there was a general perception that administration and corporate did not prioritize the needs of the residents or the facility. The Administrator's job description outlined responsibilities for budgeting, financial oversight, and ensuring quality care, but these duties were not fulfilled as evidenced by the ongoing financial issues and lack of timely bill payments. Additionally, the facility failed to employ sufficient dietary staff as outlined in its facility assessment. The dietary department was consistently understaffed, with the Dietary Director and other staff members required to cover multiple roles and avoid overtime, leading to incomplete kitchen tasks and delays in meal and snack preparation. The facility assessment called for more dietary staff than were actually employed, and the short staffing resulted in CNAs having to leave resident care duties to retrieve snacks. Training for dietary staff was also inadequate, with planned training sessions not occurring and the Dietary Director lacking sufficient support. These deficiencies were confirmed by staff interviews and review of staffing schedules.
Inaccurate Facility Assessment Leads to Inadequate Staffing for Resident Care
Penalty
Summary
The facility failed to conduct an accurate and thorough facility-wide assessment to determine the necessary resources required to care for residents competently during both routine operations and emergencies, including nights and weekends. Review of resident data revealed that the number of residents dependent on staff for activities of daily living (ADLs) such as toileting, dressing, bathing, and transferring significantly exceeded the facility's stated capacity in its assessment. Specifically, there were 15 residents dependent on staff for toileting, 14 for dressing, 14 for bathing, and 9 for transferring, while the facility assessment only accounted for the ability to care for five residents in each of these categories. Additionally, the assessment outlined staffing requirements that were not met, including the need for four full-time RNs, four full-time LPNs, and fourteen full-time CNAs, while actual staffing levels were lower in several categories. Interviews with the Director of Nursing (DON), Facility Administrator, and Dietary Director confirmed discrepancies between the facility assessment and actual staffing levels, including insufficient numbers of direct care and dietary staff to meet the needs of the current resident population. The DON and Facility Administrator acknowledged that the facility-wide assessment was not completed accurately, resulting in inadequate staffing to provide timely and quality care for residents. This deficiency was identified during a complaint investigation and had the potential to affect all residents in the facility.
Failure to Follow Physician Orders and Provide Comprehensive Resident-Centered Care
Penalty
Summary
The facility failed to provide comprehensive, resident-centered care as evidenced by multiple deficiencies in following physician orders, documenting care, and notifying providers of significant changes in residents' conditions. For several residents, there were repeated lapses in the administration and documentation of prescribed treatments, such as wound care and nutritional supplements. For example, one resident with multiple comorbidities including diabetes and skin breakdown did not consistently receive ordered wound treatments or nutritional supplements, and there was no documentation of provider notification when these treatments were missed. Additionally, this resident received insulin outside of the prescribed sliding scale without appropriate physician orders or notification when blood glucose levels exceeded the threshold requiring provider contact. Other residents experienced similar failures in care. One resident with a history of stroke and impaired mobility had orders for weekly skin checks, but there were multiple periods where no documentation of these assessments was found. Another resident, at risk for pressure ulcers and with significant medical complexity, also did not have weekly skin checks documented as ordered. In the case of a resident with congestive heart failure, there was a significant, rapid weight gain over several days, but the physician was not notified in a timely manner as required by facility protocol and physician orders. Staff interviews confirmed a lack of awareness of the resident's diagnoses and a failure to conduct thorough record reviews, contributing to the missed notifications. Additionally, a resident on anticoagulant therapy did not have weekly skin assessments completed for an extended period, and significant bruising was observed but not documented or monitored as required by the care plan. This resident also experienced interruptions in receiving a prescribed protein supplement due to supply issues, with no evidence that the provider was notified or alternative options were considered. These deficiencies were confirmed through record reviews, staff interviews, and direct observations, affecting multiple residents and demonstrating a pattern of non-compliance with physician orders and care protocols.
Failure to Implement Fall Interventions and Secure Hazardous Chemicals
Penalty
Summary
The facility failed to implement and maintain fall prevention interventions and post-fall assessments for two residents. One resident, with diagnoses including dementia, insomnia, and a history of falls, was care planned to have a floor mat at bedside as a fall prevention measure. Observation revealed that the floor mat was not present in the resident's room, and this was confirmed by an LPN, indicating the intervention was not in place as required by the care plan. Another resident, with multiple diagnoses including cerebral infarction, diabetes, and cognitive impairment, experienced an unwitnessed fall and was transported to the hospital. Review of the medical record showed that no post-fall assessment was documented after the resident returned from the hospital, a fact confirmed by the DON several hours after the incident. Additionally, the facility failed to ensure hazardous chemicals were properly stored and inaccessible to residents on the memory care unit. Observation found that cabinets behind the nurses station were left unlocked and unattended, containing items such as nail polish, nail polish remover, medication disposal compounds, bleach, disinfectant wipes, stainless steel cleaner, and needles. An LPN confirmed that all residents on the unit wandered and had access to these chemicals while staff were occupied in a resident's room. Review of the MSDS for these chemicals indicated potential for irritation, toxicity, and other health hazards upon exposure. These deficiencies affected multiple residents, including those with cognitive impairments and histories of wandering, and were identified through observation, interviews, record reviews, and policy and MSDS reviews. The facility's failure to implement care planned interventions, complete required assessments, and secure hazardous materials resulted in non-compliance with safety and accident prevention standards.
Incomplete Discharge Documentation and Instructions
Penalty
Summary
The facility failed to provide comprehensive discharge instructions and did not ensure that documentation of a resident's discharge was present in the medical record. Specifically, a resident with multiple diagnoses, including cerebral infarction, type 2 diabetes mellitus, cognitive communication deficit, chronic kidney disease, hypertension, hyperlipidemia, heart failure, gastro-esophageal reflux disease, hyperkalemia, and insomnia, was discharged to their home. Review of the multidisciplinary discharge summary showed that discharge instructions were incomplete, with no evidence of education regarding diet or activities provided to the resident or their representative. Additionally, there was no documentation of a discharge note for the resident's discharge on the specified date. The Director of Nursing confirmed the incomplete documentation during an interview.
Failure to Complete Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to ensure that baseline care plans were completed within 48 hours of admission for two residents. For one resident admitted with chronic obstructive pulmonary disease, congestive heart failure, and metabolic encephalopathy, only the dietary care plan was initiated within the required timeframe, while the remainder of the care plan was not completed until several days later. The care conference for this resident occurred after admission, but there was no evidence of a baseline care plan being established within 48 hours as required. Another resident admitted with multiple diagnoses, including cerebral infarction, type 2 diabetes mellitus, chronic kidney disease, and heart failure, also did not have a complete baseline care plan within 48 hours. Only a nutrition/hydration risk care plan was initiated, with no other care plans documented. Additionally, the care conference summary for this resident lacked signatures from the resident, family, or representative, indicating incomplete involvement. Interviews with facility leadership confirmed that the care plans for both residents were not completed fully or in a timely manner, contrary to facility policy.
Failure to Provide Scheduled Showers According to Resident Preferences
Penalty
Summary
The facility failed to provide showers to residents according to their preferences and established shower schedules. Two residents with significant cognitive and physical impairments, including diagnoses such as Alzheimer's disease, dementia, and mobility issues, were identified as being dependent on staff for bathing. Documentation showed that both residents missed multiple scheduled showers over several months, despite care plans indicating their need for staff assistance and the use of mechanical lifts or supervision for bathing. The facility's own bathing policy stated that residents could choose the frequency and timing of their baths or showers. Interviews with staff and the Director of Nursing confirmed that the missed showers were not documented as being provided at alternative times, and in one case, staff reported that a resident's behavioral challenges led to skipped showers and changes. The lack of adherence to the shower schedule and resident preferences was verified through review of shower sheets and staff interviews, demonstrating a failure to meet the residents' needs for assistance with activities of daily living as outlined in their care plans and facility policy.
Oxygen Therapy Administered Without Physician Order
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease, congestive heart failure, and metabolic encephalopathy was admitted to the facility by ambulance with oxygen in place at 2 liters per minute. Nursing documentation and observation confirmed the resident continued to receive oxygen therapy via nasal cannula and oxygen concentrator. However, review of the resident's medical record revealed there was no physician order for oxygen therapy at any point during the resident's stay. Both the Administrator and Director of Nursing confirmed that an order should have been in place for the administration of oxygen, and facility policy requires a physician order for oxygen except in emergencies.
Failure to Provide Timely and Appropriate Pain Management
Penalty
Summary
A resident with multiple serious diagnoses, including lung and brain cancer, chronic pain, and heart failure, was admitted to the facility and had physician orders for Tramadol and acetaminophen to manage pain. Despite these orders, there was a delay in obtaining the Tramadol, with the medication not being delivered to the facility until seven days after it was ordered. During this period, the resident consistently reported moderate to severe pain, with pain ratings ranging from four to six out of ten on several occasions. There was no documentation that alternative pain relief medications or methods were provided to the resident while experiencing pain during the delay in receiving the prescribed Tramadol. The resident reported being told by nursing staff that the facility was out of her pain medication and that efforts were being made to obtain it. The Director of Nursing confirmed the delay in medication delivery and the lack of documentation for alternative pain management interventions. Facility policy requires pain management to be based on professional standards, the care plan, and resident choices, but these standards were not met in this instance.
Failure to Provide Medically-Related Social Services for Psychosocial Well-Being
Penalty
Summary
The facility failed to provide medically-related social services to support a resident's psychosocial well-being, specifically for a resident with a history of major depression, anxiety disorder, and alcohol dependence in remission. The resident was identified as being at risk for psychosocial issues due to social isolation, depression, and physical limitations, and his care plan included interventions such as access to psychiatric services and opportunities for social engagement. Despite these identified needs, the resident was unable to attend Alcoholics Anonymous (AA) meetings, which he considered his primary source of social interaction and support, after the facility's transportation van broke down. Interviews revealed that the resident missed multiple AA meetings due to the lack of transportation, and no alternative arrangements were made to support his psychosocial needs during this period. The resident reported not being aware of the facility's social worker and stated that no one had offered him additional support while he was unable to attend AA. The social worker acknowledged not following up with the resident or providing in-house services to address his needs during the transportation disruption. Other staff members confirmed the importance of AA meetings to the resident's well-being and noted a decline in his mood when he was unable to attend. The facility's social services job description outlined responsibilities for addressing residents' emotional adjustment and ensuring appropriate psychosocial interventions, but these were not fulfilled in this case. The lack of timely and appropriate social services intervention resulted in the resident not receiving the support necessary to maintain his highest possible quality of life, as required by facility policy and regulatory standards.
Failure to Provide Timely Pharmaceutical Services and Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of two residents by not ensuring timely receipt and administration of prescribed medications. One resident, with multiple diagnoses including hemiplegia, GERD, anxiety, depression, COPD, and others, had a physician's order for Debrox Otic Solution for ear wax removal. Documentation showed that over a four-day period, the medication was not available and was not administered as ordered. Progress notes repeatedly indicated the facility was awaiting the medication from the pharmacy, and there was no evidence that the physician was notified about the unavailability or missed doses. Interviews with nursing staff and the DON confirmed the medication was not received or administered, and the physician was not informed. Another resident, with diagnoses including lung cancer, COPD, diabetes, brain cancer, chronic pain, and heart failure, had an order for Tramadol for pain management. The medication was ordered from the pharmacy several days after the physician's order and was not delivered for seven days. The resident reported being in pain and not receiving the medication, and staff interviews confirmed ongoing issues with timely receipt of both prescription and OTC medications from the pharmacy. Facility staff described frequent delays and the need to purchase OTC medications from outside sources due to inconsistent pharmacy deliveries. The facility's policy required medications to be administered according to orders and within required time frames, which was not followed in these cases.
Failure to Provide Palatable and Appetizing Food to Residents
Penalty
Summary
Surveyors found that the facility failed to provide palatable, appetizing, and safe food to residents, specifically affecting two individuals reviewed for food quality. One resident with severe cognitive impairment, multiple chronic conditions, and a mechanically altered, pureed diet was observed receiving pureed meals that were stringy, lumpy, watery, and lacked flavor. The dietary staff confirmed during preparation that the pureed sugar snap peas, breaded fish, and roasted potatoes were not palatable, with issues in both texture and taste. The resident had a documented history of significant weight loss and was at risk for malnutrition, with care plans and orders specifying the need for appropriate diet preparation. Another resident, with diagnoses including dementia and mild protein-calorie malnutrition, was observed eating a lunch meal that was reported to have no flavor. The resident expressed dissatisfaction, stating the meal tasted as if they "might as well eat dirt." Both observations and interviews confirmed that the food provided was not palatable or appetizing, directly contravening the requirement to ensure residents receive nutritive, palatable food and drink.
Failure to Provide Food in Appropriate Texture for Residents
Penalty
Summary
The facility failed to provide food prepared in a form designed to meet the individual needs of two residents. One resident, with diagnoses including type 2 diabetes, hypertension, GERD, and cognitive impairment, was ordered a low concentrated sweets diet with mechanical soft texture. Despite no documentation of refusal of the modified diet, this resident was observed being served a whole hot dog, which did not meet the mechanical soft texture requirement. The error was only corrected after staff intervention at the time of service. Another resident, with severe cognitive impairment and multiple chronic conditions, was ordered a pureed texture diet. During meal preparation, staff were observed pureeing food items for this resident, but the resulting pureed foods did not achieve a smooth consistency as required. The pureed peas were stringy and lacked flavor, the breaded fish was watery and lumpy, and the potatoes were lumpy and flavorless. These issues were confirmed by dietary staff and the dietary director, and were not in accordance with the facility's policy for texture and consistency modified diets.
Failure to Accurately Document and Perform Suprapubic Catheter Changes
Penalty
Summary
The facility failed to ensure the accuracy of resident records and documentation for a resident with an indwelling suprapubic catheter. The resident, who had multiple diagnoses including neuromuscular bladder dysfunction and was dependent on staff for activities of daily living, had physician orders for monthly suprapubic catheter changes. Documentation in the treatment administration records indicated that the catheter was changed as ordered each month by various LPNs. However, interviews with the LPNs revealed that none of them had actually performed the catheter change, and some believed the documentation referred only to changing the catheter bag, not the catheter itself. One LPN stated they had no training on how to perform the procedure and were unaware of any such order. Further review showed that the resident's physician was not notified that the catheter changes were not being performed as ordered. The Director of Nursing confirmed that the catheter exchange was documented as completed when it had not been done. The deficiency was identified through record review, staff interviews, and communication with the resident's power of attorney, who also confirmed through messages with staff that the catheter had not been changed as required.
Catheter Bag Found on Floor—Infection Control Lapse
Penalty
Summary
The facility failed to maintain proper infection control practices when a resident's catheter bag was repeatedly observed lying on the floor. The resident involved had a history of quadriplegia, pure hypercholesterolemia, and neuromuscular dysfunction of the bladder, and was admitted with an indwelling catheter in place per physician order. Despite a care plan indicating severely impaired cognition and frequent bladder incontinence, observations on multiple occasions showed the catheter bag on the floor while the resident was resting in bed. This was confirmed by an LPN during an interview, indicating a lapse in infection prevention and control protocols for catheter care.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
During a wound care procedure for a resident with quadriplegia, diabetes mellitus, neurogenic bladder, and peripheral vascular disease, staff failed to follow appropriate infection control practices. The resident had an unstageable right hip pressure ulcer and an indwelling urinary catheter, with physician orders for daily wound treatments and enhanced barrier precautions (EBP), which require the use of gown and gloves during high-contact care. Observation revealed that both the LPN and the Assistant Director of Nursing entered the resident's room without donning gowns, despite EBP signage and supplies being available. The LPN performed the wound care using improper technique, including using the same gauze to clean multiple areas of the wound, handling bandage scissors without cleaning them between uses, and placing potentially contaminated scissors back with clean supplies. Additionally, when a dressing fell onto the bed, it was discarded, but the scissors were again used without cleaning before cutting a new dressing. Interviews with both the LPN and the ADON confirmed that the wound care was not completed as ordered and that EBP protocols were not followed. Policy reviews indicated that the facility's procedures required the use of gloves and gowns for such care, as well as proper hand hygiene and equipment cleaning. The failure to implement these infection control measures was observed directly and verified by staff, constituting a deficiency in the facility's infection prevention and control program.
Medication and Treatment Carts Left Unlocked and Unattended on Memory Care Unit
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards when medication and treatment carts were left unlocked and unattended on the locked memory care unit. During an observation, both carts were found unsupervised and unlocked at the nurses' station, with no staff present in the immediate area. The only staff member on the unit at the time, a CNA, was serving breakfast trays in the dining room, while the LPN was downstairs administering medications. This left the medication and treatment carts accessible and out of view of any staff. Medical record reviews confirmed that seven residents on the memory care unit were severely impaired in daily decision-making, ambulatory, and capable of independently moving throughout the unit. Interviews with staff verified that these residents wandered the unit and could open the drawers of the carts. Facility policy required that medication carts be locked when out of sight or unattended, a standard not met during the observed incident.
Incomplete MDS Assessment Components for Resident
Penalty
Summary
The facility failed to complete all required components of comprehensive assessments for one resident. Medical record review showed that a resident with multiple diagnoses, including quadriplegia, chronic pain, diabetes mellitus, neurogenic bladder, major depressive disorder, and peripheral vascular disease, was admitted to the facility. The annual Minimum Data Set (MDS) 3.0 assessment for this resident did not include the required Cognitive Pattern: Brief Interview for Mental Status and Pain Assessment interview. Additionally, the quarterly MDS assessment for the same resident was missing the required Pain Assessment interview. These omissions were confirmed during an interview with the Assistant Director of Nursing.
Failure to Develop Comprehensive Care and Discharge Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, as required. For one resident admitted with hypertension, a pancreatic disorder, and a colostomy, the medical record showed that although the resident was cognitively intact and had a goal to return to the community, there was no active discharge plan, no referrals, and the local contact agency was unknown. The resident was routinely assessed for pain and received Tylenol for mild to moderate pain, but there was no evidence of a comprehensive pain care plan or a discharge care plan documented in the record. Similarly, another resident admitted with cirrhosis of the liver, diabetes mellitus, diverticulitis, and a colostomy was also cognitively intact and had a goal to return to the community. However, there was no active discharge plan, no referrals, and the local contact agency was unknown. The medical record did not contain evidence that a discharge plan of care had been developed for this resident. These findings were confirmed by interview with the Assistant Director of Nursing.
Failure to Provide Proper Pressure Ulcer Care and Infection Control
Penalty
Summary
A resident with multiple complex medical conditions, including quadriplegia, diabetes mellitus, and peripheral vascular disease, was admitted without skin impairments and later assessed as being at moderate risk for skin breakdown. Despite this, the resident developed three new facility-acquired pressure ulcers, including an unstageable pressure ulcer on the right hip. The prescribed treatment for this ulcer was to use a silver alginate dressing, which provides both autolytic debridement and antimicrobial action, but the resident was instead treated with calcium alginate, which lacks antimicrobial properties, for nearly two weeks. This discrepancy was not identified until a survey was conducted. During direct observation of a dressing change, an LPN and the ADON failed to follow proper infection control protocols, including not donning required personal protective equipment and not adhering to enhanced barrier precautions. The LPN also used unclean bandage scissors to cut dressings, reused contaminated instruments, and did not follow the wound care policy for dressing removal and hand hygiene. The ADON confirmed that the treatment was not completed as ordered and that infection control practices were not properly implemented. Facility policies required consistent treatment protocols and individualized care, which were not followed in this instance.
Failure to Provide Ordered Colostomy Care
Penalty
Summary
The facility failed to provide colostomy care as ordered for two residents who required such services. One resident, admitted with diagnoses including hypertension, pancreatic disorder, and a colostomy, had physician orders for colostomy care to be provided once per shift. Review of the Treatment Administration Records (TAR) showed that colostomy care was documented as completed on only 18 of 35 opportunities in February, 53 of 62 in March, and 24 of 30 in April. The resident's care plan also specified that the ostomy appliance should be changed as ordered. Another resident, admitted with diagnoses including cirrhosis of the liver, diabetes mellitus, diverticulitis, and a colostomy, had orders for ostomy care every shift. The TAR for April indicated that ostomy care was provided on 28 of 30 opportunities. Both residents were assessed as cognitively intact for daily decision-making. During an interview, the Assistant Director of Nursing confirmed that ostomy care was not completed as ordered for these residents.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by seven errors out of 26 observed medication administration opportunities, resulting in an error rate of 26.9%. For one resident with chronic atrial fibrillation, cerebrovascular disease, hypertension, congestive heart failure, and diabetes mellitus, a registered nurse administered prescribed morning medications outside the required timeframe. The nurse acknowledged administering the medications late, citing unfamiliarity with the hallway and being behind schedule. For another resident with dementia, diabetes mellitus, hypertension, anxiety disorder, and major depressive disorder, an LPN prepared and initially administered incorrect dosages of buspar and Effexor, and provided enteric coated aspirin instead of the ordered chewable form. The LPN confirmed the errors after being questioned and corrected the dosages, and later obtained the correct form of aspirin from the supply cabinet. Facility policy required medications to be administered as ordered and within a specific timeframe, which was not followed in these instances.
Inadequate Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program for two residents, leading to the development of pressure ulcers. Resident #13, who was admitted with diagnoses including hyperlipidemia, hypertension, and altered mental status, was identified as being at moderate risk for developing pressure ulcers. Despite this, the resident's care plan did not adequately address the risk, and the resident developed a Stage II pressure ulcer on the coccyx. The facility's records showed insufficient documentation of incontinence care, which was not provided every two hours as required, contributing to the skin breakdown. Similarly, Resident #22, admitted with rheumatoid arthritis, muscle weakness, and altered mental status, was also at risk for skin integrity issues due to impaired mobility and incontinence. The resident's care plan included interventions for turning and repositioning, but these were not consistently implemented. The resident developed a Stage II pressure ulcer on the right buttock, and there was a lack of documentation regarding the care provided and the condition of the ulcer. The facility's failure to provide adequate incontinence care and pressure-relieving devices, as ordered, contributed to the development of the pressure ulcer. Interviews with staff revealed concerns about inadequate staffing levels, which impacted the ability to provide necessary care, including regular incontinence checks and repositioning. Observations confirmed that the required pressure-relieving mattresses were not in place for both residents, further indicating a lack of adherence to physician orders and facility policies. The facility's policies on incontinence management and pressure injury risk assessment were not effectively implemented, leading to the deficiencies noted in the report.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored and served in a sanitary manner, potentially affecting all 33 residents who receive food from the facility. During an initial tour of the kitchen, expired and undated food items were found in both the walk-in and standing refrigerators, as well as in the dry storage area. Specifically, expired cream, Dijon mustard, and chili powder were noted, along with undated leftovers, coleslaw, fruit, salad, and dessert. Additionally, the dishwasher was unable to reach the required rinse temperature of 180 degrees, which was confirmed by the Dietary Supervisor, who noted this was the first occurrence of such an issue. Further observations revealed improper hand hygiene practices by a staff member during food preparation. The staff member was observed changing gloves multiple times without washing hands in between, which was confirmed during an interview. The facility's policies on food safety and hand washing, dated 2021, were reviewed and indicated that food should be stored to prevent contamination and that hands should be washed to prevent cross-contamination during food preparation. These policies were not adhered to, leading to the identified deficiencies.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment for its residents, as evidenced by several observations and interviews. The floors, walls, air vents, and rooms were not properly maintained, leading to unsanitary conditions. Specific issues included discolored and dirty tile and grout around toilets, rusty air vents, torn walls, and sticky floors. Additionally, Resident #32's room was found to be particularly unkempt, with soiled bedding, cluttered window sills, and multiple meal trays left in the room. Flies were observed in the room, and staff confirmed the presence of flies and the sticky condition of the floors. Interviews with staff revealed that the facility had not had a maintenance person for over a month, and maintenance issues were not being promptly addressed. The staff also noted that the floors had been sticky for years, possibly due to excessive soap use, and that they had reported this issue previously. The facility had a quarterly contract with an exterminator, but there was no indication of treatment for flies. The lack of timely maintenance and cleaning contributed to the unsanitary conditions observed in the facility, affecting the residents' right to a safe and comfortable environment.
Inconsistent Documentation of Advanced Directives
Penalty
Summary
The facility failed to ensure that Resident #186 had an order in place for advanced directives upon admission. Resident #186, who was admitted with multiple diagnoses including a displaced bimalleolar fracture, muscle weakness, and severe intellectual disabilities, did not have a documented code status in either the physical or electronic medical records. This oversight was confirmed by the Director of Nursing (DON) during an interview, who acknowledged that an order for code status should have been established upon the resident's admission. The facility's policy on advanced directives, dated December 2016, mandates that residents be provided with information about their rights to accept or refuse medical interventions and to formulate advanced directives, which should be prominently displayed in their medical records. Additionally, the facility failed to maintain consistent documentation of Resident #7's advanced directives across different record formats. Resident #7, admitted with severe sepsis, major depressive disorder, and congestive heart failure, had conflicting code status orders in their electronic and paper medical records. The electronic health record indicated a Full Code status, while the paper chart listed a Do Not Resuscitate Comfort Care (DNR-CC) status. The DON confirmed the discrepancy and emphasized that the records should match to avoid confusion regarding the resident's care in emergencies. The facility's policy requires that information about advanced directives be clearly displayed in the medical record.
Inaccurate PASRR Documentation for Resident with Psychiatric Diagnoses
Penalty
Summary
The facility failed to ensure the accuracy of the Preadmission Screening and Resident Review (PASRR) for a resident diagnosed with major depressive disorder and unspecified psychosis. The medical record review, staff interview, and facility policy review revealed that the PASRR documentation for the resident, dated 05/24/19, did not indicate these psychiatric diagnoses in section D, which is meant for serious mental disorders. The resident's care plan included plans for depression and psychosis, and the Minimum Data Set (MDS) indicated active diagnoses of depression and psychotic disorder, along with the administration of antidepressant medication. The Director of Nursing confirmed that the PASRR documentation did not reflect the resident's psychiatric diagnoses and that a resident review had not been completed in light of these diagnoses. The facility's policy, updated in January 2023, stated that if a resident was admitted with a negative level I PASRR result and later showed evidence of a serious mental illness, a resident review should be conducted. This policy was not followed, leading to the deficiency noted in the report.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to ensure comprehensive care plans were developed for residents to address their specific diagnoses, medications, and activities of daily living (ADLs). This deficiency affected three residents. Resident #5, who was admitted with diagnoses including dementia, major depressive disorder, hallucinations, insomnia, and diabetes mellitus, did not have a comprehensive care plan addressing these conditions or the use of psychotropic medications and insulin. The facility's Registered Nurse confirmed the care plans were incomplete and noted that the care planning process was being managed by an off-site MDS nurse and the facility's nurse managers. Resident #4, admitted with cerebral infarction, atherosclerotic heart disease, hypertension, and hyperlipidemia, lacked care plans for anticoagulation medications and the associated risk of bruising and bleeding. The Director of Nursing verified the absence of these care plans. Additionally, Resident #33, with diagnoses including dementia, hypothyroidism, anxiety disorder, and insomnia, did not have a care plan for ADLs despite requiring various levels of assistance. The Director of Nursing confirmed the lack of an ADL care plan. The facility's policy required individualized comprehensive care plans to be developed within seven days of the MDS assessment, but this was not adhered to.
Failure to Assist Resident with Personal Hygiene
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living for Resident #32, who was dependent on staff for bathing, shaving, and oral care. The resident, who had multiple diagnoses including dementia, Alzheimer's disease, and muscle weakness, required substantial to maximum assistance for personal hygiene tasks. Despite a care plan indicating the need for total assistance with bathing, the resident did not consistently receive showers or bed baths as scheduled, with gaps of up to ten days between showers. Observations and interviews revealed that Resident #32 was often left unshaven and without proper oral care supplies. The resident was found in a state of undress and with wet clothing, indicating a lack of assistance with toileting. Staff interviews confirmed that the resident's personal hygiene supplies were stored out of reach, and there was no consistent follow-up after the resident refused showers. The facility's Director of Nursing acknowledged the lack of a clear policy on handling shower refusals and confirmed the lapses in providing scheduled showers. The facility's bathing policy allowed residents to choose the frequency and timing of their baths, but it did not specify procedures for handling refusals or ensuring consistent care. This lack of guidance contributed to the failure to provide necessary assistance to Resident #32, resulting in inadequate personal hygiene care over an extended period.
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 95 citations issued within 25 miles in the last 12 months — including the 1 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 Woodsfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arbors At Woodsfield | 1.7 mi | ★★★★★ | 0 | 0 |
| The Enclave At Barnesville | 14.7 mi | ★★★★★ | 0 | 0 |
| Emerald Pointe Health And Rehab Ctr | 14.9 mi | ★★★★★ | 1 | 0 |
| Sistersville Center | 15.8 mi | ★★★★★ | 0 | 0 |
| New Martinsville Health & Rehab | 16 mi | ★★★★★ | 13 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.