Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Oaks Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Failure to Document Respiratory Assessments Before and After Nebulizer Treatment: A resident with CHF, pulmonary edema, and other cardiac diagnoses received a PRN ipratropium-albuterol nebulizer treatment for SOB, but the record had no documented respiratory assessment before or after the treatment, including lung sounds, RR, effort, skin color, or oxygen use. Later, the resident remained SOB, the treatment was not effective, the family requested ER transfer, and the resident was sent out after the provider was notified.
A resident with a history of myocardial infarction, pulmonary fibrosis, and type 2 DM had a standing order for Meclizine 12.5 mg PO TID for vertigo, but multiple scheduled doses were not administered over several days. MAR review showed repeated omissions, with nursing notes stating the drug was not on hand or not available. Interviews revealed that Meclizine had transitioned from an outside pharmacy supply to an in-house stock medication, and although it was in stock, nursing staff looked for a medication card instead of the in-house bottle. The DON reported that a particular nurse, previously known for not adequately searching for medications and instead marking them as out of stock, was passing meds on several of the days when the doses were missed, contrary to facility policy requiring administration per physician orders.
A resident with hearing loss and cognitive impairment was not provided with timely family notification when their hearing aids went missing. Despite staff awareness and documentation lapses regarding the storage of the hearing aids, the family only learned of the issue after they raised the concern themselves. This deficiency was confirmed through record review and staff interviews.
A resident with a swallowing impairment and a physician order prohibiting straw use was provided with a cup containing a straw on two occasions. Although staff and family were aware of the restriction, a Business Office Manager unfamiliar with the resident's care plan placed the cup in the room, resulting in non-compliance with the prescribed diet order.
Failure to implement nutritional orders and dietician recommendations. A resident with dementia, DM2, CKD stage 3, anxiety, and depression had significant weight loss with repeated dietician concerns. MedPass supplements were not consistently provided despite physician orders, one supplement recommendation was not addressed, and an ordered SLP eval was not completed. The resident’s weight declined substantially over the review period, and the DON/ADON verified the missed SLP eval and the lapse in MedPass administration.
Failure to document non-pharmacologic pain interventions before PRN pain meds for three residents. One resident received scheduled oxycodone, another received PRN Norco and Tylenol, and a third received PRN morphine and a lidocaine patch order, but the MARs showed no evidence that interventions such as repositioning, relaxation, breathing exercises, distraction, or music therapy were attempted first. Care plans for the residents included offering these measures, and an LPN and the ADHS confirmed there were no non-pharmacologic interventions documented prior to pain med administration.
Infection Control Not Maintained During Dressing Change: A resident with a sacral wound had a dressing change observed by surveyors, during which an LPN removed gloves and performed hand hygiene while the resident’s pants remained touching the wound after cleansing. The LPN then redonned gloves, pulled the pants down again, and applied Triad paste and a dressing. The ADON and LPN confirmed the pants re-contaminated the wound after cleansing.
A facility failed to provide enough nursing staff, leading to multiple residents not receiving their medications on time, with some doses delayed by several hours or missed entirely. Night shifts were especially understaffed, with only one nurse covering a large number of residents, resulting in delayed call light responses, incomplete treatments, and poor hygiene care. Staff and family members reported residents being left in soiled conditions, not receiving required assistance, and a general decline in care quality due to heavy reliance on agency staff and open nursing positions.
The facility did not submit required direct care staffing data to CMS for a reporting period, as confirmed by review of PBJ Staffing Data and interviews with the CEO. The CEO indicated that a change of ownership and reliance on a contracted company contributed to the lack of submission, with no documentation available to verify that the data was sent. This affected all residents in the facility.
Medication carts were found unlocked and unattended, and medications were improperly stored and labeled, including pre-filled cups with only first names and room numbers and loose, unlabeled tablets in drawers. Staff confirmed these practices, which did not comply with facility policy requiring secure, properly labeled storage of all drugs and biologicals.
Two residents with dementia were involved in a physical altercation, resulting in one resident being pushed to the floor and complaining of arm pain. Staff failed to immediately report the abuse allegation to the administrator and state agency, and there was no prompt assessment by a nurse or timely notification of the resident's family or physician. Documentation of required monitoring was missing or delayed, leading to a deficiency in abuse reporting and investigation procedures.
A resident with severe cognitive impairment and significant physical limitations did not receive adequate oral hygiene assistance as required by their care plan. Despite documentation of daily oral care, dental assessments revealed heavy plaque, multiple decayed teeth, and gingivitis, with both family and staff reporting concerns about the frequency and quality of oral hygiene provided.
Staff failed to promptly assess and monitor a resident after a fall caused by another resident, with no immediate licensed nurse assessment, 15-minute checks, or vital signs documented, and the incident was not properly investigated until days later. In a separate case, another resident with heart failure and cirrhosis did not have daily weights consistently documented, and required provider notifications for significant weight gains were not made, despite physician orders. These lapses were confirmed through record review and interviews, highlighting failures in timely assessment, monitoring, and communication.
A resident with diabetes and other comorbidities did not receive a comprehensive assessment or timely treatment for a left great toe wound. Wound care orders were delayed, several days of treatment were missed, and updated wound care instructions were not promptly implemented, resulting in both old and new treatments being administered simultaneously. Documentation of wound assessments was incomplete, and the resident reported inconsistent care due to insufficient staffing.
A resident with fragile skin and multiple comorbidities experienced repeated skin tears when her legs struck unpadded wheelchair leg rests during transfers. Despite a care plan intervention to pad the leg rests, staff did not implement this measure, and both the resident and her family reported ongoing injuries. Staff and direct observation confirmed the absence of padding, and the DON acknowledged the intervention was not put in place, resulting in multiple injuries.
A resident with a history of recurrent UTIs and multiple comorbidities experienced a significant delay in receiving treatment for a symptomatic UTI. The delay was caused by issues with urine sample collection and lab processing, as well as slow communication with the infectious disease office, resulting in the resident not receiving antibiotics for over a week after symptoms began.
The facility experienced a medication error rate of 17.8% due to multiple incidents where two residents did not receive all prescribed medications as ordered. Errors included crushing an extended-release medication that should not be altered, omitting doses, and failing to provide medications due to unavailability. Staff also documented administration of medications that were not actually given, and did not follow facility policy for safe and timely medication administration.
Two residents experienced significant medication errors when prescribed medications were not administered as ordered. One resident missed multiple doses of Metoprolol for hypertension, with some doses signed as given despite the medication being unavailable, and pharmacy records showed unaccounted tablets. Another resident missed several doses of IV Ertapenem for a UTI, as confirmed by the MAR and infection tracking log. Staff interviews and record reviews highlighted failures in medication administration and documentation.
A resident with multiple medical conditions and feeding difficulties did not receive the ordered adaptive eating equipment, including a Kennedy cup and built-up utensils, during a meal. Despite physician orders and care plan interventions specifying these devices, the resident's tray was missing them, and this was confirmed by both the resident and an LPN. Facility policy requires provision of such adaptive devices for those who need them, but this was not followed.
A resident with multiple chronic conditions did not receive their prescribed Metoprolol due to pharmacy ordering issues and lack of availability, yet an LPN inaccurately documented on the MAR that the medication was administered on several occasions, with no indication in the progress notes that the medication was unavailable or not given.
Two CNAs did not use required PPE while transferring a resident on enhanced barrier precautions due to a cholecystostomy tube, despite clear signage and available equipment. Additionally, an LPN failed to perform hand hygiene and handled medications directly with her hands during administration to another resident, contrary to facility policy and infection control standards.
A facility failed to prevent falls and elopement in residents, leading to injuries and safety risks. A cognitively impaired resident fell and fractured her hip due to inadequate assistance and care planning. Another resident with exit-seeking behavior left a secured unit, as interventions were insufficient. A third resident experienced multiple falls without proper investigation or neurological checks. The facility's policies were not followed, resulting in harm and potential risks.
The facility failed to provide comprehensive care plans for several residents, including those with severe cognitive impairments and specific needs such as ADL assistance, wandering behaviors, and contractures. A resident with multiple diagnoses lacked a care plan for ADL needs, while another resident with Alzheimer's disease had no interventions for wandering. Additionally, a resident with major depressive disorder and dementia had no care plans for these conditions, and a resident with a hand contracture lacked a specific care plan for the condition.
A resident with severe cognitive impairment and dementia exhibited inappropriate behaviors, including wandering, aggression, and inappropriate sexual conduct. The facility failed to update the care plan with specific interventions, did not consistently notify the family or physician, and did not administer prescribed Lorazepam. Documentation lacked detail on interventions and tracking of behavior patterns, contributing to a deficiency in care.
The facility failed to provide appropriately textured pureed food for residents on a pureed diet. A Dining Services Assistant prepared pureed swiss steak, which was found to be gritty and required chewing, contrary to the facility's guidelines for smooth, pudding-like consistency. The Director of Food Services confirmed the inappropriate texture, highlighting a deficiency in food preparation for residents requiring a pureed diet.
The facility failed to follow proper hand hygiene and glove use during meal service and did not ensure food temperatures were checked before serving meals to residents in the Memory Care Unit. A DSA was observed using the same gloves throughout the meal service without changing them or performing hand hygiene, despite touching clothing and handling food items. The facility's policies on hand hygiene and glove use were not adhered to.
The facility failed to implement enhanced barrier precautions for four residents and did not follow contact isolation procedures for a resident with Cdiff. Observations revealed a lack of PPE and disposal measures, confirmed by staff and residents, indicating non-compliance with infection control protocols.
The facility did not report a potential abuse incident between two residents to the state agency. One resident with intact cognition slapped another resident with severe cognitive impairment after an attempted bite on a staff member. The incident was not documented or investigated further, contrary to the facility's policy requiring immediate reporting of suspected abuse.
A resident admitted with joint replacement surgery and other conditions did not have an initial care conference until 26 days after admission, despite being cognitively intact. The delay occurred because the conference was only scheduled after the resident's family requested it, contrary to the facility's protocol of holding such conferences within five days of admission.
A facility failed to provide a discharge summary for a resident transferred to an assisted living facility. The resident, with conditions such as hemiplegia and kidney disease, had an order for a hospital bed with side rails, which was not documented in the discharge planning form. The form also noted dialysis appointments but lacked caregiver information. The Executive Director confirmed the absence of a discharge summary.
A facility failed to adhere to a resident's bathing schedule and preferences. The resident, who required substantial assistance and was cognitively intact, was scheduled for evening baths twice a week but received fewer baths than scheduled over a six-week period. The resident expressed uncertainty about their bathing schedule, and the DON confirmed the discrepancy in documentation.
A resident admitted with a surgical wound required a wound vac, but the facility failed to ensure the supplies were received on time. Despite confirmation of the order, the delivery was delayed, leading to the use of wet to dry dressings instead. The resident and family expressed concerns, and the facility confirmed the delay and interim measures taken.
A resident with multiple medical conditions developed a pressure ulcer on her right heel and ankle, which was not timely identified or treated by the facility. Despite initial observations, there were delays in notifying healthcare providers, inconsistent documentation, and treatment changes. The facility failed to recognize a separate wound area and delayed necessary appointments and tests, leading to a decline in the resident's condition.
A resident with a Foley catheter did not have appropriate orders in place for catheter care, despite having a comprehensive care plan. The resident had multiple diagnoses and severely impaired cognition. Facility staff confirmed the absence of necessary orders, which should have been documented to guide care.
A resident with Parkinson's disease and other conditions experienced delays in the facility's response to pharmacy recommendations regarding medication use. Recommendations to reconsider certain medications were not reviewed or documented by the nurse practitioner until months later, as confirmed by the Administrator and DHS. The facility's procedures lacked a specified timeframe for addressing such recommendations.
A facility failed to justify the use of psychotropic medication for a resident with Parkinson's disease and psychosis. Despite the absence of documented behaviors such as delusions or hallucinations, an antipsychotic was prescribed based on staff reports. The facility could not provide supporting documentation for the diagnosis of psychosis prior to the medication prescription.
The facility failed to maintain accurate medical records for two residents, leading to deficiencies in care. One resident had inconsistencies in wound documentation and treatment orders, while another resident's medical record lacked documentation of a resident-to-resident altercation. These issues highlight a lapse in adherence to the facility's policy of maintaining complete and accurate records.
Failure to Document Respiratory Assessments Before and After Nebulizer Treatment
Penalty
Summary
The facility failed to complete respiratory assessments before and after administering a PRN nebulizer treatment for Resident #73. The resident had diagnoses including hypertensive heart disease with heart failure, non ST elevation myocardial infarction, acute pulmonary edema, chronic diastolic congestive heart failure, atrial fibrillation, peripheral vascular disease, depression, and generalized anxiety disorder. The resident’s MDS indicated cognitive intactness and required partial to substantial assistance with mobility and toileting. A physician order dated 04/10/26 was in place for ipratropium-albuterol solution via nebulizer every four hours as needed for shortness of breath or wheezing. On 04/11/26, the resident received the nebulizer treatment at 12:43 P.M. for shortness of breath, but the record contained no documented respiratory assessment before or after the treatment, including lung sounds, respiratory rate, rhythm, depth, effort, skin color, or oxygen use. Later that day, the resident complained of shortness of breath and the treatment was not effective; vital signs showed respirations of 24 and pulse oximetry of 94%. The resident’s family requested transfer to the emergency room, the provider ordered a STAT chest x-ray, and the resident was sent out. The Administrator confirmed the expectation for a respiratory assessment prior to a breathing treatment and verified that no such assessment was documented for this resident.
Failure to Administer Prescribed Meclizine Due to Medication Availability Errors
Penalty
Summary
The deficiency involves the facility’s failure to administer a prescribed medication as ordered for one cognitively intact resident. The resident, admitted with diagnoses including myocardial infarction, pulmonary fibrosis, and type 2 diabetes, had a physician’s order for Meclizine 12.5 mg by mouth three times daily for vertigo starting in late November. Review of the January medication administration record showed multiple missed doses on specific mornings, late mornings, and one evening throughout the month. Progress notes corresponding to these missed doses documented that the medication was not on hand or not available at the time of administration. Interviews revealed that the resident’s Meclizine supply changed from an outside pharmacy to an in-house stock medication in mid-January, and nurses were expected to notify the DON if a medication was unavailable. The Regional Nurse confirmed the resident did not receive the prescribed Meclizine on the identified dates and attributed this to nurses looking for a medication card instead of the in-house bottle. The DON stated that Meclizine was in stock in the medication rooms during January and confirmed the missed doses. The DON also identified a specific nurse with a history of not adequately searching for medications and instead marking them as out of stock, and confirmed that this nurse was responsible for the medication passes on several of the dates when Meclizine was not administered. Facility policy required medications to be administered in accordance with physician orders.
Failure to Notify Family of Missing Hearing Aids
Penalty
Summary
The facility failed to notify the family of a resident with hearing loss and impaired cognition when the resident's bilateral hearing aids went missing. The resident had a history of hearing loss, degenerative disease of the nervous system, seizures, and required assistance with personal care. Physician orders required that the hearing aids be checked every shift and stored in a medication cart each night. Documentation showed that the order to store the hearing aids was not completed from mid-October through November, and there were no progress notes referencing the missing hearing aids or family notification during this period. The resident's family was not informed of the missing hearing aids until they themselves reported the issue via a Resident Concern Form nearly two weeks after the aids were last seen. The facility's records confirmed that staff noticed the hearing aids were missing and searched for them, but failed to communicate this to the family in a timely manner. The deficiency was identified through record review and interviews, which verified the lack of timely family notification regarding the missing hearing aids.
Failure to Follow Physician-Ordered Diet Restrictions for Swallowing-Impaired Resident
Penalty
Summary
The facility failed to follow a physician's order regarding dietary restrictions for a resident with a swallowing impairment. The resident had a documented history of laryngeal/pharyngeal impairment and penetration of liquids when using a straw, leading to a specific physician order prohibiting the use of straws. Despite this, observations on two occasions revealed a cup with a straw filled with fresh ice water in the resident's room. A sign above the resident's bed clearly stated that no straws were to be used. Interviews confirmed that staff were aware of the no-straw restriction, and the family provided appropriate drinking cups for the resident. However, the Business Office Manager, who was assisting with distributing morning ice and water, was unaware of the restriction and placed the lidded cup with a straw in the resident's room. This oversight resulted in the resident not receiving care in accordance with the physician's order and established dietary restrictions.
Failure to Implement Nutritional Orders and Dietician Recommendations
Penalty
Summary
The facility failed to ensure physician-ordered nutritional interventions were implemented for a resident with significant weight loss and failed to address dietician recommendations. Resident #17 was admitted with diagnoses including dementia without behavioral disturbance, type 2 diabetes mellitus, chronic kidney disease stage 3, anxiety disorder, and major depressive disorder. The resident experienced a 41-pound weight loss, from 172 pounds on 12/16/24 to 128.8 pounds on 07/01/25, with documented declines throughout the period. The care plan identified risk for altered nutritional status related to dementia, depression, chronic kidney disease, significant weight loss, poor intake, and refusing meals, and included interventions such as administering supplements per orders and SLP referral/evaluation/treatment as needed. Dietary documentation showed repeated concerns about the resident’s weight loss and recommendations for supplements and SLP evaluation. On 04/03/25, the dietician documented a 21-pound weight loss in one month and recommended adding MedPass 120 cc twice daily and an appetite stimulant, but the MedPass recommendation was not addressed. On 05/01/25, the dietician recommended an SLP evaluation and increasing MedPass to three times daily; the physician order for SLP evaluation and MedPass 120 cc three times daily was written on 05/03/25. The record showed MedPass was not provided from 06/07/25 through 07/03/25, with no order to discontinue it, and it was not administered until reordered on 07/03/25. There was no evidence the SLP evaluation was completed, and Therapy Director #200 and ADON #152 both verified that the ordered SLP evaluation had not been completed and that MedPass had been discontinued from documentation before being reordered.
Failure to Document Non-Pharmacologic Pain Interventions Before PRN Pain Medications
Penalty
Summary
The facility failed to ensure non-pharmacologic pain interventions were implemented before administering as-needed pain medication for three residents reviewed for pain management. Resident #45 had diagnoses including myocardial infarction, spinal stenosis, diabetes, post-laminectomy syndrome, and chronic venous insufficiency. His record showed an order for oxycodone 15 mg every 6 hours for pain, and the July 2025 MAR showed the medication was given as ordered, but there was no documentation that non-pharmacologic interventions were attempted before administration. Although his care plan included offering interventions such as distraction, relaxation and breathing exercises, music therapy, and repositioning, an LPN confirmed there were no non-pharmacologic interventions for pain medications. Resident #25 had diagnoses including cerebral infarction due to occlusion or stenosis of a small artery, Parkinson's disease, CHF, COPD, acute respiratory failure, and repeated falls, and her MDS showed intact cognition. Her orders included Norco 5/325 mg every 6 hours PRN for pain and Tylenol 650 mg every 8 hours PRN for pain, and the June and July 2025 MARs showed both medications were administered without documentation of non-pharmacologic interventions beforehand. Her care plan also directed staff to offer non-pharmacologic interventions such as distraction, relaxation and breathing exercises, music therapy, and repositioning if accepted. Resident #61 had Parkinson's disease, dementia, depression, and CKD, with severely impaired cognition and a BIMS score of 2. He had orders for a lidocaine patch and morphine concentrate PRN for pain, and the MAR showed morphine was administered on two occasions without documented non-pharmacologic interventions prior to the doses. The ADHS confirmed there were no non-pharmacologic pain interventions attempted and/or documented before pain medication administration and stated nurses are expected to offer such interventions prior to medication.
Infection Control Not Maintained During Dressing Change
Penalty
Summary
The facility failed to maintain infection control guidelines during a dressing change for Resident #47, who was admitted with diagnoses including chronic obstructive pulmonary disease, chronic respiratory failure, and hypertension. Physician orders directed staff to cleanse the sacral wound with normal saline and apply Triad paste and a large dry dressing daily. During the observed dressing change, Nurse #129 and the Assistant Director of Nursing #152 removed the old dressing, and Nurse #129 removed her gloves, performed hand hygiene, and put on clean gloves. After cleansing the wound with normal saline using 4x4 gauze, Nurse #129 again removed her gloves to perform hand hygiene while the resident’s pants remained touching the wound. She then donned a new pair of clean gloves, pulled the resident’s pants down exposing the wound, and applied Triad paste with a sterile cotton tip applicator before covering the wound with a dressing. During interview, ADON #152 and LPN #129 confirmed that the resident’s pants re-contaminated the wound after cleansing, and Nurse #129 stated she did not want to leave the resident exposed while changing her gloves.
Failure to Provide Adequate Nursing Staff Resulting in Delayed Medication Administration and Insufficient Supervision
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of all residents, resulting in multiple instances where residents did not receive their medications in a timely manner and lacked appropriate supervision. Several residents with complex medical histories, including psychiatric disorders, diabetes, heart failure, and mobility issues, reported not receiving their evening or bedtime medications until several hours after the scheduled administration times, with some medications being given as late as 2:00 or 3:00 A.M. instead of the ordered 8:00 or 9:00 P.M. In some cases, residents did not receive their medications at all, and staff interviews confirmed that agency nurses were unfamiliar with residents and unable to manage the workload effectively. Documentation audits and resident interviews corroborated these delays and omissions, with residents expressing concerns about trust in night shift staff and the impact on their health and well-being. The staffing shortages were particularly acute during night shifts, where there were documented occasions of only one licensed nurse being responsible for up to 91 residents across both the skilled nursing facility and the attached assisted living unit. Staff and residents reported that call lights went unanswered for extended periods, residents did not receive timely assistance with activities of daily living, and treatments and hygiene care were not consistently performed. Observations revealed that nurses were pre-setting medications to expedite administration due to being overwhelmed with responsibilities, and dietary staff were assisting with tasks outside their scope, such as delivering meal trays without ensuring they were within residents' reach. The facility's own assessment indicated that the number of licensed nurses and CNAs on duty was insufficient to meet the care needs of the resident population, and the assessment did not account for the staffing needs of the attached assisted living unit. Multiple complaints and concern logs documented issues with grooming, call light response, toileting, and medication administration. Family members and staff described residents being left in soiled conditions, not receiving two-person transfers as required, and experiencing a decline in care quality. The facility was relying heavily on agency staff and had several open nursing positions, contributing to inconsistent care and supervision.
Failure to Submit Required Staffing Data to CMS
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) for the first quarter of 2025, as required. Review of the Payroll Based Journal (PBJ) Staffing Data Report showed that staffing data for the period from October 1st to December 31st, 2025, was not submitted, resulting in the facility receiving a one-star staff rating. During interviews, the Chief of Operation (CEO) confirmed there was no documented evidence that the required staffing data had been reported to CMS. The CEO explained that the facility underwent a change of ownership in December 2024, and it was the previous owner's responsibility to report the staffing data. The CEO also stated that the previous owner had sent the data to a contracted company, which was responsible for submitting it to CMS, but there was no documentation to confirm that this submission occurred. This deficiency had the potential to affect all 72 residents in the facility.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Surveyors observed that medication carts on two separate halls were not properly secured and medications were not properly stored or labeled. On one hall, a medication cart was found unlocked and unattended between resident rooms, and an LPN confirmed leaving it in that state while attending to duties elsewhere. On another hall, three medication carts were inspected: one cart contained seven medication cups pre-filled with medications, labeled only with first names and room numbers, including two cups with the same first name but different room numbers. Additionally, two other carts contained numerous loose, unlabeled, and unpackaged tablets in various drawers. These findings were confirmed by staff present at the time of observation. Interviews with staff, including the DON, confirmed that medication carts should be locked when unsupervised, medications should not be pre-set, and all drugs must be stored in their original packaging with proper labeling. The facility's policy requires all drugs and biologicals to be stored securely, in their original containers, and properly labeled, with each resident's medications kept separate to prevent mixing. The observed practices did not comply with these requirements, affecting all residents on the 100 and 200 halls.
Failure to Timely Report and Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that all allegations of resident abuse were reported immediately to the administrator and the state survey agency, as required by policy and regulation. An incident occurred in which one resident, with a history of dementia and other medical conditions, pushed another resident, who also had significant cognitive impairment, to the floor after a verbal altercation. The event was witnessed by staff, and the resident who was pushed complained of arm pain, but there was no immediate assessment by a licensed nurse, and no documentation of vital signs or neurological checks as directed by the medication technician. Despite the facility's policy requiring immediate reporting of abuse allegations, the incident was not reported to the administrator or the state survey agency until four days after it occurred. Staff involved in the incident were unclear about their responsibilities for reporting, with some believing that the medication technician was a nurse and would handle the notification. The administrator and DON were not made aware of the incident until several days later, and there was confusion and lack of documentation regarding the required monitoring and assessment of the resident who was pushed. Medical record review confirmed that the resident who was pushed was not assessed by a nurse or had their family or physician notified until several days after the incident. The facility's investigation also revealed missing or undated documentation related to the required 15-minute checks and vital signs. The failure to report the incident in a timely manner and to follow established protocols for assessment and notification constituted a deficiency in the facility's abuse reporting procedures.
Failure to Provide Adequate Oral Hygiene to Dependent Resident
Penalty
Summary
A dependent resident with severe cognitive impairment, functional limitations, and a need for substantial assistance with activities of daily living, including oral hygiene, was not provided adequate oral care. The resident's care plan specified the need for daily oral hygiene assistance and monitoring for signs of dehydration and dental problems. Despite documentation indicating that oral care was being provided almost daily, multiple assessments and family concerns indicated otherwise. The resident's dental records showed a significant decline in oral health over several months. While earlier dental visits did not note any major concerns, a later assessment by the facility dentist identified multiple decayed teeth, heavy plaque, and poor oral hygiene, recommending increased staff assistance with daily oral care. An outside dental examination further confirmed extremely heavy plaque buildup, gingivitis, and pain, attributing these issues to inadequate home care. The resident's family also raised concerns about mouthwash not being used and reported that the dentist described the oral condition as a result of neglect. Interviews with staff and administration revealed that oral hygiene was not being performed as frequently as required, and there were ongoing concerns from families about the adequacy of oral care. Staff confirmed that oral hygiene was sometimes neglected, and the administrator was unable to explain the deterioration in the resident's oral health despite documentation of care. The deficiency was substantiated by direct observations, medical record reviews, and interviews, all indicating a failure to provide necessary assistance with oral hygiene to a dependent resident.
Failure to Timely Assess, Monitor, and Report Resident Condition Changes
Penalty
Summary
The facility failed to timely assess, monitor, and report significant changes in resident condition, specifically regarding a fall incident and weight gain. In one case, a resident with severe cognitive impairment was pushed to the floor by another resident. Staff present at the time did not ensure a licensed nurse assessed the resident immediately after the incident, nor were 15-minute checks, neurological assessments, or vital signs documented as directed. The incident was not discovered or properly investigated until four days later, and there was no evidence of a physical assessment by a licensed nurse until that time. The facility also lacked a clear policy or procedure for staff to follow when a fall occurs, and the Director of Nursing confirmed that education on documentation and notification was provided only during staff training or as needed for agency staff. In another case, a resident with multiple diagnoses, including heart failure and cirrhosis, had physician orders for daily weights and specific instructions to notify the provider if there was a two-pound weight gain in 24 hours or a five-pound gain in a week. The resident's medical record and treatment administration record showed several days where weights were not documented, and there was no evidence that the provider was notified when the resident experienced weight gains that met the criteria for notification. The resident reported difficulty finding working scales and required staff assistance to obtain weights, contradicting the DON's statement that the resident weighed himself. There was no documentation of weight refusals or provider notifications as required by the care plan and physician orders. These deficiencies were identified through medical record review, staff and resident interviews, and review of facility policies. The findings revealed lapses in timely assessment, monitoring, and communication regarding significant changes in resident condition, as well as a lack of clear procedures for staff to follow in the event of a fall or significant weight change.
Failure to Provide Comprehensive and Timely Foot Wound Care
Penalty
Summary
A resident with multiple complex medical conditions, including diabetes, heart failure, and venous insufficiency, was admitted with a wound on the left great toe. Upon admission, there was no comprehensive assessment of the wound's size or characteristics, and no wound assessment was documented from several days after admission until later in the month. The initial hospital order for wound care was not implemented until four days after admission, and subsequent treatment administration records showed multiple missed days where the prescribed wound care was not documented as completed. Additionally, when the wound clinic updated the treatment order, the new order was not initiated promptly, and the previous treatment was not discontinued, resulting in both treatments being administered concurrently for over two weeks. Wound evaluation notes repeatedly lacked documentation of the wound bed assessment, and the peri-wound appearance was consistently described as dry and flaky. Interviews with the resident revealed that wound care was not provided daily as ordered, and the resident reported insufficient staff to administer treatments in a timely manner. The Assistant Director of Nursing confirmed the lack of comprehensive assessment, delays in implementing treatment orders, missed documentation of treatments, and improper handling of updated wound care orders. The facility's wound nurse was absent during this period, and there was no evidence of weekly wound assessments until her return.
Failure to Implement Wheelchair Padding Results in Repeated Resident Injuries
Penalty
Summary
The facility failed to implement safety measures to prevent injuries for a resident with multiple medical conditions, including diabetes, respiratory failure, chronic kidney disease, heart failure, and dysphagia. Despite documented incidents of skin tears caused by the resident's legs coming into contact with the wheelchair leg rests during transfers, the intervention to pad the wheelchair leg rests was not put in place. The resident's care plan included padding the wheelchair leg piece and encouraging the use of long pants, but observations and interviews confirmed that the leg rests remained unpadded on both the old and new wheelchairs. Multiple staff members, including LPNs, CNAs, and the DON, verified that the intervention to pad the leg rests was not implemented, resulting in repeated skin tears for the resident. The resident and her daughter both reported ongoing injuries due to the lack of padding, and the daughter noted that even pool noodles brought from home to protect the bed frame were not used. Direct observation confirmed the absence of padding on the wheelchair leg rests, and the DON acknowledged that the failure to implement the intervention led to multiple injuries.
Delay in UTI Treatment Due to Lab and Communication Issues
Penalty
Summary
A deficiency was identified when a resident with a history of diabetes mellitus, chronic kidney disease, heart failure, and recurrent urinary tract infections (UTIs) experienced a delay in the treatment of a symptomatic UTI. The resident, who was cognitively intact and dependent for transfers with frequent incontinence, reported worsening burning and discomfort during urination. A nurse practitioner ordered a urine analysis, and a urine sample was collected via straight catheter. However, the initial sample was rejected by the hospital lab due to being in the wrong container, causing a delay as the sample had to be resent to another lab the following day. The urine culture results were received several days later and subsequently sent to the infectious disease office for review. Despite the resident's ongoing symptoms, including discomfort and pain with urination, no antibiotic treatment was initiated for over a week after the onset of symptoms. Interviews with the resident and her daughter confirmed the prolonged wait for treatment, and the Director of Nursing acknowledged the extended delay in both obtaining lab results and starting appropriate therapy.
Medication Error Rate Exceeds Acceptable Threshold Due to Administration and Availability Failures
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, with five errors identified out of 28 opportunities, resulting in a 17.8% error rate. For one resident with multiple complex diagnoses, including bipolar disorder, hypertension, and a history of esophageal surgery, a medication technician crushed an extended-release Metoprolol tablet, which should not be crushed, and omitted two prescribed medications, Sertraline and Spironolactone, during a medication pass. The technician had signed off on the administration of all medications, but only 12 out of 14 pills were actually given. The resident confirmed that receiving the wrong medication was not uncommon, especially during night shifts, and that he preferred his medications crushed due to swallowing difficulties. Another resident with a history of cerebral infarction, heart failure, and hypertension did not receive the full prescribed dose of Amlodipine and missed several doses of Metoprolol due to the medication being unavailable for an extended period. The LPN administering the medication provided only one Amlodipine tablet instead of two and reported that Metoprolol had been out of stock since a specific date, with unsuccessful attempts to obtain it from the pharmacy and contingency box. The nurse practitioner was notified of the omission, and additional blood pressure monitoring was ordered, but no harm was noted from the missed doses at the time of review. Facility policy requires medications to be administered as prescribed and for staff to document administration on the medication administration record (MAR) after giving the medication. In both cases, staff failed to follow these procedures, either by not administering all prescribed medications, administering them incorrectly, or failing to ensure medication availability, leading to a medication error rate significantly above the acceptable threshold.
Significant Medication Errors Due to Missed and Unaccounted Doses
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors, as evidenced by missed and unaccounted doses of prescribed medications for two residents. One resident with multiple complex diagnoses, including hypertension and heart failure, had several documented omissions of Metoprolol 100 mg, a medication ordered to be given twice daily. The Medication Administration Record showed multiple missed doses over a one-month period, with some doses signed as given when the medication was not available. Pharmacy records indicated that sufficient medication had been delivered, but tablets were unaccounted for, and staff interviews revealed confusion regarding the availability and administration of the medication. The Assistant Director of Nursing confirmed that tablets delivered were not used as intended, and the Director of Nursing could not verify administration for several dates, especially when agency staff were involved. Another resident, with diagnoses including diabetes, chronic kidney disease, and frequent urinary tract infections, did not receive four out of fourteen ordered doses of intravenous Ertapenem Sodium for a UTI. The Medication Administration Record and infection tracking log confirmed the missed doses. The Director of Nursing verified the omissions and noted the resident's ongoing issues with UTIs and involvement of an infectious disease physician. These findings were substantiated through medical record review, staff interviews, observation, and policy review, demonstrating a failure to administer medications as prescribed.
Failure to Provide Required Adaptive Eating Equipment During Meals
Penalty
Summary
The facility failed to ensure that all residents requiring assistive eating devices had them available during meal times. Specifically, one resident with diagnoses including diabetes mellitus, respiratory failure with hypoxia, chronic kidney disease, heart failure, dysphagia, and other feeding difficulties, and who had intact cognition, did not receive the ordered adaptive equipment during breakfast. Physician orders and the resident's care plan specified the use of a divided plate, Kennedy cup, and built-up utensils for all meals as tolerated. However, during observation, the resident's breakfast tray only included regular utensils and Styrofoam cups with a lid and straw, and lacked the required Kennedy cup and built-up utensils. The resident confirmed during interview that she preferred and found it easier to use the Kennedy cup and built-up utensils, as these helped her eat and drink without making a mess. Review of the meal ticket on the tray also indicated that adaptive equipment was to be provided. An LPN verified that the resident was supposed to have the Kennedy cup and built-up utensils for all meals, and acknowledged that these were missing from the breakfast tray. Facility policy requires that adaptive devices be provided for residents who need or request them, but this was not followed in this instance.
Failure to Accurately Document Medication Administration on MAR
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including cerebral infarction, chronic right heart failure, hypertension, and peripheral vascular disease, did not receive their prescribed Metoprolol 100 mg twice daily for hypertension. The medication was unavailable beginning on 05/24/25, and the LPN reported issues with reordering the medication from the pharmacy, including the need to discontinue and rewrite the order so it would be recognized by the pharmacy system. The LPN also stated that the contingency box did not contain the correct dosage, and the medication had not arrived despite follow-up calls to the pharmacy. Despite the medication not being administered, the LPN documented on the medication administration record (MAR) that the Metoprolol was given on several dates. There was no evidence in the resident's progress notes that the medication was unavailable or not administered. The facility's policy required appropriate documentation if a drug was withheld, refused, or given at a different time, but this was not followed, resulting in inaccurate documentation of medication administration.
Failure to Maintain Enhanced Barrier Precautions and Infection Control During Resident Care and Medication Administration
Penalty
Summary
Certified Nursing Assistants (CNAs) failed to follow enhanced barrier precautions (EBP) during the care of a resident with a cholecystostomy tube. The resident, who had multiple diagnoses including acute cholecystitis, acute renal failure, diabetes, and required assistance with personal care, was on EBP due to the presence of an indwelling device. Despite clear signage and the availability of personal protective equipment (PPE) outside the room, two CNAs transferred the resident using a Hoyer lift without wearing gloves or gowns. Both CNAs acknowledged during observation that they should have been wearing PPE, and the Director of Nursing (DON) confirmed this requirement based on the resident's EBP status. Additionally, an LPN failed to maintain infection control practices during medication administration for another resident. The LPN did not perform hand hygiene before administering medications and handled pills directly with her hands before placing them into a medication cup. This was observed and confirmed by the surveyor, and the LPN admitted to being new. The DON confirmed that medications should not be handled directly by hand and should be placed into the cup or on the lid. Facility policy requires staff to follow infection control procedures, including handwashing and proper technique, during medication administration.
Failure to Prevent Falls and Elopement in Residents
Penalty
Summary
The facility failed to provide appropriate assistance and follow care planned interventions for a resident, leading to a fall with injury. The resident, who was severely cognitively impaired, sustained a fall and fractured her left hip while ambulating without her walker and wearing inappropriate footwear. Despite being at high risk for falls, the care plan did not adequately address her assistance needs for dressing, applying footwear, or transfers from sit to stand. Staff failed to intervene appropriately when the resident was seen without shoes and a walker, resulting in her fall. Another resident, with a history of exit-seeking behavior and severe cognitive impairment, was able to leave a secured unit due to inadequate interventions. The resident had previously eloped and was found outside the facility, yet no exit-seeking event was documented for one of the incidents. The care plan called for assessing the need for a wander guard, but the facility policy did not allow for wander guards on memory care residents. The facility's response to the resident's ability to learn door codes was insufficient, as the code was not changed frequently enough to prevent further incidents. A third resident experienced multiple falls, some resulting in head injuries, but the facility failed to complete fall investigations and neurological checks as ordered. The resident, who had impaired cognition and required assistance with mobility, had falls that were either unwitnessed or witnessed without proper follow-up. The facility's policy required a thorough investigation and reassessment after falls, but these were not completed, leaving the resident at risk for further incidents.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to ensure comprehensive care plans were in place for several residents, addressing their specific needs related to activities of daily living (ADL), wandering behaviors, and contractures. Resident #18, who had multiple diagnoses including multiple sclerosis and dementia, did not have a care plan specifying her ADL needs such as bed mobility, ambulation, and personal hygiene until a later date. This oversight was confirmed by the Campus Support Resident Assessment and MDS coordinator. Resident #59, diagnosed with Alzheimer's disease and dementia, was observed wandering the unit without a care plan addressing her wandering behavior. Her care plan also lacked details on her assistance needs for mobility, oral hygiene, and dressing. Despite being on a locked unit for safe wandering, the facility did not have specific interventions in place, as verified by the MDS coordinator. Resident #16, with diagnoses including major depressive disorder and unspecified dementia, did not have care plans for these conditions, which would include specific target behaviors and measurable interventions. The Director of Nursing and MDS Coordinator acknowledged the absence of these care plans. Additionally, Resident #40, who had severe cognitive impairment and a right hand contracture, did not have a care plan with interventions for the contracture, despite observations of the condition and the resident's spouse mentioning a brace at home. The MDS Coordinator confirmed the lack of a specific care plan for the contracture.
Deficiency in Dementia Care Documentation and Intervention
Penalty
Summary
The facility failed to appropriately document, revise, and implement care plans for a resident diagnosed with dementia, leading to a deficiency in addressing the resident's dementia-related behaviors. The resident, who had severe cognitive impairment and a history of Alzheimer's disease and dementia, exhibited behaviors such as wandering, inappropriate sexual behavior, and aggression towards other residents and staff. Despite these behaviors being documented in progress notes and behavior and mood events, the facility did not consistently notify the resident's family or physician, nor did they assess the other residents involved in these incidents. The facility's care plan for the resident was not updated to reflect new or specific interventions for the resident's behaviors. Interventions such as providing snacks, redirection, and activities were attempted but were often ineffective. The facility also failed to administer prescribed Lorazepam as needed for anxiety and agitation, despite the family agreeing to the order. The facility's documentation lacked thoroughness in detailing the interventions used or in place during each incident, and there was no evidence of tracking trends and patterns in the resident's behavior. Interviews with the Executive Director and Director of Health Services confirmed that the facility did not have policies related to dementia care and that the care plan was not updated to address the resident's behaviors adequately. The facility's failure to notify the family and physician of every incident, identify all residents involved in altercations, and document interventions and trends contributed to the deficiency in providing appropriate care for the resident with dementia.
Inappropriate Texture of Pureed Food for Residents
Penalty
Summary
The facility failed to ensure that pureed food items were prepared to an appropriate texture for residents on a pureed diet. During an observation, Dining Services Assistant (DSA) #123 was seen preparing pureed swiss steak for six residents who required a pureed diet. The process involved adding whole swiss steak patties to a blender, along with beef base and thickener. DSA #123 tasted the mixture and believed it was of the correct texture before transferring it to a serving container. However, upon tasting the pureed swiss steak, the surveyor found it to be gritty with small bits of fat that required chewing, which is not suitable for a pureed diet. The Director of Food Services (DFS) #159 confirmed the inappropriate texture upon tasting it as well. The facility's policy on pureed food guidelines, revised in 2012, specifies that pureed foods should be smooth, homogenous, and pudding-like, requiring very little chewing ability. The failure to adhere to these guidelines resulted in the preparation of food that was not safe for residents requiring a pureed diet.
Failure in Hand Hygiene and Food Temperature Monitoring
Penalty
Summary
The facility failed to adhere to proper hand hygiene and glove use during dinner meal service, as well as to ensure that food temperatures were taken before serving meals to residents in the Memory Care Unit. Observations revealed that the steam table in the kitchen was malfunctioning, and food temperatures were not checked before being delivered to the Memory Care Unit. Staff interviews confirmed that food temperatures were not taken by kitchen staff prior to delivery, which affected multiple residents, including those on specific dietary orders. Additionally, during the dinner meal service in the main dining room, a Dining Services Assistant (DSA) was observed not following hand hygiene protocols. The DSA did not change gloves or perform hand hygiene after touching clothing and continued to serve food with the same gloves, which were used to handle dinner rolls and other food items. The facility's policies on hand hygiene and glove use were not followed, as confirmed by the Director of Food Services and Assistant Director of Food Services.
Failure to Implement Infection Control Measures
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for four residents, despite physician orders requiring such measures. Resident #58, who was admitted with orthopedic aftercare and dysphagia, had orders for enteral feeding and required EBP during high-contact care activities. However, observations revealed no EBP signs or personal protective equipment (PPE) in place, which was confirmed by the Director of Nursing (DON). Similarly, Resident #63, with a wound vacuum in place, and Resident #171, with an indwelling catheter, also lacked EBP signs and PPE, as verified by the DON and a Licensed Practical Nurse (LPN). Resident #371, with a sacral wound and orders for a wound vacuum, was also observed without EBP, despite orders for gown and glove use during high-contact care. The facility also failed to adhere to contact isolation precaution procedures for Resident #2, who was on contact isolation for Clostridioides difficile (Cdiff). Although a sign and PPE cabinet were present outside the resident's room, there were no disposal bins or red bags for used gowns inside or near the room. This was confirmed by both the resident and a Registered Nurse (RN), who acknowledged the absence of proper disposal containers. The facility's guidelines for contact precautions require the removal and disposal of gowns before leaving the resident's room, but these procedures were not followed. These deficiencies indicate a lack of adherence to infection prevention and control protocols, as evidenced by the absence of necessary PPE and disposal measures for residents requiring EBP and contact isolation. The observations and interviews with staff and residents highlight the facility's failure to implement and maintain appropriate infection control practices, potentially compromising resident safety and care quality.
Failure to Report Potential Abuse Incident
Penalty
Summary
The facility failed to report a potential abuse incident involving two residents to the state agency, as required by their policy. Resident #37, who had intact cognition, was involved in an altercation with Resident #35, who had severe cognitive impairment. The incident occurred when Resident #35 attempted to bite a staff member, prompting Resident #37 to slap Resident #35 on the right arm and scream at her. Both residents were separated following the incident, and Resident #35 was assessed and reported no pain. Despite the incident, the facility did not report it to the state agency or conduct any further investigation or documentation. The Executive Director confirmed that no incidents related to the altercation were reported to the state agency, and there was no additional investigation or documentation. The facility's policy mandates that any suspected abuse should be reported immediately to the Executive Director, who is responsible for notifying the state department of health and other relevant agencies.
Delayed Initial Care Conference for Resident
Penalty
Summary
The facility failed to conduct an initial care conference in a timely manner for a resident who was admitted with diagnoses including joint replacement surgery, osteoarthritis, pain, and anxiety. The resident was cognitively intact, as indicated by the Minimum Data Set (MDS). Despite the requirement for initial care conferences to be held within five days of admission, the care conference for this resident was not conducted until 26 days after admission, following a request from the resident's family. This delay was confirmed by the Director of Social Services during an interview.
Failure to Provide Discharge Summary
Penalty
Summary
The facility failed to provide a discharge summary for Resident #66 at the time of discharge to an assisted living facility. Resident #66 was admitted with diagnoses including hemiplegia, hemiparesis, kidney disease, and dependence on renal dialysis. An order was placed for a hospital bed with side rails, but this need was not documented in the discharge planning form. The form also noted dialysis appointments on Monday, Wednesday, and Friday, with transportation to be provided by the facility, but lacked caregiver information. The Executive Director confirmed that a discharge summary was not provided upon discharge.
Failure to Adhere to Resident's Bathing Schedule and Preferences
Penalty
Summary
The facility failed to provide a resident with bathing as scheduled and according to their preference. The resident, who was admitted with diagnoses including joint replacement surgery, osteoarthritis, pain, and anxiety, was cognitively intact and required substantial to maximal assistance for bathing. The resident was scheduled for evening baths twice a week, on Wednesdays and Saturdays. However, documentation from early May to mid-June showed the resident received only three showers, two bed baths, four partial bed baths, and refused bathing once. During an interview, the resident expressed uncertainty about their bathing schedule and stated they were not being bathed twice a week as expected. The Director of Nursing confirmed the documentation did not reflect the scheduled bathing frequency or the resident's preference for showers twice a week.
Delayed Delivery of Wound Vac Supplies
Penalty
Summary
The facility failed to ensure that a resident's wound vac and supplies were received prior to admission, affecting the resident's care. The resident, who was admitted with multiple medical diagnoses including sepsis and a surgical wound, required a wound vac for treatment. The medical record indicated that the wound vac order was placed and confirmed with the medical supply company, with an expected delivery on the day of admission. However, the delivery was delayed, and the facility was notified that the supplies would not arrive until the following day. Upon admission, the resident's wound was managed with a wet to dry dressing as a temporary measure until the wound vac could be applied. The hospital had discharged the resident with the understanding that the wound vac would be available at the facility, but due to the delay, the resident continued with the wet to dry dressing. The resident's sister and hospital staff were informed of the delay, and the facility confirmed the absence of the wound vac and supplies upon the resident's arrival. Interviews with the resident and the resident's sister revealed dissatisfaction with the facility's handling of the situation, as the resident was not supposed to be off the wound vac. The Executive Director confirmed the delay in receiving the necessary supplies and the use of wet to dry dressings in the interim. The facility did not follow up with the hospital after being notified of the delivery delay, contributing to the deficiency in care provided to the resident.
Failure to Timely Identify and Treat Pressure Ulcers
Penalty
Summary
The facility failed to timely identify, accurately assess, and treat a resident's pressure ulcer areas on her right heel and ankle. The resident, who had multiple medical diagnoses including Alzheimer's Disease and Type II Diabetes Mellitus, was initially noted to have a soft, spongy area on her right heel that was red/blue in color. Despite this observation, there was no immediate notification to the physician or Director of Health Services, and the initial treatment was not clearly indicated in the skin assessment. Over time, the wound progressed to an unstageable deep tissue injury, and there were significant gaps in documentation and treatment adjustments. The facility's Treatment Administration Record showed multiple changes in wound care orders, but there were inconsistencies in the application and documentation of these treatments. There were periods where no progress notes were documented, and the resident's wound was not reassessed for significant changes. When signs of a possible wound infection were noted, there was a delay in the resident being seen by a Certified Nurse Practitioner, and the wound culture results were not promptly communicated or acted upon. Additionally, the facility did not recognize a separate wound area on the resident's right lateral ankle, failing to initiate appropriate assessments and treatments for this area. The resident's appointments for wound consults and diagnostic tests were delayed, and there was a lack of coordination in managing the resident's care. The facility's policy required weekly documentation and reassessment of wounds, which was not consistently followed, contributing to the decline in the resident's condition.
Lack of Catheter Care Orders for Resident
Penalty
Summary
The facility failed to ensure that appropriate orders were in place for a resident who had a catheter. This deficiency was identified during a review of the medical records, which revealed that the resident, admitted with a Foley catheter, did not have any orders related to catheter care from the time of admission until the survey date. The resident had several diagnoses, including Parkinsonism, type two diabetes mellitus, chronic kidney disease stage four, anxiety disorder, and rheumatoid arthritis, and was noted to have severely impaired cognition. Despite the presence of a comprehensive care plan that included interventions for catheter care, such as maintaining a closed system and observing for complications, there were no formal physician's orders documented. Interviews with facility staff, including a Certified Resident Medication Assistant and the Executive Director, confirmed the absence of these necessary orders, which should have been in place to guide the care provided to the resident.
Delayed Response to Pharmacy Recommendations
Penalty
Summary
The facility failed to address pharmacy recommendations in a timely manner for a resident with multiple complex medical conditions, including Parkinson's disease and cognitive impairment. The resident was admitted with a range of diagnoses, and a pharmacy recommendation was made to reconsider the use of a specific medication not recommended for Parkinson's associated dementia. The recommendation suggested either a trial dose reduction or documentation of risk versus benefit if the medication was to continue. However, the progress note indicating the nurse practitioner's review of this recommendation was not recorded until two months later. A subsequent pharmacy recommendation was made regarding the resident's use of Olanzapine, suggesting a review due to its unsuitability for Parkinson's disease, with alternatives provided. Again, the progress note documenting the nurse practitioner's review was recorded more than a month after the recommendation. Interviews with the Administrator and Director of Health Services confirmed the delays in reviewing and documenting the pharmacy recommendations. The facility's Medication Regimen Review procedures lacked a specified timeframe for addressing pharmacy recommendations, contributing to the deficiency.
Failure to Justify Psychotropic Medication Use
Penalty
Summary
The facility failed to timely address pharmacy recommendations regarding the use of psychotropic medication for a resident. The resident, who was cognitively intact, had a complex medical history including Parkinson's disease, psychosis, and major depressive disorder. Despite the absence of documented behaviors such as delusions, hallucinations, or psychosis from July to November, an antipsychotic medication was prescribed in November based on staff reports of delusions. However, there was no supporting documentation in the medical records to justify the use of the medication. Interviews with staff confirmed that any resident behaviors should be documented in the medical records and reported to the nurse. The facility's administration could not provide documentation to support the diagnosis of psychosis prior to the prescription of the antipsychotic medication. This lack of documentation and failure to address pharmacy recommendations led to a deficiency in the facility's medication administration practices.
Inaccurate Medical Records for Two Residents
Penalty
Summary
The facility failed to maintain accurate medical records for two residents, leading to deficiencies in care. For Resident #9, the medical records showed inconsistencies in the documentation of a wound on the right heel. Initially identified as an unstageable deep tissue injury, the wound was later noted to have worsened, with discrepancies in measurements and classification between the facility's records and the wound clinic's assessment. Additionally, treatment orders were inaccurately documented for the left heel, despite the wound being on the right heel, and these errors persisted until they were corrected on June 20, 2024. Resident #48's medical records were incomplete, as an incident involving a resident-to-resident altercation was not documented. Despite the altercation occurring on April 22, 2024, there was no record of the event in Resident #48's medical file. This omission was confirmed during an interview with the Executive Director, highlighting a failure to adhere to the facility's policy of maintaining a complete and ongoing resident record. The facility's policy, which mandates the creation and maintenance of a complete, timely, and accurate medical record for each resident, was not followed in these cases. The deficiencies in documentation for both residents indicate a lapse in the facility's adherence to its own guidelines, affecting the quality of care provided to the residents involved.
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 275 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 Zanesville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Altercare Zanesville Inc. | 1.2 mi | ★★★★★ | 0 | 0 |
| Oaks At Bethesda The | 1.3 mi | ★★★★★ | 4 | 0 |
| Continuing Healthcare At Willow Haven | 1.7 mi | ★★★★★ | 58 | 0 |
| Adams Lane Healthcare And Rehabilitation Center | 2 mi | ★★★★★ | 0 | 0 |
| Continuing Healthcare At Cedar Hill | 2.5 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for The Oaks Rehabilitation And Healthcare Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.