Average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Vancrest-upper Valley during CMS and state inspections, most recent first.
Failure to timely assess and treat a pressure ulcer led to a resident’s wound worsening from a stage II blister on the buttock to a stage III pressure injury with slough. The resident had dementia, fractures, and incontinence-related skin risk, but the wound was not reassessed or measured for an extended period, the wound specialist referral was not implemented promptly, and the ordered treatment was documented as completed despite the lack of follow-up assessment. An LPN later confirmed the delay and noted the wound had deteriorated before the wound specialist evaluation.
Dirty Ice Machine and Unsafe Food Handling: The kitchen ice machine had a black buildup along the ice chute, and the DM confirmed it was dirty. During tray service, an employee handled buns and tacos with the same gloves after touching unclean items, and the DM confirmed the employee did not change gloves before returning to the serving line. Facility policy noted cross contamination can occur when gloved hands and utensils are not adequately cleaned.
The facility failed to offer and administer the COVID-19 vaccine to employees and did not document staff vaccination status. The BO/HRM confirmed employee files contained no vaccine records, and the ICN verified there was no documentation that staff were offered or received the vaccine per the facility's COVID policy.
A facility failed to place managed resident funds into interest-bearing accounts for four residents whose personal funds were authorized for facility management. Quarterly statements for residents with COPD, CHF, HTN, dysphagia, cerebral infarction, heart failure, anxiety, and Alzheimer's disease showed account balances but no documentation of interest being credited, and AR staff confirmed the accounts had not been set up to earn interest.
Medication Administration and Cart Security Lapses: An LPN left a resident with several medications in hand without staying to observe ingestion, despite the resident's severe cognitive impairment and need for staff assistance. In a separate event, another LPN left the med cart unlocked and unattended in the hallway while administering meds to a resident, with another resident nearby. Facility policy required staff to remain with the resident until all meds were taken and to keep the cart locked when unattended.
Failure to Offer and Document Flu and Pneumococcal Vaccines: The facility did not document offering or administering influenza and pneumococcal vaccines for multiple residents. Two residents had no record that either vaccine was offered or given, one resident had consent for both vaccines but did not receive the pneumococcal vaccine, and another resident had no pneumococcal follow-up despite later receiving the flu vaccine. An LPN Unit Manager confirmed the missing documentation and lack of follow-up, despite facility policies requiring all residents to be offered both vaccines and for receipt or refusal to be documented.
The facility failed to notify the physician when one resident repeatedly refused a prescribed left hand splint, and failed to notify the physician when another resident had significant weight gains that met the MD’s notification parameters. The first resident had diabetes, paraplegia, and COPD, while the second resident had CHF, dysphagia, and an esophageal ulcer. Staff confirmed the refusals and weight increases occurred, but the required physician notifications were not made as ordered.
The facility failed to submit discharge MDS assessments for two residents who were discharged from the LTC facility. One resident had anemia, HTN, and atherosclerotic heart disease, and another had DM, cirrhosis of the liver, and HTN. The DON confirmed the assessments were not submitted to CMS, and the RAI manual requires discharge assessments to be completed and submitted within the required timeframes.
Incomplete Person-Centered Care Plans: Two residents had care plans that did not reflect key ordered interventions and observed needs. One resident's plan omitted an indwelling Foley catheter and treatment for a skin tear, while another resident's plan did not include a left hand splint order or the resident's repeated refusal to wear it. The DON and MDS nurse confirmed the missing documentation, and staff observed the splint was not being worn.
Failure to Provide Grooming Assistance: A resident with encephalopathy, DM, COPD, HTN, and moderate cognitive impairment required substantial to maximum staff assistance with ADLs and was dependent for bathing and personal hygiene. Although shower documentation showed routine bathing, observations and staff interviews confirmed the resident had not been shaved for several days, and CNAs stated grooming was to be provided on shower days.
A resident with diabetes, paraplegia, COPD, moderate cognitive impairment, and limited ROM had a physician order for a left hand splint as tolerated, but the care plan did not include the splint or the resident’s refusals. Splint records showed daily refusals for several months, observations found bilateral hand contractures and no splint in place, and an LPN confirmed the physician had not been notified and no interventions had been implemented for the contracture.
Failure to Maintain Ongoing Dialysis Communication and Assessment: The facility did not provide ongoing dialysis assessments and routine communication with the dialysis center for a resident receiving dialysis. An LPN stated there was no routine paperwork documenting communication on dialysis days, and the DON confirmed the prior communication flowsheet had not been used for months. The resident had ESRD, chronic osteomyelitis, and dependence on renal dialysis, and the care plan called for staff to coordinate care with the dialysis center.
A resident with COPD, nonrheumatic aortic stenosis, and Raynaud's Syndrome had an order for amlodipine 5 mg daily to be held if systolic BP was below 100. The record showed no BP documentation on three days, yet the MAR showed the medication was given each day, and an LPN was observed administering it without checking BP first. The DON confirmed there was no documentation supporting BP checks before administration, despite the facility policy requiring medications be given as prescribed.
Failure to coordinate and document hospice services for a resident on hospice care. The resident had diagnoses including senile degeneration of the brain, CKD, metabolic encephalopathy, and DM2, and the care plan called for hospice nurse and aide visits, comfort measures, and communication with hospice for changes. However, the record lacked a signed hospice contract and documentation of hospice nurse or aide visits, and an LPN confirmed there was no communication or documentation of hospice visits between the facility and the hospice provider.
An LPN did not follow medication administration infection control procedures when a resident's opened med packet was found loose in the med cart drawer; the tablets were picked up and given to the resident, and a pill that missed the resident's mouth was picked up with a bare hand and placed back in the mouth. In a separate event, a CNA did not follow contact precautions for a resident with MRSA, assisting the resident to the bathroom and then leaving the room without hand hygiene after glove removal.
A resident in a persistent vegetative state was prescribed Augmentin for a bacterial infection, but the facility failed to notify the resident's representative about the new antibiotic order and its purpose. The representative was informed only days later without details on the medication's name or duration. The DON confirmed the lack of documentation and absence of a notification policy.
A resident reported missing blankets after returning from a hospital stay, suspecting they were taken by a discharged roommate's family. Social Service staff made an initial call to the family but did not follow up or document the grievance, contrary to the facility's Lost and Found policy requiring immediate investigation and reporting to the DON.
A facility failed to complete a timely significant change MDS assessment for a resident who experienced a decline in condition, including a Stage III pressure ulcer and significant weight loss. Despite these changes, the necessary assessment was not conducted between May and July, as confirmed by the QA nurse. The facility's policy and the RAI manual require a comprehensive assessment when a significant change impacts multiple health areas.
A facility failed to implement a care plan for a resident with dementia and Alzheimer's, who was at high risk for wandering. Despite assessments indicating this risk, the care plan lacked focus and interventions for wandering or residing on a secure unit. An LPN confirmed these omissions.
A facility failed to follow proper mechanical lift protocols during a resident's transfer, as only one STNA was present instead of the required two. The resident, with impaired cognition and multiple health issues, was dependent on staff for transfers. This action was against the resident's care plan and the facility's policy, leading to a deficiency.
A facility failed to provide medical justification for the continued use of an indwelling catheter for a resident admitted with urinary obstruction. The resident, with moderate cognitive impairment and multiple health conditions, had a history of bladder continence and required assistance with toileting. The facility lacked documentation supporting the catheter's use and did not attempt to discontinue it, as confirmed by the DON.
A facility failed to assess and document the need for bed rails for a resident receiving hospice care. Despite the use of bed rails being noted in a consent form, there were no physician orders or assessments, and the form lacked necessary signatures. Observations confirmed the use of bed rails, but they were not coded in the MDS assessments. The facility's policy required assessments and evaluations that were not completed, leading to the deficiency.
A facility failed to respond promptly to pharmacy recommendations for a resident with multiple diagnoses, including Parkinson's and dementia. Despite a physician's approval for lab tests, the necessary vitamin and iron panels were delayed by three months, affecting the resident's care. The DON confirmed the oversight, indicating a lapse in medication management.
A resident with a history of renal cancer and an acquired absence of a kidney was prescribed Macrodantin indefinitely to prevent UTIs, despite experiencing only nocturnal urination without other UTI symptoms. The medication was continued based on a urologist's recommendation, even though the resident had four UTIs in the past year.
A significant medication error occurred when an LPN failed to prime an insulin pen before administering insulin to a resident with diabetes. The facility's policy and manufacturer instructions require a two-unit air shot to ensure proper dosing, which was not performed, resulting in a deviation from proper medication administration procedures.
A resident was found with a medication cup left unsupervised on their bedside table, as the LPN left to get supplies for an IV medication. The resident, who was alert and oriented, had a history of joint replacement and other conditions. The facility's policy requires medications to be administered safely and timely, which was not followed.
A resident with open wounds was placed under Enhanced Barrier Precautions (EBP) due to infection risk, but a State tested Nursing Aide (STNA) failed to wear the required personal protective equipment (PPE) while providing personal care. The STNA confirmed not following the EBP protocols, and the Infection Control Preventionist (ICP) reiterated the facility's policy requiring PPE for residents under EBP.
The facility failed to provide two residents with the required SNF ABN and NOMNC. For one resident, the last covered day of Part A service was noted, but the form was not signed by the resident or family, and there was no verification of notification. Similarly, another resident's last covered day was documented without signatures or proof of notification. These deficiencies affected two of the three residents reviewed.
Failure to Timely Assess and Treat a Pressure Ulcer
Penalty
Summary
The facility failed to properly assess and obtain timely consultation for an existing pressure ulcer and failed to administer pressure ulcer treatment per the physician’s order for one resident. The resident was admitted with diagnoses including Alzheimer’s disease, left humerus fracture, sacrum fracture, and hypertension, and was identified as at risk for skin breakdown due to decreased mobility and incontinence. A Braden score of 15 indicated mild risk for pressure ulcers, and on readmission from the hospital the resident was documented to have a fluid-filled blister to the right buttock measuring 2 cm by 1 cm with an order for skin prep and referral to a wound specialist. The record showed no documented wound assessments or measurements from the time of readmission until the wound was reassessed later, when it was found open and measured 1.6 cm by 1.4 cm by 0.2 cm with yellow slough and serosanguineous drainage. At that time, the wound was classified as a stage III pressure ulcer. The wound specialist did not evaluate the resident until several days later, when the wound was documented as a stage III pressure injury measuring 2 cm by 1.5 cm by 0.2 cm with a large amount of adherent slough, and mechanical debridement was performed. The treatment record showed the ordered skin prep was signed off as completed, but the medical record did not contain wound assessments or measurements during the period when the wound worsened. During interview, the LPN stated the resident’s skin was assessed on readmission, that the wound was a stage II pressure ulcer, that the facility did not assess it again until it had deteriorated to stage III with slough, and that the referral to the wound specialist was not implemented timely. The same nurse also confirmed pressure ulcers should be assessed and measured at least weekly. An observation later showed a dressing applied that did not match the physician’s order, and the nurse stated it appeared the resident had an adverse reaction to the wrong dressing.
Dirty Ice Machine and Unsafe Food Handling
Penalty
Summary
The facility failed to maintain the kitchen ice machine in a sanitary condition and failed to distribute food in a sanitary manner. Review of the monthly ice machine cleaning log showed the kitchen ice machine was cleaned on 06/05/26. During an observation on 07/14/26 at 10:02 A.M., the Dietary Manager observed a thin black layer along the lip of the ice chute, and when the lip was wiped with a damp cloth, a black substance came off onto the cloth. The Dietary Manager confirmed the ice chute was dirty and stated the maintenance department was responsible for monthly cleaning of the ice machine. Manufacturer instructions reviewed by surveyors stated the ice machine should be cleaned and sanitized every six months and when dirty. During a food line observation on 07/14/26 at 11:02 A.M., [NAME] #403, wearing gloves, moved the dish holder cart, retrieved a package of buns, reached into the bag with the same gloved hand, removed a bun, and prepared a sandwich. While still wearing the same gloves, [NAME] #403 continued serving lunch trays and used a gloved hand to remove tacos from the tray. The Dietary Manager then placed a set of tongs on the serving line in front of the tacos. When interviewed, the Dietary Manager confirmed [NAME] #403 had stepped away from the tray line, touched unclean items, and returned to the serving line to touch food items without changing gloves. The facility policy on Food Preparation and Service stated cross contamination can occur when disease-causing microorganisms are transferred to food by hands, including gloved hands, and by food contact surfaces, utensils, and other items that are not adequately cleaned.
Failure to Offer and Document COVID-19 Vaccination for Staff
Penalty
Summary
The facility failed to offer and administer the Coronavirus (COVID-19) vaccine to employees and failed to document employee vaccination status. During interview, the Business Office/Human Resource Manager confirmed there were no employee vaccinations in the employee files and stated the Infection Control Nurse would have any employee vaccine forms. The Infection Control Nurse then verified there was no documentation showing any employee was offered or given the COVID vaccine per the facility's COVID policies. Review of the facility policy titled Coronavirus Disease (COVID-19), dated May 2023, stated all staff would be educated and offered the COVID-19 vaccine and that the date of administration would be recorded and kept in the employee file.
Resident Funds Not Held in Interest-Bearing Accounts
Penalty
Summary
The facility failed to ensure residents' personal funds were deposited in an interest-bearing account for four residents whose funds were being managed by the facility. Resident #11, admitted with COPD, HTN, and Alzheimer's disease, had authorized the facility to manage personal funds, and the quarterly statement showed a balance of $374.15 with no documentation of interest being disbursed to the account. Resident #22, admitted with CHF, HTN, and dysphagia, also authorized the facility to manage funds, and the quarterly statement showed a balance of $650.00 without documentation of interest disbursement. Resident #40, admitted with COPD, HTN, and cerebral infarction, had a quarterly statement showing a balance of $237.60 with no documentation of interest being disbursed. Resident #77, admitted with HTN, heart failure, and anxiety, had a quarterly statement showing a balance of $1,995.62 with no documentation of interest disbursement. During interview, Accounts Receivable staff confirmed the accounts for these residents had not been placed in interest-bearing accounts and stated none of the residents who had resident fund authorization had received interest on the money in their accounts. The facility policy stated that when the facility manages resident funds, it acts as a fiduciary and holds, safeguards, manages, and accounts for those personal funds.
Medication Administration and Cart Security Lapses
Penalty
Summary
Medications were not left with a resident during administration. Resident #21 had diagnoses including diabetes mellitus, schizoaffective disorder, Alzheimer's disease, and hypertension, and the MDS dated 04/25/26 indicated severe cognitive impairment and a need for staff assistance with ADLs. On 07/13/26 at 11:42 A.M., the resident was observed sitting in a chair in the common area on the memory care unit holding a medication cup with several medications in her hand while LPN #324 was across the room assisting another resident with medication administration. At 11:44 A.M., LPN #324 confirmed she had given Resident #21 her medications and then went across the room to assist another resident, and she verified she had not stayed with Resident #21 to observe the resident consuming the medications. The medication cart was also left unlocked and unattended in the hallway. On 07/14/26 at 7:30 A.M., LPN #337 was observed leaving the medication cart unlocked and unattended while administering medications to Resident #118, with the cart located in the hallway across from the resident's room. Resident #7 was near the cart at the time. At 7:40 A.M., LPN #337 confirmed she had left the cart unlocked and unattended while she administered medications to Resident #118. Facility policy stated that during medication administration, the person administering the medication will stay in the resident's presence until all medications have been given, and that the medication cart is kept closed and locked when out of sight.
Failure to Offer and Document Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to offer influenza and pneumococcal vaccinations to residents, affecting four of five residents reviewed for vaccinations. Resident #22, admitted with congestive heart failure, dysphagia, and an ulcer of the esophagus, had no documentation that either the influenza or pneumococcal vaccine was offered or administered. Resident #34, admitted with venous insufficiency, type 2 diabetes mellitus, and rheumatoid arthritis, also had no documentation that either vaccine was offered or administered. Resident #59, admitted with rheumatoid arthritis, dementia, and chronic kidney disease, had a signed immunization consent form from the family representative for both the influenza and pneumococcal vaccines, but the record showed the pneumococcal vaccine was not administered. Resident #111, admitted with type 2 diabetes mellitus, nontraumatic subdural hemorrhage, and COPD, had no consent for either vaccine on the immunization consent form reviewed, and the immunization report later showed the influenza vaccine was given, but there was no follow-up regarding whether the pneumococcal vaccine was to be administered. An LPN Unit Manager confirmed there was no documentation for Residents #22 and #34, verified Resident #59 had not received the pneumococcal vaccine despite consent, and stated there was no follow-up for Resident #111 regarding pneumococcal vaccination. Facility policies stated all residents would be offered influenza and pneumococcal vaccines and that receipt or refusal would be documented in the medical record.
Failure to Notify Physician of Treatment Refusal and Significant Weight Gain
Penalty
Summary
The facility failed to notify the physician of Resident #94’s repeated refusal to wear a left hand splint as ordered. Resident #94 had diagnoses including diabetes mellitus, paraplegia, and COPD, and the physician ordered a left hand splint as tolerated during first shift with monitoring for redness or discomfort. The care plan did not include use of the splint or the resident’s refusal of it. Documentation for April, May, and June 2026 showed the resident refused the splint daily, and observations in July 2026 showed the resident with bilateral hand contractures and no left hand splint in place. CNAs confirmed the resident had refused the splint for several months, and the LPN unit manager confirmed she was not aware of the refusals and that the physician had not been notified. The facility also failed to notify the physician of Resident #22’s weight gains as required by the physician’s order. Resident #22 had diagnoses including congestive heart failure, dysphagia, and ulcer of the esophagus, and the physician ordered daily weights with notification for a gain greater than 2 pounds in one day or 5 pounds in one week. The record showed a weight increase from 168.8 pounds to 172.0 pounds and later from 174.0 pounds to 178.0 pounds, but there was no documentation that the physician was notified on either occasion. The LPN unit manager confirmed both weight gains and confirmed the physician was not notified per the order; the physician was notified later regarding the 4.2-pound gain, at which time Lasix 40 mg daily was ordered.
Late Submission of Discharge MDS Assessments
Penalty
Summary
The facility failed to submit completed discharge MDS assessments within the required timeframe for two residents who were discharged from the facility. Resident #2 was admitted with diagnoses including anemia, hypertension, and atherosclerotic heart disease and was discharged without a discharge MDS assessment in the medical record. Resident #3 was admitted with diagnoses including diabetes mellitus, cirrhosis of the liver, and hypertension and was also discharged without a discharge MDS assessment in the medical record. During interview, the DON confirmed the facility had not submitted the discharge assessments for both residents to CMS. Review of the facility policy stated assessments were to be completed and submitted according to current federal and state timeframes, and the RAI manual stated discharge assessments must be completed within 14 days of discharge and submitted within 14 days of the MDS completion date.
Incomplete Person-Centered Care Plans
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for two residents reviewed for ADLs. Resident #40, admitted with diagnoses including COPD, cerebral infarctions, hypertension, and chronic respiratory failure, was cognitively intact and required staff assistance with ADLs. Physician orders included an indwelling Foley catheter and treatment for a left forearm skin tear, but the care plan did not reflect either the catheter or the skin tear. The DON confirmed the care plan had not been developed to address these needs. Resident #94, admitted with diagnoses including diabetes mellitus, paraplegia, and COPD, had an order for a left hand splint as tolerated during first shift with monitoring for redness or discomfort. The care plan did not include the splint or the resident's refusal to wear it. MDS assessment showed moderate cognitive impairment and limited range of motion to both upper and lower extremities. Splint documentation for April, May, and June 2026 showed the resident refused to wear the left hand splint daily, and observations showed the resident was not wearing the splint and had contractures to both hands. CNAs confirmed the resident had refused the splint for several months, and the MDS nurse confirmed the care plans lacked documentation of the splint and the refusal.
Failure to Provide Grooming Assistance
Penalty
Summary
The facility failed to ensure a resident received showers and assistance with grooming. Resident #94 had an admission date of 07/22/14 and diagnoses including encephalopathy, diabetes mellitus, chronic obstructive pulmonary disease, and hypertension. The MDS dated 05/14/26 showed moderate cognitive impairment and that the resident required substantial to maximum staff assistance with eating and personal hygiene and was dependent on staff for bathing, bed mobility, and toilet hygiene. Shower/bathing documentation showed the resident received showers or baths every Monday and Thursday from 06/15/26 through 07/13/26 as scheduled. Observations on 07/13/26, 07/14/26, and 07/15/26 showed the resident lying in bed with an overgrowth of facial hair and not shaved. The resident stated staff had not shaved his face in a while, and CNAs #309 and #289 confirmed the resident had not been shaved in several days. CNA #309 stated the resident did not refuse care and that staff were to shave the resident on shower days. The facility policy titled Activities of Daily Living dated September 2023 stated staff would provide grooming assistance for residents unable to carry out ADLs independently.
Failure to Manage Left Hand Splint Refusals and Contracture Care
Penalty
Summary
The facility failed to ensure interventions for contracture management were implemented as needed for one resident with diagnoses including diabetes mellitus, paraplegia, and chronic obstructive pulmonary disease. The resident’s care plan did not include use of the left hand splint or refusal of the splint, even though a physician’s order dated 10/23/25 directed use of a left hand splint as tolerated during first shift and monitoring for redness or discomfort. The resident’s MDS assessment dated 05/14/26 documented moderate cognitive impairment and limited range of motion to both upper and lower extremities. Splint documentation for April, May, and June 2026 showed the resident refused to wear the left hand splint daily. Observations on 07/13/26 and 07/14/26 showed the resident had bilateral hand contractures and was not wearing the left hand splint. CNAs confirmed the resident had refused the splint for several months, and the unit manager stated she was not aware of the refusals and confirmed the physician had not been notified. The unit manager also confirmed the facility had not implemented any interventions to treat the resident’s contracture.
Failure to Maintain Ongoing Dialysis Communication and Assessment
Penalty
Summary
The facility failed to provide ongoing dialysis assessments and communication for a resident who received dialysis. The resident had diagnoses including end stage renal disease, chronic osteomyelitis, and dependence on renal dialysis, and the care plan stated that facility staff would coordinate the resident’s care with the dialysis center. The Minimum Data Set assessment indicated the resident had intact cognition, required set-up assistance with ADLs, and received dialysis. During interview, an LPN stated there was no routine paperwork documenting communication to or from the dialysis center on the resident’s scheduled dialysis days, and that communication was only recalled when there was a diet change, a lab order, or pertinent lab results. The DON confirmed the facility previously used a flowsheet for communication between the facility and the dialysis center, but it had not been used since January 2026 and she was unsure why it had been discontinued. The facility policy titled Dialysis stated there should be ongoing assessment before and after dialysis treatments and ongoing communication and collaboration with the dialysis facility.
Blood pressure medication given without required blood pressure checks
Penalty
Summary
The facility failed to ensure that blood pressure medication was administered as ordered for Resident #118. The resident was admitted with diagnoses including COPD, nonrheumatic aortic stenosis, and Raynaud's Syndrome, and the MDS indicated the resident was cognitively intact and needed assistance with ADLs. The physician's order dated 04/17/26 directed amlodipine besylate 5 mg daily and to hold the medication for systolic blood pressure less than 100. Review of the blood pressure record showed no blood pressure documentation for 07/12/26, 07/13/26, or 07/14/26, yet the MAR showed amlodipine was administered on those dates. During observation on 07/14/26 at 7:30 A.M., an LPN administered amlodipine to the resident without obtaining a blood pressure first, and later confirmed this in interview. The DON also confirmed the medical record did not support that blood pressure had been obtained before amlodipine administration on those three dates. The facility policy stated medications are to be administered in accordance with prescriber orders, including any required timeframe.
Failure to Coordinate and Document Hospice Services
Penalty
Summary
The facility failed to communicate and collaborate with hospice services for one resident receiving hospice care. Resident #9 was admitted with diagnoses including senile degeneration of the brain, chronic kidney disease, metabolic encephalopathy, and type two diabetes mellitus, and later had a physician order for hospice admission for senile degeneration of the brain. The MDS assessment indicated the resident was cognitively intact, required assistance with ADLs, and received hospice care, and the care plan included calling hospice with any changes, assisting with ADLs, providing comfort measures, and having hospice aide and nurse visits weekly and as needed. The medical record did not include a signed hospice contract between the facility and the hospice provider, and it also lacked documentation of hospice nurse and aide visits. During interview, the LPN Unit Manager confirmed the resident remained on hospice services, stated there was no signed contract with hospice services for the resident, and said there was no communication or documentation in the facility of hospice visits or any documentation of communication between the facility and the hospice provider. The facility policy stated it would obtain the hospice plan of care, hospice election form, physician certification and recertification of terminal illness, and hospice physician and attending physician orders specific to each resident.
Infection Control and Contact Precautions Not Followed
Penalty
Summary
Infection control procedures were not followed during medication administration for a resident with COPD, non-rheumatic aortic stenosis, and Raynaud's syndrome who was cognitively intact and required staff assistance with ADLs. During medication pass, an LPN found one medication packet already opened and the resident's Wellbutrin, Buspar, docusate, ferrous sulfate, and famotidine tablets lying loose on the bottom of the medication cart drawer. The LPN used a gloved hand to pick up the tablets, verified them against the packet description, placed them in a medication cup, and administered them to the resident. The LPN also poured all of the medications into the resident's mouth at one time, and when one pill missed the resident's mouth, used a bare hand to pick it off the resident's chest and place it into the resident's mouth. Transmission-based precautions were also not followed for a resident on contact precautions for MRSA in a surgical wound. Although a sign at the room indicated staff and providers must clean their hands before entering and leaving, wear gloves and a gown before room entry, and remove them before room exit, a CNA assisted the resident from the bed, readjusted the resident's gown, helped the resident stand, and held the resident's gown while walking him to the bathroom. The CNA then exited the bathroom and walked into the hallway, and later confirmed he did not wash his hands after removing his gloves and leaving the resident's room. The facility policy stated staff and visitors should wear gloves when entering the room and remove gloves and perform hand hygiene before leaving.
Failure to Notify Resident Representative of Antibiotic Order
Penalty
Summary
The facility failed to notify the representative of a resident in a persistent vegetative state about a new antibiotic order and the reason for its use. The resident, who had diagnoses including quadriplegia, chronic respiratory failure, anoxic brain damage, and a tracheostomy, was prescribed Augmentin for a bacterial infection following an examination that revealed redness and swelling of the right jaw and swollen glands. Despite the initiation of this treatment, there was no documentation in the medical record indicating that the resident's representative was informed about the antibiotic order or its purpose. The resident's representative reported being informed of the antibiotic treatment only a few days after it had started and was not provided with details about the medication's name or duration. The Director of Nursing confirmed the absence of documentation regarding the notification of the resident's representative and acknowledged that the facility lacked a policy for notifying residents or their representatives about changes in medical orders.
Failure to Resolve Resident's Grievance on Missing Property
Penalty
Summary
The facility failed to promptly resolve a grievance related to missing property for a resident. The resident, who was cognitively intact and had diagnoses including diabetes mellitus with diabetic peripheral angiopathy, peripheral vascular disease, and congestive heart failure, was hospitalized in early June 2024. During her absence, her roommate was discharged, and the roommate's family packed and took home the roommate's belongings. Upon returning to the facility, the resident noticed that three of her blankets were missing and reported this to Social Service. Social Service staff confirmed that the resident had informed them about the missing blankets and suspected that the roommate's family had taken them. Although a call was made to the roommate's family, no follow-up was conducted after leaving a message, and the grievance was neither documented in the grievance log nor in the resident's medical record. The facility's policy on Lost and Found requires that complaints of missing items be reported to the DON and that such reports are immediately investigated, which was not adhered to in this case.
Failure to Complete Timely Significant Change MDS Assessment
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment in a timely manner for a resident who experienced a significant change in condition. The resident, who was cognitively intact, had been admitted with multiple diagnoses including a nondisplaced intertrochanteric fracture, diabetes mellitus, peripheral vascular disease, and congestive heart failure. The resident was initially assessed as requiring varying levels of assistance with activities of daily living (ADLs) and did not have a pressure ulcer or weight loss. However, subsequent assessments revealed a decline in the resident's condition, including the development of a Stage III pressure ulcer and significant weight loss. Despite these changes, the facility did not complete a significant change MDS assessment for the resident between May and July. The Quality Assurance nurse confirmed that the facility had not conducted the necessary assessment following the resident's significant weight loss, the emergence of a Stage III pressure ulcer, and a decline in two or more ADLs. The facility's policy and the Resident Assessment Instrument (RAI) manual both require a comprehensive assessment when a significant change in a resident's condition occurs, impacting more than one area of health status. The RAI manual specifies that a significant change MDS is warranted when the resident's condition is not expected to return to baseline within two weeks and involves a decline in multiple areas, including ADLs, weight loss, and the emergence of a new pressure ulcer.
Failure to Implement Care Plan for Wandering Risk
Penalty
Summary
The facility failed to develop and implement a care plan for a resident with a known risk of wandering and residing on a secure unit. The resident, admitted on 05/13/24, had diagnoses of dementia with behavioral disturbance and Alzheimer's disease. The admission Minimum Data Set (MDS) assessment and a Wandering Risk assessment both indicated that the resident was at high risk for wandering. However, a review of the resident's care plan revealed no focus area or interventions addressing the risk of wandering or the need for residing on a secure unit. This deficiency was confirmed during an interview with an LPN, who verified the absence of these critical elements in the care plan.
Failure to Follow Mechanical Lift Protocols
Penalty
Summary
The facility failed to adhere to proper mechanical lift protocols during the transfer of a resident from bed to wheelchair, resulting in a deficiency. The resident involved had a history of cerebral infarction, diabetes mellitus type two, obesity, and heart disease, and was dependent on staff for transfers due to impaired cognition. According to the resident's care plan, transfers were to be conducted using a Hoyer lift with the assistance of two staff members to prevent falls and injuries related to mobility. During an observation, a State tested Nurse Aide (STNA) was seen using the mechanical lift to transfer the resident without the assistance of another staff member, contrary to the care plan and facility policy. The STNA confirmed that she was the only staff member present during the transfer, acknowledging the requirement for two staff members as per the resident's care plan and the facility's 'Mechanical Lift Policy'. This oversight in following established protocols led to the identified deficiency.
Lack of Medical Justification for Indwelling Catheter Use
Penalty
Summary
The facility failed to ensure that a resident with an indwelling catheter had a valid medical justification for its use. This deficiency affected one resident who was admitted with an indwelling catheter due to urinary obstruction while hospitalized. However, the medical record did not contain documentation to support the continued use of the catheter, nor was there evidence that the facility attempted to discontinue it. The resident had a history of bladder continence, used a urinal, and required extensive assistance with toileting. The resident, who had moderate cognitive impairment and was dependent on staff for toileting, was admitted with several diagnoses, including right above the knee amputation, atrial fibrillation, diabetes mellitus, hypertension, peripheral vascular disease, and anemia. Despite these conditions, the facility did not have a policy related to the use of indwelling catheters, only on how to care for them. The Director of Nursing confirmed the lack of documentation for medical justification and the absence of attempts to discontinue the catheter.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to assess the need for bed rails for a resident, identified as Resident #21, who was admitted to the facility and began receiving hospice services. The resident had multiple diagnoses, including Alzheimer's disease and dementia, and was under the care of a medical Power of Attorney (POA), their daughter. Despite the use of bed rails being documented in a consent form, there was no indication of the purpose, release schedule, or physician orders for the bed rails. Additionally, the consent form lacked signatures from the POA or a physician. The resident's care plans included the use of bed rails for bed mobility, but no physician orders or assessments for bed rails were found in the medical records. Observations and interviews revealed that the bed rails were in use, but the facility's documentation did not reflect this. A State tested Nurse Aide confirmed the use of bed rails during care, and a Quality Assurance Nurse verified that the bed rails were not coded in the Minimum Data Set (MDS) assessments. The facility's policy on bed safety and bed rails required specific criteria to be met before their use, including resident assessment and interdisciplinary team evaluation, which were not completed for this resident. The lack of proper assessment and documentation led to the deficiency identified by the surveyors.
Delayed Response to Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure timely response to pharmacy recommendations for a resident, leading to a deficiency in medication management. The resident, who was admitted with diagnoses including Parkinson's disease, depression, anxiety, vascular dementia, and unspecified psychosis, was receiving an antipsychotic medication. The pharmacist recommended that vitamin B12 level, vitamin D level, and an iron panel be completed for the resident. The physician agreed to have these labs drawn at the next laboratory draw. However, the laboratory tests were not conducted until three months after the recommendation, despite a lab draw occurring in the interim. The Director of Nursing confirmed that the physician had signed off on the recommendation, but the necessary tests were not ordered until much later. This delay in executing the pharmacy's recommendations affected the resident's care and highlighted a lapse in the facility's medication management process.
Unnecessary Medication Use for UTI Prevention
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medication use. This deficiency was identified in the case of a resident who had been diagnosed with a urinary tract infection (UTI) on multiple occasions. The resident, who had a medical history of renal cancer and an acquired absence of a kidney, was prescribed Macrodantin indefinitely for prophylactic purposes. Despite the resident experiencing only nocturnal urination without other symptoms of a UTI, the medication was continued as per the recommendation of an outside urologist. Interviews with the resident's physician and a urology nurse practitioner confirmed the indefinite use of Macrodantin to prevent further UTIs and protect the remaining kidney, despite the resident having experienced four UTIs in the past year without specific dates provided.
Failure to Prime Insulin Pen Leads to Medication Error
Penalty
Summary
The facility failed to adhere to proper medication administration procedures, resulting in a significant medication error involving a resident with diabetes mellitus. The resident, who was cognitively intact and required insulin, was prescribed Humalog Kwikpen to be administered subcutaneously before meals. During an observation, an LPN prepared the insulin pen for administration but did not prime the pen as per the manufacturer's instructions. The LPN attached the needle, set the dose to 10 units, and administered the insulin without performing the necessary air shot to ensure the correct dose. The facility's policy on medication administration, as well as guidance from Medscape and the Kwikpen reference guide, clearly state the importance of priming the insulin pen with a two-unit air shot before each use to avoid air and ensure the proper dose. The LPN confirmed in an interview that she did not perform this step prior to administering the insulin. This oversight was identified as a significant medication error, affecting the resident's care and highlighting a deviation from established medication administration protocols.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that medications were consumed at the time of administration and not left unsupervised at the resident's bedside. This deficiency was identified during an observation and interview with a resident, who had a medication cup with several medications left on their bedside table. The resident reported that the nurse left the medications there while she went to get supplies for an intravenous medication, and no nurse was present in the room or hallway at the time. The resident involved was alert and oriented, with a medical history that included aftercare following joint replacement, acquired absence of the right hip joint, anemia, anxiety, and hypertension. The medications due for administration included celecoxib, cholecalciferol, Cymbalta, folic acid, leflunomide, metoprolol, a multivitamin, aspirin, rifampin, ferrous sulfate, gabapentin, and pantoprazole. The facility's policy on administering medications, revised in April 2019, requires that medications be administered safely, timely, and as prescribed, with observation of consumption, which was not adhered to in this instance.
Failure to Follow Isolation Protocols for Resident with Open Wounds
Penalty
Summary
The facility failed to adhere to its infection prevention and control program, specifically regarding isolation protocols for a resident with open wounds. Resident #47, who was at risk for infection due to conditions such as cerebral infarction, diabetes type two mellitus, and heart disease, was placed under Enhanced Barrier Precautions (EBP) as per the facility's policy. The care plan for Resident #47 included interventions to follow isolation protocols to prevent infection spread. However, during an observation, it was noted that a State tested Nursing Aide (STNA) entered the resident's room without donning the required personal protective equipment (PPE), such as gloves and a gown, while performing personal care tasks including incontinence care and transferring the resident from bed to wheelchair. The STNA confirmed in an interview that she did not follow the EBP protocols, acknowledging the absence of gloves and a gown during the care process. The Infection Control Preventionist (ICP) also confirmed that Resident #47 was under isolation protocols due to open wounds and that the facility's policy mandated the use of appropriate PPE for all staff providing personal care to residents under EBP. The facility's policy, dated 07/15/22, clearly stated that all residents with wounds should be placed under EBP, requiring staff to wear gowns and gloves during care activities to prevent infection spread.
Failure to Provide Required Beneficiary Notices
Penalty
Summary
The facility failed to provide two residents with the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) and the Notice of Medicare Provider Non-Coverage (NOMNC). For Resident #58, the medical record indicated that the last covered day of Part A service was 03/11/24, and the NOMNC stated that services would end on the same date. A handwritten note by Quality Assurance (QA) #328 mentioned that the resident's daughter was informed of the last covered day and the right to appeal through Livanta. However, the form was not signed by the resident or their family, and there was no verification that the notification letter had been sent, despite QA #328's claim of sending it via certified mail. Similarly, for Resident #91, the SNF ABN indicated that the last covered day of Part A service was 03/08/24, with the NOMNC also stating that services would end on that date. QA #328 documented that the resident's daughter was notified of the last covered day and the right to appeal, but again, the form lacked signatures from the resident or family. QA #328 stated that the letter was sent via certified mail, yet the facility had no proof of this action. These deficiencies affected two of the three residents reviewed for beneficiary notices, with the facility census being 99.
What surveyors are citing around you — mapped
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What surveyors actually found near you
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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.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Troy
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Troy Rehabilitation And Healthcare Center | 3.8 mi | ★★★★★ | 19 | 0 |
| Ayden Healthcare Of Piqua | 4 mi | ★★★★★ | 0 | 0 |
| Piqua Manor | 4.8 mi | ★★★★★ | 13 | 0 |
| Stillwater Skilled Nursing And Rehabilitation | 6.9 mi | ★★★★★ | 11 | 0 |
| Springmeade Healthcenter | 8.1 mi | ★★★★★ | 0 | 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 October 2026) and official state health department websites.