Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 Warren Nursing & Rehab during CMS and state inspections, most recent first.
A resident with chronic lung disease and ventilator dependence developed severe pneumonia and tested positive for legionella after the facility failed to maintain an effective water management plan, including proper flushing and documentation of water systems, and did not update protocols following flooding and unit closure. Environmental observations revealed mold, water damage, and lack of signage or communication about water restrictions. Additionally, a respiratory therapist provided care to a resident in contact isolation for C. diff without proper PPE, putting multiple residents at risk.
Multiple residents experienced the development or worsening of pressure ulcers due to the facility's failure to ensure pressure-relieving mattresses were functioning, delays in implementing recommended nutritional interventions, and inadequate monitoring and communication among staff. These deficiencies resulted in actual harm, including new and deteriorating wounds.
A resident with a history of UTIs reported symptoms of frequent urination and burning, but despite a nurse practitioner ordering a urine analysis, the order was not entered or acted upon by an LPN for two days. The resident's symptoms persisted, and after further decline, including altered mental status, she was hospitalized and diagnosed with acute UTI, bacteremia, and acute kidney injury. Staff interviews confirmed the delay in obtaining and processing the UA, and the resident expressed that her complaints were not taken seriously.
The facility assigned an RN as Infection Preventionist before she obtained the required certification and without prior formal training. Infection control logs and surveillance maps were incomplete, with several infections, including C. diff and Candida Auris, not documented for multiple months. The previous IP provided only brief on-the-job training and ceased oversight after changing roles. Staff and the infectious disease physician confirmed ongoing issues with infection control documentation and oversight.
Surveyors identified multiple failures to maintain a safe and sanitary environment, including unresolved water leaks, mold, pest infestations, and structural hazards such as broken flooring and unsecured door protectors. Staff confirmed ongoing issues with rodents, persistent odors, and delayed repairs, while observations revealed unsanitary conditions in resident areas and utility rooms.
Unsanitary Dumpster Area: The facility failed to maintain a sanitary garbage storage area when surveyors observed a torn-open trash bag on the ground beside the dumpsters and two additional trash bags on the ground between them, with used gloves, straws, and plastic silverware scattered nearby. The Administrator verified the condition of the dumpster area, and the facility policy stated storage areas should be kept clean and outside dumpsters free of surrounding litter.
Incomplete CNA Orientation Documentation: Personnel record review found that 14 newly hired CNAs had no completed clinical nursing assistant orientation forms in their files. The HRD verified the missing documentation, and the facility’s orientation agenda stated the checklist must be returned before a CNA takes an individual assignment. The CNA job description also stated responsibility for resident care and adherence to Residents Rights.
The facility did not maintain required room temperatures, resulting in cold conditions in resident rooms and common areas. Several residents reported discomfort, used extra blankets, or avoided communal spaces due to the cold. Staff confirmed the issue, and maintenance records showed unresolved heating system problems and improper gas pressure settings.
The facility did not consistently complete or provide required information on dialysis handoff communication reports for multiple residents receiving dialysis, omitting vital signs, weights, code status, mental status, and other critical information. Nurse signatures were often missing, and there was a lack of documentation regarding access sites and catheter dressings after dialysis. Staff interviews confirmed that the expected processes for communication and assessment were not followed, and care plans lacked necessary interventions for monitoring dialysis-related complications.
Surveyors found that two residents had medication cups with tablets left at their bedsides without authorization for self-administration, and expired wound care supplies, tracheostomy kits, and enteral feeding formula were stored for use. Nursing staff and the DON confirmed these lapses, which were not in accordance with facility policy requiring secure storage and removal of expired items.
Surveyors observed that trays of mini pizza were transported uncovered from the kitchen to the dining area, which was confirmed by the Dietary Manager as not meeting professional food service standards. This affected multiple residents receiving meals from the second floor kitchenette.
Delayed Nutrition Orders and Inadequate Monitoring of High-Risk Residents: The facility failed to timely implement RD recommendations and to monitor high-risk residents receiving enteral nutrition. A resident with ventilator dependence and a G-tube had a tube feeding increase delayed, another resident with multiple serious conditions had a liquid protein supplement delayed for wound healing, and two residents on tube feeds did not consistently receive nutrition meeting estimated needs. An LPN also verified one resident’s tube feeding pump had not been restarted after dialysis. In addition, a high-risk resident with ESRD and dialysis was not evaluated monthly as expected and had a gap in nutrition follow-up despite significant weight loss.
The facility failed to keep sugar-free syrup and sugar-free jelly available for residents on CCHO/LCS diets. An LPN reported diabetic residents were receiving regular syrup and regular jelly instead of sugar-free condiments, and observation confirmed none were available in the kitchen. The diet spreadsheet and facility policy both indicated diet syrup and diet jelly were part of the planned menu.
Missing vaccine consent and administration documentation: The facility failed to obtain or retain influenza and pneumococcal consent or declination forms for several residents, and for residents who received vaccines, required MAR details such as site, lot number, and expiration date were not documented. Affected residents had significant medical histories including CHF, CKD, ESRD, COPD, respiratory failure, diabetes, and ventilator or tracheostomy dependence. The IP RN confirmed signed consent was required before vaccination and that the missing documentation elements should have been recorded.
Failure to obtain and document COVID-19 vaccine consent or declination for five residents. One resident had signed consent, but the vaccine was not administered and the IP RN could not explain why. Four other residents had no consent or declination in their records. Diagnoses included CHF, CKD, ESRD, COPD, trach status, ventilator dependency, and respiratory failure.
Three residents with self-care deficits did not receive adequate assistance with ADLs, resulting in unwashed hair, dirty fingernails, and lack of oral care, despite the availability of supplies and care plans indicating the need for such support. Staff and policy review confirmed that necessary hygiene care was not consistently provided.
The facility failed to ensure that a resident received an ordered MRI following a suspicious mass finding, with no documentation confirming completion or results. Another resident with a surgical wound did not receive wound care for several days after returning from hospitalization due to missing orders, and a third resident with arterial ulcers did not have dressings changed daily as ordered. Staff interviews and record reviews confirmed lapses in following physician orders and documentation requirements.
A resident with a PICC line for IV therapy did not have appropriate orders or interventions in place for routine line maintenance, including flushing before and after medication administration, dressing changes, or infection monitoring. As a result, the resident missed doses of IV antibiotics due to line occlusion, and there was no documentation of line replacement or discontinuation. Facility policy requirements for central line care were not followed.
Three residents did not receive respiratory care in accordance with professional standards and facility policy. An LPN performed tracheostomy care using only saline instead of the required hydrogen peroxide, and two residents receiving oxygen therapy had tubing that was either not dated or not changed weekly as required. Staff interviews and policy reviews confirmed these lapses.
Two residents experienced significant medication errors when an LPN failed to prime an insulin pen before administration and an RN delayed both notifying a physician about a wound infection and starting a prescribed antibiotic, despite the medication being available on-site. These actions did not follow manufacturer instructions or facility policy for timely and correct medication administration.
The facility did not obtain or complete physician-ordered laboratory tests for three residents with complex medical needs, including those with diabetes and chronic illnesses. Despite orders for regular lab monitoring, required tests such as Hemoglobin A1C, TSH, Depakote levels, CBC, CMP, and uric acid were missed or not performed as scheduled. Staff interviews confirmed the absence of a tracking system for labs and no formal lab policy, resulting in missed tests for multiple residents.
A resident with multiple complex medical conditions had a recommended MRI scheduled several times, but there was no documentation confirming completion or results in the medical record. After a significant change in condition and new medication orders, there was also no documented follow-up or further physician communication. Interviews with the DON and an LPN revealed gaps in awareness of documentation policy and inability to confirm care details, resulting in incomplete records and communication lapses.
Call lights were not kept within reach for three residents. One resident had severe cognitive impairment, bilateral extremity impairment, and was dependent for all ADLs; two other residents were cognitively intact, with one at fall risk related to COPD and another with blindness. In each observation, the call light was wrapped around the overbed light and placed out of reach, and an LPN or CNA verified the findings. The facility policy stated call lights should be placed within resident reach when leaving the room.
Advance directive code status was not kept accurate for a resident with dementia and other significant diagnoses. The resident remained documented as Full Code even after the mother requested a change to DNRCC during a care conference, and the update was not reflected in the record until later when an LPN verified the signed DNRCC form was on the nurse’s desk for scanning.
Failure to notify the emergency contact of a resident’s change in condition. A resident with respiratory failure, ventilator dependence, neurogenic bladder, UTI, HTN, and trach status had a sudden decline with fever, low O2 sat, tachypnea, bleeding with suctioning, and blood in the urine. The MD ordered ER transfer, but the resident’s husband, listed as the primary emergency contact, was not informed of the transfer or hospital admission and later discovered she was gone when he came to visit. The DON confirmed the husband should have been notified.
Incomplete Comprehensive Care Plans for Mental Health, Discharge, and Trauma Needs. The facility failed to develop and implement complete comprehensive care plans for three residents. One resident had a mental health day program and psychiatric meds, but the care plan did not include related goals or interventions. Another resident had depression and wanted discharge planning discussed, but discharge needs were not included in the care plan. A third resident with PTSD and a trauma hx had documented triggers, but the care plan did not address those triggers, and staff were unaware of them.
Failure to ensure required physician visits were completed for a resident with severe cognitive impairment and multiple complex diagnoses, including malnutrition, aphasia, and a PEG history. Record review showed only two documented MD visits, and staff interviews confirmed the resident had not been seen by a physician since the last documented visit and that responsibility for monitoring routine physician oversight was unclear.
A resident with dementia and other chronic conditions did not receive timely dental services after staff and family reported broken or missing dentures. The resident’s mother was concerned about his ability to eat, but staff documentation was inconsistent, no follow-up notes addressed the denture issue, and interviews showed the resident had neither his own teeth nor dentures in place.
Failure to Honor Resident Food Preference: A resident with dx including PVD, COPD, and dysphagia ordered peaches from the at-your-request menu but received diced pears instead. During lunch observation, staff verified the wrong fruit was on the tray, and the DM stated the kitchen would not open a can of peaches for one resident. The RD later stated the resident’s reasonable dietary request should have been honored and peaches should have been provided.
A facility failed to maintain enhanced barrier precautions during care for a resident with multiple medical devices, including a tracheostomy and feeding tube. Staff, including an LPN and respiratory therapists, did not wear gowns during high-contact care, contrary to facility policy. The resident had a history of conditions such as epilepsy and respiratory failure, requiring strict infection control measures.
A facility failed to provide appropriate catheter care for a resident who required an indwelling urinary catheter. Despite a physician's recommendation, the catheter was not placed before hospitalization, and upon the resident's return, the care plan was not updated to include catheter care. Complications such as a labial tear and vaginal discharge were noted without follow-up or notification to the physician or family, violating facility policy.
A facility failed to maintain a medication error rate below five percent, resulting in a 7.69% error rate. An LPN did not administer two prescribed medications to a resident due to unavailability and incorrect dosage in stock. The resident, with a complex medical history, did not receive Fluticasone Propionate nasal spray and folic acid as ordered, violating the facility's medication administration policy.
A facility failed to notify a resident's representative about significant changes in the resident's condition, including infections with Candida auris and CRAB, and the need for contact isolation. The resident, who had severe cognitive impairment, was not documented as having their representative informed, contrary to facility policy. This deficiency was confirmed by the DON during an investigation.
A facility failed to implement a comprehensive care plan for a resident with epilepsy, bipolar disorder, and depression. The care plan lacked interventions for these conditions, and staff were unaware of necessary precautions. The DON confirmed the absence of required interventions, which were not reinstated after the resident's hospitalization.
A resident with complex medical conditions continued to receive venlafaxine ER capsules through a PEG tube, contrary to manufacturer's instructions, due to a failure in timely communication of a pharmacist's recommendation. The pharmacist identified the issue during a monthly review, but the recommendation to switch to an immediate release formulation was not communicated to the prescribing provider until over two months later. Interviews with staff confirmed the delay and inappropriate medication administration.
The facility failed to assess wounds, obtain appropriate treatment orders, ensure wound care supplies were available, and complete pressure ulcer treatments as ordered for three residents. This led to the deterioration of a resident's pressure ulcer into a Stage IV ulcer with osteomyelitis, lack of wound vac dressing changes due to supply shortages, and inadequate wound care for another resident.
The facility failed to develop and implement a comprehensive pressure ulcer prevention program for two residents, resulting in unstageable pressure ulcers. Staff were not knowledgeable about care plans, and treatments were not completed as ordered.
The facility failed to store tortillas, cheese, salami, and turkey properly, risking foodborne illness and contamination. Expired tortillas and undated packages of cheese, salami, and turkey were found during inspections. The Dietary Manager verified these findings, which violated the facility's food storage policy. This issue potentially affected 69 residents receiving food from the kitchen, with a total facility census of 86.
The facility failed to administer its resources effectively and efficiently, impacting the well-being of all 86 residents. Deficiencies included inadequate pressure ulcer prevention, care planning, environmental concerns, ADL care, hearing treatment, lab work, antibiotic stewardship, and vaccinations. The Administrator and DON were unaware of these issues and had not implemented any quality improvement plans.
The facility failed to have an updated and signed transfer agreement in place to accommodate residents in the event of an emergency. This affected 10 ventilator-dependent residents and had the potential to affect all 86 residents residing in the facility. The transfer agreement was last updated in July 2020 and was not signed by the local hospital listed in the agreement.
The facility failed to ensure residents and/or their responsible parties were included in quarterly care plan meetings, affecting five residents. The Social Service Designee and other staff confirmed that care plan meetings were not performed timely or on a quarterly schedule for these residents.
The facility failed to obtain proper written and witnessed authorizations to manage resident funds for four residents, including those with cognitive impairments and a court-appointed guardian. The Business Office Manager confirmed the lack of required signatures and witness verification.
The facility failed to maintain a clean, safe, and comfortable environment for several residents. One resident's room was repeatedly observed with a dirty floor, foul odor, and missing plaster. Two residents had broken window blinds that were not reported for repair. Additionally, two residents experienced uncomfortable room temperatures, with one wearing a coat indoors and the other confirming the room was cold. The facility lacked a policy for maintaining a comfortable environment, contributing to the residents' discomfort.
The facility failed to update care plans according to physician's orders for two residents. One resident with congestive heart failure and chronic kidney disease had no intake and output records despite it being in the care plan. Another resident dependent on renal dialysis also had no intake and output records, with the DON confirming the intervention was outdated.
The facility failed to ensure an effective antibiotic stewardship program, resulting in inappropriate antibiotic use for 28 residents. The Infection Control Preventionist identified that many residents did not meet the McGreer criteria for antibiotic use but did not take further action or inform the DON or Administrator. The facility's policy on antibiotic stewardship was not effectively implemented.
A resident, who was cognitively intact and had multiple diagnoses, requested a blanket from an Agency LPN but was only offered a sheet due to a perceived shortage of linen. Despite the resident's repeated complaints and visible frustration, the staff did not check other units or the laundry room, where blankets were available. The facility's policy on Resident Rights was not upheld in this instance.
The facility failed to convey funds within 30 days upon the death of a resident and did not notify two residents when their personal funds account balance was within two hundred dollars of the state-allowed limit. The Business Office Manager admitted to only making phone calls for notifications and not providing written notices.
The facility failed to ensure staff were knowledgeable about locating baseline care plans and utilizing Kardexes for newly admitted residents, leading to inadequate care for two residents. One resident did not receive necessary interventions to prevent pressure ulcers and proper ADL care, such as oral hygiene, while another lacked interventions for pressure ulcer prevention and ADL care. The DON's unfamiliarity with the electronic medical record system and the lack of staff training contributed to these deficiencies.
A resident with a history of multiple health issues experienced significant delays in receiving a hearing aid despite repeated requests and documented recommendations. The facility's lack of follow-through, missed appointments, and management turnover contributed to the prolonged delay, causing frustration and communication difficulties for the resident.
The facility failed to change nasal cannula oxygen tubing in a timely manner for two residents, one with outdated tubing and another with undated tubing, despite orders for weekly changes. Staff confirmed the discrepancies during observations.
Failure to Implement Effective Infection Control and Water Management Program
Penalty
Summary
The facility failed to develop, implement, and follow a comprehensive and effective infection prevention and control program, specifically regarding its water management plan to prevent the growth and spread of legionella bacteria. The deficiency was identified after a resident, who was bedbound, ventilator-dependent, and had not left the facility for over two weeks, became unresponsive and was hospitalized with septic shock and pneumonia. The resident subsequently tested positive for legionella pneumophila antigen and died in the hospital. Review of the facility's water management documentation revealed significant gaps, including the absence of updated control measures for areas affected by flooding and closure, lack of detailed plumbing schematics, and insufficient documentation of water system maintenance, flushing, and monitoring. There was no evidence that the water management plan had been revised to address changes in the physical plant, such as the closure of the Somerset unit after flooding, nor was there a written description of how water was supplied, heated, stored, or circulated throughout the building. Observations and interviews further revealed that water stagnation and potential sources of contamination were not adequately addressed. For example, the Somerset unit, which had been closed after flooding, still had water running to certain areas, and there were no logs or documentation to confirm that water lines were being flushed to prevent stagnation. In addition, the attic area above the affected resident's room showed signs of mold, water damage, a decomposed animal carcass, and leaking pipes, all of which were verified by maintenance staff. These environmental conditions, combined with the lack of clear signage and communication to staff regarding water restrictions and infection control measures, contributed to the risk of legionella exposure. The facility's infection control practices were also found lacking in other areas. For instance, a respiratory therapist was observed providing suctioning and tracheostomy care to a resident in contact isolation for Clostridium difficile infection without wearing appropriate personal protective equipment. This failure to adhere to standard infection control protocols had the potential to affect multiple residents on the same unit. Overall, the facility's inaction and insufficient oversight in both water management and general infection control practices led to the identified deficiencies.
Removal Plan
- Registered Nurse (RN) #431 notified the Medical Director, Administrator, Director of Nursing (DON) and Infection Control Physician of the Legionella case.
- Administrator, DON, Assistant Director of Nursing (ADON) and Human Resources instructed staff to avoid unflushed/restricted water and to use alternative (bottled or approved) water and ice.
- Administrator, Maintenance Director #368 and Dietary Director #317 implemented bottled water for all drinking and cooking.
- Use of ice machines, showers, whirlpool tub, hoppers were restricted on the Aspen unit and on the Birch, Dogwood, Crabapple units only bed baths with provided wipes were permitted as use of showers was restricted.
- Administrator, DON, ADON and Human Resources provided staff education to RNs, Licensed Practical Nurses (LPN), certified nursing assistants (CNA), Housekeepers, Activity staff, Respiratory Therapists (RT), and agency staff. The education included the Centers for Disease Control Legionella signs and symptoms, transmission, surveillance/detection, and the facility's water management program. For any staff not on the schedule due to leave or other reasons, education would be provided prior to start of next shift.
- DON and Registered Nurse (RN) #350 assessed all current residents for signs/symptoms of legionella infection (cough with phlegm, chest pain, fever, chills, and shortness of breath).
- Water was delivered to the facility by commercial provider.
- Bags of ice were delivered by commercial provider.
- Use of ice machine, sinks, showers, whirlpool tub, and hoppers were restricted on the remaining units of Birch, Crabapple, Dogwood and Somerset.
- A phone call was held with the local health department and Ohio Department of Health Bureau of Environmental and Radiation Protection for guidance on legionella mitigation and testing.
- Portable handwashing sinks were delivered and stationed on Aspen unit.
- Signage was posted by VPCS #806, RDCS #803, the DON, ADON and Respiratory Therapy Director instructing staff to avoid unflushed/restricted water and to use alternative (bottled/approved) water.
- ServPro performed professional attic cleaning on the Aspen unit including debris removal, HEPA vacuuming, antimicrobial treatment, stain/odor blocking sealant application, air/surface testing, removal of wet insulation, ceiling repair below the attic and vent pipe repair within the Aspen unit Hallway/Attic area between rooms 503, 508, 502, 509, 510 and 501.
- A phone call meeting was held with a legionella consultant to review the facility water management plan.
- Portable handwashing stations were delivered and stationed throughout the facility.
- Maintenance Supervisor (MS) #368 installed legionella prevention filters on the Aspen unit (in the shower room, medication room and rooms 501, 502, 503, 504, 505, 506, 507, 509, 510, 515, 516, 517, 518 and 519).
- Regional Director of Operation completed Somerset unit water flush which included full flushing of all pipes, bathrooms, sinks, hoppers and dialysis den. Documentation was submitted to the Administrator.
- An Ad Hoc Quality Assessment and Performance Improvement (QAPI) meeting was held with the Medical Director, VPCS, RDO, RDCS, Administrator, DON, MDS, Housekeeping, MS #368, Human Resources, RN #431 and the ADON for QAPI tracking including weekly flushing compliance, audit outcomes, symptom surveillance, environmental concerns, legionella water management program review and risk assessment analysis review.
- MS #368 installed additional legionella prevention filters to two hand sinks in dialysis, one hand sink in the therapy gym, one hand sink in the first floor public rest room, one hand sink in laundry and six sinks in the kitchen, one sink in the Birch, Dogwood, Crabapple medication rooms, one sink in the first floor dining room, one sink in the Dogwood shower room and the Crabapple room sinks in rooms 710, 716 and 718.
- RDO re-educated MS #368 on weekly flushing, documentation rules, proper procedures (15 minutes run time, full toilet flush/hopper flush) and reporting/escalation steps.
- RDO contacted an additional Legionella Consultant #901 for mitigation support.
- Legionella Consultant #901 performed water testing of samples collected across Aspen, Birch, Crabapple, Dogwood and Somerset units.
- The facility implemented a plan for clinical monitoring by the DON/ADON or designee to review resident documentation weekly for four weeks for symptoms such as temperature, pulse, respirations, blood pressure, oxygen level, lung sounds, cough and phlegm, chest pain, fever/chills, shortness of breath.
- The facility implemented a plan for environmental monitoring by the Administrator or designee to review flushing logs weekly for four weeks and monthly thereafter.
- The facility implemented a plan for enhanced surveillance by the DON/ADON to include enhanced respiratory illness monitoring and immediate reporting of suspected cases.
- The facility implemented a plan for the water management program to be on-going and include daily monitoring of temperature, disinfectant levels, flushing logs, legionella filters for placement and function twice a day and monthly Water Management Plan meetings until investigation closed.
Failure to Prevent and Manage Pressure Ulcers Due to Equipment Malfunction and Inadequate Nutritional Interventions
Penalty
Summary
The facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program, resulting in the development and worsening of pressure ulcers among multiple residents. Specifically, the facility did not ensure that pressure-relieving equipment, such as low air loss (LAL) mattresses, was functioning as intended. For example, one resident with severe cognitive impairment and a history of pressure ulcers developed a deep tissue injury to the thoracic spine due to a malfunctioning LAL mattress. Despite multiple work orders and staff notifications, the mattress remained unrepaired for an extended period, and there was no system in place for routine checks of air mattresses. Another resident was observed to be sunk into a malfunctioning LAL mattress with an active alarm, and the issue persisted for at least 30 minutes without resolution. The facility also failed to ensure that nutritional interventions were initiated and maintained as ordered to prevent and promote healing of pressure ulcers. Several residents with pressure ulcers or at high risk for skin breakdown did not receive timely or appropriate nutritional supplements, despite recommendations from registered dietitians. In some cases, recommendations for protein supplements or increased tube feeding rates were not communicated to or acted upon by nursing staff for weeks, and there was a lack of evidence that dietitians were notified of new or worsening wounds. Communication breakdowns between dietary, nursing, and administrative staff contributed to delays in implementing necessary interventions. Additionally, the facility did not provide adequate monitoring or documentation to demonstrate that residents were being properly assessed and interventions were being carried out as required by facility policy. For example, one resident was found to have an unstageable pressure ulcer without prior documentation of skin concerns or evidence of monitoring, and the dietitian was not notified of the wound until two weeks after its identification. The lack of interdisciplinary communication, failure to follow established protocols, and insufficient monitoring led to actual harm for several residents, including the development of new pressure ulcers and the deterioration of existing wounds.
Delayed Response to UTI Symptoms and Urine Analysis Order
Penalty
Summary
A deficiency occurred when a resident with a history of urinary tract infections (UTIs) reported symptoms including frequent urination and burning, which she stated had been present for a couple of days. The resident communicated her symptoms to nursing staff, and a nurse practitioner assessed her and ordered a urine analysis (UA) and labs to evaluate for a UTI. However, the order for the UA was not entered into the physician orders by the responsible LPN until two days later, and the UA was not collected at the time it was initially ordered. The resident continued to report symptoms and was seen again by the nurse practitioner, who reiterated the need for a UA, but the test was still not promptly obtained. On the day the UA was finally collected, the resident experienced a significant drop in oxygen saturation and heart rate during the process, requiring intervention by respiratory therapy and nursing staff. Shortly after, the resident exhibited altered mental status, and the physician was notified. The resident was subsequently sent to the hospital, where she was diagnosed with acute UTI, bacteremia, and acute kidney injury, and required intravenous antibiotics and hospitalization. The UA that was eventually collected was not sent to the lab due to the resident's transfer to the hospital. Interviews with facility staff confirmed that the initial order for the UA was not entered or acted upon in a timely manner, and staff could not provide a reason for the delay. The resident expressed dissatisfaction with the response to her complaints and believed that her condition worsened due to the delay in obtaining the UA. The facility's policy referenced following clinical guidelines for identifying UTIs but did not specify what those guidelines were.
Infection Preventionist Lacked Certification and Incomplete Infection Control Documentation
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP), a registered nurse, obtained the required Infection Prevention Certificate prior to assuming the role. The IP was hired and began working in the dual role of Infection Preventionist and Wound Care Nurse without prior formal infection prevention training, only receiving on-the-job training from the previous IP for two weeks. The certificate was obtained nearly two months after starting in the position. Additionally, the previous IP ceased oversight and involvement in infection prevention activities after transitioning to a floor nurse role. The facility also failed to maintain accurate and complete infection control logs and surveillance maps. Several infections, including Clostridium Difficile and Candida Auris, were not documented in the logs or maps for multiple months, and the December infection control log was not available for review until the end of the month, with no surveillance map provided. Interviews with staff and the infectious disease physician confirmed ongoing issues with infection control documentation and oversight, with the physician noting a severe problem related to high rates of severe opportunistic infections.
Environmental Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment, as evidenced by multiple observations of water damage, mold, pest infestation, and structural disrepair. Surveyors observed a large ceiling stain near a resident room, which was attributed to a roof leak that had occurred about a month prior. Despite claims that duct work had been replaced, further inspection revealed that the duct work was not replaced, wet insulation was left in the attic, and there were signs of water stains and mold on drywall. Additionally, a decomposed rodent was found in the ceiling, and animal nests were observed in the attic. Staff interviews confirmed ongoing issues with rodents and water leaks, and it was verified that air from the attic circulated into resident rooms. Further deficiencies were noted in various units, including the presence of lint and mold in ceiling vents, holes drilled through ceiling soffits, and standing water with black biofilm in a utility sink. There was also a pervasive musty odor in one unit, and a vent fan with a buildup of black substance. In the dialysis unit, broken and lifting floor panels were observed, along with a persistent foul odor consistent with drain backup. Staff reported that the flooring had been damaged by a flood and that repairs had not been completed, despite repeated requests. The odor was attributed to resident body waste draining under the floors, and cleaning efforts had not resolved the issue. Additional observations included a door protector that had separated from a resident room door, creating a sharp hazard, and a privacy curtain with a large stained area of either dried blood or feces. Attempts to secure the door protector were unsuccessful until it was eventually attached with screws. The facility's Infection Preventionist's office was also found to have extensive ceiling staining from prior roof leaks. Review of facility policy confirmed that the environment was expected to be clean, sanitary, and orderly, but these standards were not met.
Unsanitary Dumpster Area
Penalty
Summary
The facility failed to maintain a sanitary garbage storage area. During observation of the dumpsters, one large trash bag was found torn open and on the ground to the left of the dumpsters, and two large trash bags were on the ground between the dumpsters with trash including used gloves, straws, and plastic silverware lying on the ground. The Administrator verified the trash bags and trash on the ground around the dumpster area during interview. Review of the facility policy titled Food-Related Garbage and Refuse Disposal, dated October 2022, stated that storage areas would be kept clean at all times and would not constitute a nuisance, and that outside dumpsters would be free of surrounding litter.
Incomplete CNA Orientation Documentation
Penalty
Summary
The facility failed to ensure complete orientation for 14 newly hired CNAs, with personnel record review showing no completed clinical nursing assistant orientation form in the files for CNAs #436, #450, #440, #439, #457, #437, #438, #453, #455, #454, #408, #411, #416, and #388. The review was completed with the HRD, who verified that the clinical nursing assistant orientation forms were missing from those personnel files at the time of review. The records reviewed showed date of hire entries for each CNA, including hires from February through November 2025, but no completed orientation documentation was present in the files. The job description for State Tested Nursing Assistant stated that the CNA is responsible for delivering nursing care, monitoring resident stability and well-being, and demonstrating knowledge of and adhering to all Residents Rights. The undated New Employee Orientation Agenda - Day 2 (STNA ONLY) stated that the orientation checklist must be returned to the Staff Development Coordinator before taking an individual assignment.
Failure to Maintain Adequate Room Temperatures
Penalty
Summary
The facility failed to maintain adequate room temperatures in both the common area/dining room and resident rooms, resulting in temperatures consistently below the facility's policy requirement of 71 to 81 degrees Fahrenheit. Multiple residents reported discomfort due to the cold, with some choosing to remain in their rooms or use extra blankets to stay warm. Staff interviews confirmed that the cold temperatures led to residents refusing showers and avoiding communal spaces. Observations and temperature readings taken by staff and surveyors verified that temperatures in affected areas ranged from 64 to 69 degrees Fahrenheit. Maintenance records revealed ongoing issues with the heating system, including a need for replacement parts and improper gas pressure settings on several units. Despite adjustments made to some units, not all heating systems were properly serviced, leaving parts of the facility inadequately heated. The inability of staff to adjust thermostats in common areas further contributed to the problem, and documentation showed that the facility was aware of the heating deficiencies but had not fully resolved them at the time of the survey.
Failure to Maintain Communication and Documentation for Dialysis Care
Penalty
Summary
The facility failed to maintain adequate communication and collaboration with the dialysis clinic regarding the care and services for multiple residents requiring dialysis. Specifically, the facility did not consistently complete or provide required information on the Dialysis Hand Off Communication Reports for several residents, including vital signs, weights, code status, mental status, vaccination status, allergies, diet and fluid restrictions, compliance with diet and fluids, new medications, medical problems, lab draws, and signs or symptoms of infection. Additionally, nurse signatures were frequently missing from both pre- and post-dialysis sections of the communication forms, and there was a lack of documentation regarding the condition of access sites and catheter dressings upon residents' return from dialysis. Several residents with complex medical histories, such as end stage renal disease, chronic respiratory failure, dependence on ventilators, and feeding tubes, were affected by these deficiencies. For example, one resident with severe cognitive impairment and multiple comorbidities had repeated omissions in the reporting of vital signs, infection status, and nurse signatures before and after dialysis sessions. Other residents, including those with moderate cognitive impairment or intact cognition, also experienced similar lapses in documentation and communication, with entire sections of the required forms left blank and no evidence of pre- or post-dialysis assessments being completed. Interviews with facility staff, including LPNs and the DON, confirmed that the expected process for completing and reviewing dialysis communication reports was not being followed. The facility's own policies and the dialysis coordination agreement required written communication of changes in resident condition and compliance with medical management, but these were not adhered to. Furthermore, care plans for residents receiving dialysis often lacked interventions related to monitoring for changes in mental status, infection, or fluid status, and there were no physician orders for pre- and post-dialysis assessments for the affected residents.
Failure to Remove Expired Supplies and Secure Medications
Penalty
Summary
Surveyors observed that the facility failed to properly store and manage medications and biologicals, as well as remove expired medical supplies from storage. Specifically, two residents were found with medication administration cups containing tablets and capsules left on their bedside tables. Interviews with the residents and nursing staff revealed uncertainty about how long the medications had been left at the bedside, and there was no documentation indicating that either resident was authorized to self-administer medications. Both residents had significant medical histories, including chronic respiratory failure, tracheostomy status, and mental health conditions, but were assessed as having no cognitive impairment. Further observations in the medication storage rooms on two separate units revealed multiple expired tracheostomy care kits, wound dressings, enteral feeding formula, and dietary supplements stored for potential use. Interviews with nursing staff and the Director of Nursing confirmed the presence of these expired items. Facility policies required that all drugs and biologicals be stored securely and that expired or discontinued items be removed from storage, but these procedures were not followed, resulting in the cited deficiencies.
Uncovered Food Trays Transported During Meal Service
Penalty
Summary
During an observation of the evening meal service on the second floor, surveyors noted that an open food transport cart containing three full trays of mini pizza was being moved from the elevator toward the kitchenette near the dining room. The trays of pizza were not covered during transport from the kitchen on the first floor to the second floor dining area. In an interview, the Dietary Manager confirmed that the trays should have been covered during transport and acknowledged that they were not. This practice was not consistent with professional standards for food service safety and had the potential to affect 35 residents who received meals from the second floor kitchenette. The facility census at the time was 72, with 15 residents identified as not eating by mouth (NPO).
Delayed Nutrition Orders and Inadequate Monitoring of High-Risk Residents
Penalty
Summary
The facility failed to ensure nutritional recommendations were implemented in a timely manner for residents receiving enteral nutrition and other high-risk nutritional care. Resident #25, who had multiple serious diagnoses including chronic respiratory failure with ventilator dependence, tracheostomy, gastrostomy status, dysphagia, diabetes, congestive heart failure, and a history of traumatic injuries, was assessed for tube feeding and later had a recommendation to increase Jevity 1.5 from 40 ml per hour to 60 ml per hour. The recommendation was not ordered until 11/19/25, and the RD verified that the change had not been implemented until then after the recommendation had been communicated to ADON #350 by email and written notice. Resident #11, admitted with diagnoses including acute duodenal ulcer with perforation, acute kidney failure, acute respiratory failure with ventilator dependence, anemia, sepsis, diabetes, and other serious conditions, had a nutrition assessment recommending 30 ml of liquid protein daily to promote wound healing. The recommendation was made on 11/18/25, but the physician order was not entered until 12/02/25 and started on 12/03/25. The RD stated the expectation was that the facility would implement the recommendation within 24 to 48 hours after notification, and verified that the supplement was not implemented until 12/03/25 after the recommendation had been sent to ADON #350 and placed under the ADON’s door. Resident #2, who was dependent on enteral feeding, dialysis, and had diagnoses including chronic respiratory failure, end stage renal disease, dysphagia, and nutritional deficiency, was found to have tube feeding that did not meet estimated energy needs. The admission nutrition assessment documented estimated needs of 1500 to 1700 calories and about 55 grams of protein, while the ordered Nepro at 35 ml per hour for 20 hours provided 1260 calories and 56 grams of protein. After weight loss was identified, the tube feeding was increased to 40 ml per hour and later to 45 ml per hour, but the resident continued to lose weight. On observation, the tube feeding pump was not powered on after dialysis and the LPN verified it had not been restarted since the resident returned from dialysis at noon. Resident #21, who had sepsis, moderate protein calorie malnutrition, end stage renal disease requiring dialysis, diabetes, encephalopathy, cerebral infarction, dysphagia, and acute respiratory failure, was also receiving enteral feeding that did not meet estimated energy needs. The admission nutrition assessment documented estimated needs of 1682 calories and 67 grams of protein, while the ordered Vital AF at 45 ml per hour for 20 hours provided 1296 calories and 81 grams of protein. After significant weight loss was documented, the RD requested an increase to 65 ml per hour on 12/05/25, but the order was not implemented until 12/20/25 after a second request. The RD and ADON both described a breakdown in communication regarding who was responsible for contacting the physician and notifying the family. Resident #33, who had end stage renal disease, congestive heart failure, diabetes, morbid obesity, and dialysis dependence, was identified as high nutritional risk but was not evaluated on a monthly basis as expected. The record showed monthly nutrition notes were documented through 07/21/25, then none again until 10/14/25, despite the resident being considered high risk and having significant weight loss. The facility’s policy stated that significant weight loss or gain should be reported to the DON and reviewed in a risk meeting, and that nursing should notify the physician and family of significant weight loss. The record also showed the resident was not care planned to be on a weight loss program.
Missing Sugar-Free Condiments for CCHO/LCS Diets
Penalty
Summary
The facility failed to ensure sugar-free condiments were available in accordance with the planned consistent carbohydrate, limited concentrated sweets menu. An LPN reported that residents with diabetes had previously received sugar-free condiments, but recently were being served regular jelly and regular syrup instead of sugar-free syrup or sugar-free jelly on meal trays. During observation of the dry kitchen storage area and general kitchen environment, no sugar-free syrup or sugar-free jelly was available for resident use, and the Diet Manager verified that none was in the kitchen because none had been ordered. Record review showed the facility’s Consistent Carbohydrate Diet Spreadsheet included sugar-free or diet syrup and diet jelly with multiple breakfast meals for residents on the CCHO/LCS diet. The dietitian stated she was responsible for monthly kitchen inspection but was not sure whether the facility had the appropriate consistent carbohydrate food items according to the spreadsheets. Facility policy for the CCHO Diet (LCS) stated the diet used sugar substitutes, diet jelly, and diet syrup.
Missing vaccine consent and administration documentation
Penalty
Summary
The facility failed to ensure that consent or declination forms were obtained for influenza and pneumococcal vaccinations for multiple residents, and it also failed to document required vaccine administration details when vaccines were given. Resident #5, who had diagnoses including major depressive disorder, bipolar disorder, hypertension, congestive heart failure, and chronic kidney disease stage III, had documentation showing consent for both vaccines, and the MAR showed influenza and pneumococcal vaccines were administered, but the record did not include the site of administration, lot number, or expiration date. Resident #25 had diagnoses including chronic respiratory failure with hypoxia, hypertension, tracheostomy status, gastrostomy status, and traumatic subdural hemorrhage; the record showed consent for pneumococcal vaccination and documentation that the vaccine was given, but there was no influenza consent or declination and no documentation of the pneumococcal administration site, lot number, or expiration date. Resident #20, with diagnoses including acute on chronic respiratory failure, end stage renal disease, acute on chronic congestive heart failure, history of sepsis, and COVID-19, had no consent or declination documented for either influenza or pneumococcal vaccination. Resident #29, who had dependence on renal dialysis, end stage renal disease, COPD, and pulmonary hypertension, had documentation of pneumococcal vaccination but no influenza consent or declination. Resident #38, with type II diabetes, major depressive disorder, hypertension, tracheostomy status, ventilator dependency, acute pulmonary edema, and acute on chronic respiratory failure with hypoxia, also had no consent or declination documented for either vaccine. The Infection Preventionist RN confirmed that vaccinations were not to be given without signed consent and that administration site, lot number, and expiration date were required documentation, and the facility policy required signed consent or declination and documentation of vaccine details in the medical record.
Failure to Obtain and Document COVID-19 Vaccine Consent or Declination
Penalty
Summary
The facility failed to ensure resident consent or declinations were obtained for COVID-19 vaccinations for five residents reviewed. Resident #5 had a COVID-19 vaccination consent form dated 09/17/25, but the Medication Administration Record for September 2025 showed the vaccine was not administered, and the Infection Prevention RN stated she was not sure why the resident did not receive it after consenting. Resident #20, Resident #25, Resident #29, and Resident #38 each had medical records reviewed, including physician orders, MARs, and progress notes, and no consent or declination for the COVID-19 vaccine was present. Resident #5’s diagnoses included major depressive disorder, bipolar disorder, hypertension, congestive heart failure, and chronic kidney disease stage III. Resident #20 was admitted with acute on chronic respiratory failure, end stage renal disease, acute on chronic congestive heart failure, history of sepsis, and COVID-19. Resident #25 had chronic respiratory failure with hypoxia, hypertension, tracheostomy status, gastrostomy status, and traumatic subdural hemorrhage. Resident #29 had dependence on renal dialysis, end stage renal disease, COPD, and pulmonary hypertension. Resident #38 had type II diabetes, major depressive disorder, hypertension, tracheostomy status, ventilator dependency, acute pulmonary edema, and acute on chronic respiratory failure with hypoxia. Facility policy required residents to be offered the COVID-19 vaccine and for consent or declination, and if administered, vaccine details to be documented in the medical record.
Failure to Provide Assistance with ADLs Including Hair, Nail, and Oral Care
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs), specifically hair, nail, and oral care, for three residents who required such support. Observations and interviews revealed that these residents had unwashed, oily, and uncombed hair, as well as visible dirt under their fingernails. One resident also reported not having their teeth brushed since admission, despite oral care supplies being available in their room. These deficiencies were noted during multiple observations by surveyors and confirmed by nursing staff. The affected residents had significant medical conditions, including morbid obesity, diabetes with foot ulcers, and chronic respiratory failure, all of which contributed to their need for assistance with personal care. Care plans for each resident documented self-care deficits and interventions requiring staff to assist with ADLs as needed. Despite this, documentation and direct observation indicated that staff did not consistently provide the necessary grooming and hygiene care, even though alternative supplies such as bathing wipes and shampoo caps were available during a facility water emergency. Interviews with staff and review of facility policies confirmed that supplies for waterless hair washing and oral care were accessible and stocked. However, staff failed to utilize these resources to maintain residents' hygiene. The facility's policy required that residents unable to perform ADLs independently receive appropriate care to maintain grooming and personal hygiene, but this standard was not met for the residents reviewed.
Failure to Provide Ordered MRI and Wound Care Treatments
Penalty
Summary
The facility failed to ensure that a resident received a Magnetic Resonance Imaging (MRI) study as ordered following the identification of a suspicious right adnexal mass on a pelvic ultrasound. The MRI was scheduled on three separate occasions, but there was no documentation in the medical record confirming that the MRI was completed or providing results. Interviews with the DON and nursing staff revealed a lack of awareness regarding whether the MRI was performed or why it was rescheduled multiple times, and the DON was unfamiliar with the facility's documentation policy. The facility's policy requires that the medical record facilitate communication among the interdisciplinary team regarding the resident's condition and response to care, but this was not achieved in this case. Another deficiency involved a resident with a surgical wound on the coccyx, who was admitted with a stage 2 pressure sore that progressed to stage 4 and was later covered by a skin graft. After a hospitalization for unresponsiveness, the resident returned to the facility, but wound care orders were not re-entered until six days after readmission. There was no evidence of any dressing changes during this period, and the wound nurse confirmed that the receiving nurse did not re-enter the wound care orders as required. A third deficiency was identified for a resident with peripheral vascular disease and multiple arterial ulcers, who had physician orders for daily dressing changes to both lower extremities. Observation revealed that the dressings were not changed daily as ordered, with the dressing dates indicating they had not been changed on the required schedule. An LPN verified that the dressings should have been dated for the current day if they had been changed as ordered, confirming the lapse in care.
Failure to Maintain and Monitor PICC Line for IV Therapy
Penalty
Summary
The facility failed to implement appropriate interventions and orders for the maintenance of a peripherally inserted central catheter (PICC) line for a resident who required intravenous (IV) access for treatment of a wound infection. The resident had significant medical conditions, including diabetes with a foot ulcer, local skin infection, and MRSA. Medical orders included daily flushing of the PICC line, administration of thrombolytic agents for de-clotting, and IV antibiotics. However, there were no orders in place to monitor the PICC line for infection, change the dressing, or flush the line before and after medication administration, as required by facility policy. The care plan only included monitoring for infection and leaking, with no interventions for routine PICC line care. Review of the medication administration record showed that the prescribed thrombolytic agent was not administered, and progress notes documented missed antibiotic doses due to PICC line occlusion. There was also no documentation regarding when the PICC line was replaced or discontinued. The DON confirmed the absence of necessary orders for PICC maintenance and flushing after medication administration. Facility policies required regular flushing and dressing changes for central venous catheters, but these were not followed for the resident in question.
Failure to Provide Proper Respiratory and Tracheostomy Care
Penalty
Summary
The facility failed to provide respiratory care according to professional standards for three residents. For one resident with a tracheostomy and chronic respiratory failure, an LPN performed tracheostomy care using only saline-moistened gauze, without any cleansing agent or disinfectant, despite facility policy requiring the use of hydrogen peroxide for cleaning and disinfection. The LPN confirmed that only saline was used and acknowledged the policy requirement after reviewing it. Review of CDC recommendations also indicated that high-level disinfection is required for semi-critical patient care equipment, such as endotracheal tubes. Additionally, two other residents receiving oxygen therapy did not have their oxygen tubing changed or dated according to facility policy. One resident's oxygen tubing was not dated, and a nurse confirmed this during observation. Another resident's oxygen tubing was found to be dated more than two weeks prior, exceeding the facility's policy of weekly changes. The DON and respiratory therapist both confirmed that tubing should be changed weekly, and facility policy supported this requirement. These deficiencies were identified during complaint investigations.
Failure to Ensure Residents Are Free from Significant Medication Errors
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors, as evidenced by two separate incidents involving medication administration. In the first incident, a resident with diabetes mellitus type two was observed receiving insulin via a pen injector by an LPN who did not prime the pen prior to administration. The manufacturer's instructions for the insulin pen required priming before each use, and the facility's policy stated that nursing staff should have access to and follow manufacturer instructions for all insulin delivery systems. The LPN confirmed during interview that she did not prime the pen, directly contradicting both manufacturer guidance and facility policy. In the second incident, a resident with multiple complex medical conditions, including chronic respiratory failure, severe cognitive impairment, and a documented wound infection, experienced a significant delay in receiving a physician-ordered antibiotic. The wound culture results indicating infection were reported to the facility, but the responsible RN did not notify the physician until the following day, citing the end of her shift as the reason for the delay. After obtaining a verbal order for antibiotics, the RN entered the order to begin more than a day later, without checking the facility's medication supply or informing the physician of the delayed start. The antibiotic was available in the facility's automated medication machine at the time the order was given, but was not administered until 52 hours after the culture results were reported. Both incidents demonstrate failures to follow established protocols for timely and correct medication administration. The facility's policies required medications to be administered safely, timely, and as prescribed, and for staff to follow manufacturer instructions. In both cases, staff actions did not align with these requirements, resulting in significant medication errors affecting two residents.
Failure to Complete Physician-Ordered Laboratory Testing
Penalty
Summary
The facility failed to obtain and complete physician-ordered laboratory tests for three residents who required regular monitoring due to complex medical conditions. For one resident with diagnoses including diabetes mellitus, mood disorder, and other chronic illnesses, there was no evidence that Hemoglobin A1C or Depakote levels were completed after early August, nor that a TSH level was completed after early August, despite orders for these labs every three months. Another resident with multiple diagnoses such as acute respiratory failure, CHF, chronic kidney disease, and diabetes had orders for quarterly CBC, CMP, A1C, uric acid, and TSH tests, but none were completed after early June. A third resident with diabetes had a quarterly Hemoglobin A1C order, but no test was completed in September as required. Interviews with the DON and ADON confirmed that the ordered labs were not completed as scheduled and revealed there was no system in place for tracking when labs were due or completed. Additionally, facility leadership confirmed there was no formal lab policy, and staff relied solely on following physician orders without a structured process for ensuring compliance. These failures were identified during the review of medical records and staff interviews, affecting three residents reviewed for laboratory testing.
Incomplete Medical Record and Lack of Follow-Up Documentation
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident, resulting in missing documentation regarding a recommended MRI and inadequate follow-up after a significant change in the resident's condition. The resident, who had multiple complex diagnoses including cervical disc disorder, spinal stenosis, diabetes, quadriplegia, and a suspicious right adnexal mass, was admitted with a need for extensive assistance with activities of daily living. An ultrasound identified a large mass and recommended an MRI, which was scheduled three times, but there was no documentation in the medical record confirming whether the MRI was completed or the results obtained. Additionally, after the resident experienced elevated blood pressure and received new medication orders, there was no documented follow-up or further communication with the physician until vital signs were recorded again several weeks later. Interviews with the DON and an LPN revealed a lack of awareness regarding the facility's documentation policy and an inability to confirm whether the MRI was performed or why appointments were rescheduled. The facility's policy requires that the medical record facilitate communication among the interdisciplinary team regarding the resident's condition and response to care, but this was not achieved in this case. The deficiency was identified during the annual survey and was also investigated under multiple complaint numbers.
Call lights not kept within resident reach
Penalty
Summary
The facility failed to have call lights within reach for Resident #41, Resident #50, and Resident #56. Review of records showed Resident #41 was admitted with chronic respiratory failure and nontraumatic intercerebral hemorrhage, had severe cognitive impairment, impairment to both upper and lower extremities, and was dependent for all ADLs. The care plan identified a fall risk related to limited mobility and post-CVA status and included interventions to ensure the call light was available on the resident’s unaffected side and in reach. During observation, Resident #41 was lying in bed and the call light was wrapped around the overbed light approximately five feet above the resident’s head and completely out of reach; an LPN verified this finding. Resident #50 was admitted with heart failure, COPD, and diabetes mellitus type two, was cognitively intact, and had a care plan directing that the call light and personal items be within reach. During observation, Resident #50 was lying in bed and the call light was wrapped around the overbed light across the room; an LPN verified it was out of reach. Resident #56 was admitted with unqualified visual loss of both eyes and expressive language disorder, was cognitively intact, and had a care plan directing that the call light be maintained within reach. During observation, Resident #56 was lying in bed and the call light was wrapped around the overbed light approximately five feet above the resident’s head; a CNA verified the placement. The facility policy titled Answering Call Lights stated that when leaving the room, the call light should be placed within resident reach.
Advance Directive Code Status Not Kept Current
Penalty
Summary
The facility failed to ensure Resident #6’s advance directive code status was accurate. The resident was admitted with diagnoses including major depressive disorder, dementia, intracranial injury, essential hypertension, anxiety disorder, occlusion and stenosis of an unspecified cerebral artery, alcohol dependence, and unspecified psychosis. The medical record showed an advance directive order dated 05/07/20 for Full Code status, and a care plan dated 03/19/25 also identified the resident as full code. The Minimum Data Set indicated the resident had moderate cognitive impairment. During the care conference on 11/18/25, the resident’s mother requested that the code status be changed from Full Code to Do Not Resuscitate Comfort Care (DNRCC). The mother later confirmed she wanted the change made. The Director of Social Services stated the nurse unit manager was supposed to obtain the updated order and physician signature, but the code status remained unchanged in the record until 12/15/25, when an LPN verified the DNRCC form had been signed by the physician and was on the nurse’s desk for scanning into the medical record.
Failure to Notify Emergency Contact of Resident’s Change in Condition
Penalty
Summary
The facility failed to ensure that the emergency contact was notified of a resident’s change in condition and hospital transfer. Resident #38 had an admission diagnosis that included acute on chronic respiratory failure, ventilator dependence, neurogenic bladder, urinary tract infection, hypertension, and tracheostomy status, and the MDS showed intact cognition with dependence on staff for all ADLs except eating, which required substantial to maximal assistance. On 12/19/25, the resident experienced a significant change in condition with bleeding during suctioning, blood in the urine, a temperature of 102.1 degrees Fahrenheit, respiratory rate of 31 breaths per minute, and oxygen saturation of 66 percent. The resident was removed from the ventilator, manually bagged on 15 liters of oxygen, suctioned for moderate amounts of brown bloody secretions, and noted to have dried blood on the front teeth. The physician was notified and ordered transfer to the emergency room, and the resident was admitted to the hospital. A Change in Condition assessment authored by the DON stated the resident’s family was not notified of the hospital transfer. A progress note later documented that the resident’s husband came to the facility to visit and discovered she was not there and had not been informed. During interview, the husband stated he was upset that he was not notified when his wife was sent to the ER and admitted to the hospital, including admission to the ICU. The DON confirmed that the husband should have been called because he was listed as emergency contact number one and the resident was not able to make decisions on her care at the time of transfer due to altered mental status and the emergent situation. Facility policy required prompt notification of the resident, attending physician, and representative of changes in the resident’s medical or mental condition and/or status.
Incomplete Comprehensive Care Plans for Mental Health, Discharge, and Trauma Needs
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents, including care plan elements tied to mental health services, discharge planning, and trauma-related triggers. For Resident #19, the record showed diagnoses including type 2 diabetes mellitus with hyperglycemia, adult failure to thrive, homelessness, mood disorder, glaucoma, Guillain-Barre syndrome, obstructive sleep apnea, and panic disorder. The resident had a BIMS score of 15 and required set-up/supervision with all ADLs and mobility. The resident also signed consent for a mental health day program that included daily group therapy, individual behavioral support, psychiatric medication management, individual psychotherapy, and family psychotherapy, but the care plan only addressed social isolation and did not include any focus areas, goals, or interventions related to the mental health day program. For Resident #13, the record showed diagnoses including acute kidney failure, dehydration, anemia, osteoarthritis, chronic pain, hypertension, hyperlipidemia, major depressive disorder, moderate protein-calorie malnutrition, prior TIA, cerebral infarction without residual deficits, muscle weakness, and need for assistance with personal care. The MDS showed a BIMS score of 14, set-up assistance with oral care and eating, maximum assistance with dressing and bathing, dependence for toileting, verbal inappropriateness at times, and feeling down or depressed less than daily. The resident stated he hoped to go home soon to help care for his ex-wife and said no staff member had discussed discharge planning with him. The SSD stated discharge to the community was not appropriate at the time and also stated she did not have a part in creating the comprehensive care plan or in addressing psychosocial needs or interventions. The MDS nurse stated she was responsible for creating the entire care plan except dietary and activities needs and verified that discharge plans were not included in the resident's comprehensive care plan. For Resident #14, the record showed a diagnosis of PTSD and an order for haloperidol 10 mg at bedtime for PTSD. The quarterly MDS showed a BIMS of 15, PTSD as an active diagnosis, and use of an antipsychotic medication. A trauma evaluation documented a history of physical and sexual abuse and listed triggers as talking about the past. However, the care plan listed self-care deficit related to PTSD and later history of trauma with potential for re-traumatization, but did not list the triggers identified in the trauma assessment. A CNA stated she was unaware the resident had PTSD or any triggers that might upset him. The SSD acknowledged the trauma assessment listed triggers that were not addressed, and the facility policy stated the interdisciplinary care planning team is responsible for developing an individualized comprehensive care plan for each resident.
Failure to Ensure Required Physician Visits
Penalty
Summary
The facility failed to ensure that Resident #69 was seen face-to-face by a physician at the required intervals. The resident was admitted on 09/24/24 with diagnoses including cerebral infarction due to embolism of the left cerebellar artery, idiopathic aseptic necrosis of the right humerus, severe protein-calorie malnutrition, aphasia, adult failure to thrive, gastrostomy, hyperosmolality and hypernatremia, hypothyroidism, acute kidney failure, hyperkalemia, and dehydration. The record showed the resident was seen by an Infectious Disease doctor on 05/08/25 for a UTI and by the Medical Director on 09/07/25 after a fall, with no other physician visits listed. The MDS assessment indicated the resident had no BIMS score, and the resident was described as having memory problems, severely impaired cognitive skills, altered level of consciousness, and dependence on all ADLs except eating, which required setup assistance. Staff interviews confirmed the lack of ongoing physician oversight. The NP stated she had not seen the resident recently and had not heard any recent concerns from staff. An LPN confirmed the only documented physician visits were the two noted above. The DON stated she did not know who was responsible for monitoring whether residents were seen every 60 days by a physician, while the VPCS stated that responsibility belonged to the previous DON. The Regional Director of Clinical Services and the VPCS confirmed the resident had not been seen by a physician since 09/07/25 and that it did not appear the resident was being overseen by a physician. The facility policy on Physician Services stated physician visits are to be provided in accordance with current regulations and facility policy.
Delayed Dental Services and Missing Dentures
Penalty
Summary
The facility failed to provide timely dental services for one resident with a history of major depressive disorder, dementia, intracranial injury, hypertension, anxiety disorder, cerebral artery stenosis, alcohol dependence, and unspecified psychosis. The resident’s annual dental exam noted full dentures and stated he was doing well with them and had no dental concerns, but later progress notes documented the resident’s mother was concerned about broken dentures and asked staff to contact the dental company. After that note, there were no follow-up progress notes addressing the resident’s dentures or dental status, even though the care plan identified full upper and lower dentures and directed staff to report dental problems needing attention. Interviews and observations showed conflicting information about the resident’s dentures and no clear evidence that the denture issue was resolved. The resident’s mother stated the dentures were broken and she was concerned about his ability to eat. An LPN later found the resident did not have dentures in his mouth, and the resident said he did not know where they were. The resident then stated he had his own teeth, but observation showed he had neither his own teeth nor dentures. Additional staff interviews revealed one staff member believed the dentures should be in the resident’s room, another had never seen him with dentures in 10 years, and a CNA could not locate them in the room. A social service designee later stated the dentures had been broken and/or missing for one year and that the resident was added to the dentist list for the next routine visit.
Failure to Honor Resident Food Preference
Penalty
Summary
The facility failed to accommodate Resident #27’s food preference when the resident ordered peaches for lunch on the at-your-request menu but received diced pears instead. Resident #27 was admitted on 01/14/25 with diagnoses including peripheral vascular disease, COPD, and dysphagia, and had orders for a regular diet with mechanical soft texture, Magic Cup twice daily, and a health supplement twice daily. The quarterly MDS assessment indicated no cognitive impairment, and the care plan noted a potential for altered nutrition and hydration related to peripheral vascular disease and dysphagia, with interventions including food in separate bowls per resident request and serving the diet as ordered. During lunch observation, the menu listed peaches and Resident #27 stated he ordered peaches because he was unable to chew other fruit. The Therapy Director verified that diced pears were on the tray instead of peaches. The Dietary Manager stated the kitchen would not open a can of peaches for one resident, so Resident #27 did not receive the requested item. The Registered Dietician later stated she was unaware of the issue and that a resident’s reasonable dietary requests should be honored, adding that peaches should have been given to Resident #27.
Failure to Maintain Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure enhanced barrier precautions (EBP) were maintained during care for a resident with multiple medical conditions and devices, including a tracheostomy, ventilator, and feeding tube. The resident, identified as Resident #73, had a history of epilepsy, respiratory failure, congestive heart failure, muscular dystrophy, COPD, and other conditions. The resident required EBP due to the presence of indwelling medical devices and wounds, which increased the risk of multidrug-resistant organism (MDRO) infections. Observations revealed that staff members, including an LPN and respiratory therapists, did not adhere to the facility's EBP policy. The LPN was observed performing tasks such as ventilator tubing management, tracheal suctioning, and PEG tube care without wearing a gown, which was required for high-contact care involving medical devices. Similarly, respiratory therapists and a student were seen changing ventilator tubing and performing suctioning without donning gowns, despite the presence of thick mucus and the need for protective measures. Interviews with staff confirmed the lack of compliance with EBP protocols. The facility's policy, updated shortly before the observations, mandated the use of gowns and gloves for high-contact care activities for residents with wounds or indwelling medical devices, regardless of MDRO status. The deficiency was identified during a complaint investigation, highlighting non-compliance with the established infection prevention and control program.
Failure to Provide Appropriate Catheter Care
Penalty
Summary
The facility failed to provide appropriate care for Resident #80, who required an indwelling urinary catheter as recommended by a wound care physician. Despite the recommendation on 05/30/24, there was no attempt to obtain an order or place the catheter before the resident's hospitalization on 06/06/24. Upon returning from the hospital on 06/18/24 with an indwelling urinary catheter, the facility did not update the care plan to include catheter care, nor were there any documented orders or monitoring of the catheter until 06/28/24. Resident #80, who had multiple diagnoses including stage four chronic kidney disease and vascular dementia, returned from the hospital with an indwelling urinary catheter to prevent soiling of pressure ulcers. However, the facility failed to document any follow-up or care related to the catheter, leading to complications such as an open skin area on the labia and vaginal discharge, which were noted by RN #213 on 06/26/24. There was no evidence of follow-up or notification to the physician or family regarding these complications. The facility's policy required observation for complications and maintenance of the catheter system, but these were not adhered to. The Director of Nursing confirmed the lack of catheter orders and monitoring prior to 06/28/24, and there was no documented evidence of addressing the labial tear and discharge. This deficiency was investigated under Complaint Number OH00158051.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 7.69% during a review of medication administration. This deficiency was identified when two medication errors occurred out of 26 opportunities, affecting one resident. The resident involved had a complex medical history, including chronic obstructive pulmonary disease, chronic embolism and thrombosis, morbid obesity, hyperlipidemia, congestive heart failure, major depressive disorder, stage three chronic kidney disease, acute respiratory failure, and chronic gout. The resident was cognitively intact and on a scheduled pain regimen, receiving medications from high-risk drug classes such as antidepressants, anticoagulants, diuretics, and opioids. The errors occurred when the resident did not receive two prescribed medications: Fluticasone Propionate nasal spray and folic acid. The LPN responsible for administering the medications confirmed that the medications were not available at the time of administration. Although folic acid was in stock, it was not in the correct dosage, and the electronic ordering system did not allow for reordering the correct strength. The facility's policy required medications to be administered according to prescriber's orders, which was not adhered to in this instance. This deficiency was investigated under a specific complaint number.
Failure to Notify Resident's Representative of Infections and Isolation
Penalty
Summary
The facility failed to notify the representative of Resident #27 about significant changes in the resident's condition, specifically regarding infections and the need for contact isolation. Resident #27, who had severe cognitive impairment and was dependent on enteral feedings, tested positive for Candida auris and Carbapenem Resistant Acinetobacter baumanii. Despite these findings, there was no documentation indicating that the resident's representative was informed of these infections or the subsequent changes in treatment and care plan. The medical records and progress notes lacked entries confirming that the representative was notified of the positive cultures for C. auris and CRAB, or the need for contact isolation. The Director of Nursing confirmed the absence of such documentation, which was contrary to the facility's policy requiring notification of significant changes in a resident's condition. This deficiency was identified during an investigation under Complaint Number OH00155063.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to implement a person-centered comprehensive care plan for a resident, identified as Resident #27, which addressed their physical, mental, and psychosocial needs. The resident had a complex medical history, including intractable epilepsy, bipolar disorder, and depression, and was taking medications such as venlafaxine for depression and clonazepam for seizures and agitation. Despite these conditions, the care plan lacked focus, goals, or interventions for epilepsy, bipolar disorder, or depression, and did not include any measures related to the resident's recent hospitalizations for increased seizure activity or the use of psychotropic or antidepressant medications. Interviews with facility staff, including an LPN and STNA, revealed a lack of awareness and understanding of specific seizure precautions or care plan interventions for the resident's conditions. The Director of Nursing confirmed that the care plan was current but acknowledged the absence of necessary interventions for the resident's primary diagnosis of epilepsy. It was also confirmed that the care plan interventions were discontinued following the resident's hospitalization in March 2024 and were not reinstated upon their re-entry to the facility. This deficiency was investigated under Complaint Number OH00155063.
Failure to Act on Pharmacist's Drug Irregularity Report
Penalty
Summary
The facility failed to ensure that drug irregularities noted by the pharmacist were reported to the attending physician and acted upon in a timely manner. This deficiency affected a resident who was receiving venlafaxine ER capsules through a PEG tube, despite the manufacturer's specifications indicating that this formulation should not be opened and mixed with water. The pharmacist identified this irregularity during a monthly drug regimen review on 05/10/24 and recommended changing the medication to an immediate release formulation suitable for PEG tube administration. However, this recommendation was not communicated to the prescribing provider or attending physician until 07/18/24. The resident involved had a complex medical history, including intractable epilepsy, bipolar disorder, and depression, and was noted to have severely impaired cognition. Despite the pharmacist's recommendation, the resident continued to receive the inappropriate medication formulation for over two months. Interviews with facility staff, including an LPN and the DON, confirmed the delay in communication and the continued administration of the medication inappropriately. The DON revealed that incorrect contact information for the pharmacist contributed to the communication failure.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to assess wounds and obtain appropriate treatment orders upon re-admission from the hospital, failed to ensure wound care supplies were available, and failed to complete pressure ulcer treatments as ordered by the physician for three residents. Resident #60, who was severely cognitively impaired and dependent on staff for all activities of daily living, developed an unstageable pressure ulcer on the left sacrum that deteriorated into a Stage IV ulcer with osteomyelitis. The facility did not consistently assess or complete treatments as ordered, leading to the resident's transfer to the hospital. Additionally, there were no updated sacral wound care orders upon the resident's re-admission to the facility, and wound care was not completed as ordered on multiple occasions. Resident #79, who had moderate cognitive impairment and was dependent on staff for most activities of daily living, had two unstageable pressure ulcers upon admission. The facility failed to change the resident's wound vac dressing on multiple occasions due to a lack of available supplies. Despite the facility's policy to keep an extra stock of wound vac supplies, the wound vac representative confirmed that the facility had not reported running out of supplies. The facility's documentation also confirmed that wound vac supplies were not available on specific dates, and the wound care nurse was not informed about the shortage. Resident #7, who had severe cognitive impairment and multiple diagnoses including a Stage IV pressure ulcer, was re-admitted to the facility from the hospital without appropriate wound care orders. The facility failed to assess and document the resident's wounds properly, and there were no treatments in place for a pressure ulcer on the right hip. Observations revealed that the resident's coccyx dressing was saturated and not changed as required, and the wound care nurse was unaware of the right hip wound. The facility's policy on pressure ulcer prevention was not followed, leading to inadequate wound care for the resident.
Failure to Implement Comprehensive Pressure Ulcer Prevention Program
Penalty
Summary
The facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program for Resident #76 and Resident #82. Resident #82, who required substantial to maximum staff assistance with bed mobility and was totally dependent on staff for transfers and toileting, was found to have an unstageable pressure ulcer on his right buttock and an unstageable deep tissue pressure ulcer on his left heel eight days after admission. The facility did not provide evidence of effective interventions being in place prior to the development of these pressure ulcers or evidence that the pressure ulcers were identified before becoming unstageable. Additionally, the facility failed to ensure timely and accurate assessments and treatments were completed as ordered for Resident #82. Resident #76 was admitted with a stage four pressure ulcer to his coccyx and later developed a stage two pressure ulcer on his right ear. The facility did not have a baseline care plan in place for Resident #76 regarding the prevention of pressure ulcers and interventions until his comprehensive care plan was created nearly a month after admission. The Kardex for Resident #76 only included interventions related to seizure precautions and did not have any interventions for pressure ulcer prevention, which the STNAs relied on for care instructions. Additionally, there were instances where treatments for Resident #76's pressure ulcers were not completed as ordered. Interviews with facility staff, including the DON, LPNs, and STNAs, revealed a lack of knowledge on how to locate baseline care plans in the electronic medical record. The DON admitted to not being familiar with the system and therefore had not been educating the nurses on where to find the baseline care plans. This lack of knowledge and training contributed to the failure to implement and follow appropriate interventions for pressure ulcer prevention and management for both residents.
Improper Food Storage Leading to Potential Contamination
Penalty
Summary
The facility failed to store tortillas, cheese, salami, and turkey in a manner that prevents foodborne illness and contamination. During a tour of the dry storage area, a 36-count package of tortillas with an expired use-by date was found. Additionally, an inspection of the snack refrigerator revealed undated packages of American cheese, Genoa salami, and smoked sliced turkey breast. These findings were verified by the Dietary Manager at the time of observation. The facility's policy on food storage requires all products to be dated upon receipt, when opened, and when prepared, and any outdated or expired food products should be discarded. This deficiency had the potential to affect all 69 residents receiving food from the kitchen, although 15 residents were identified as receiving nothing by mouth. The facility census was 86.
Facility Fails to Administer Resources Effectively and Efficiently
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, impacting the well-being of all 86 residents. The Administrator and Director of Nursing (DON) did not identify or develop quality improvement plans for several critical areas, including pressure ulcer treatment, care planning, environmental concerns, ADL care, hearing treatment, lab work, antibiotic stewardship, and vaccinations. The Administrator and DON were unaware of these deficiencies and had not implemented any Quality Assurance Performance Improvement (QAPI) projects to address them. The facility did not develop and implement a comprehensive pressure ulcer prevention program, resulting in inadequate care for two residents. Additionally, the facility failed to ensure that residents and their responsible parties were offered the opportunity to participate in quarterly care plan meetings. The Social Service Designee (SSD) was not trained to conduct these meetings, and the Administrator was unaware of this oversight. Environmental concerns were also noted, with several residents' rooms being dirty, having broken window blinds, and experiencing cold temperatures. The facility failed to provide adequate ADL care for multiple residents, including oral care, hygiene, and grooming. One resident had not brushed his teeth since admission, while another had long, dirty fingernails and an unshaven face. The facility also did not address a resident's hearing concerns in a timely manner, and there was an incident of staff-to-resident physical abuse due to improper handling of an agitated resident. Additionally, the facility did not ensure that lab work was obtained as ordered by the physician and lacked an effective antibiotic stewardship program. Finally, the facility did not ensure that residents received or were offered pneumococcal and influenza vaccines.
Lack of Updated and Signed Transfer Agreement
Penalty
Summary
The facility failed to have an updated and signed transfer agreement in place to accommodate residents in the event of an emergency. This deficiency affected 10 ventilator-dependent residents and had the potential to affect all 86 residents residing in the facility. The facility utilized mechanical Ventilation, Oxygen, Cough, Suction, and Nebulizer (VOCSN) therapies with a total of up to 22 hours of battery backup per ventilator. During a document review, it was found that the transfer agreement was last updated in July 2020 and was not signed by the local hospital listed in the agreement. The Administrator confirmed the outdated and unsigned status of the transfer agreement during the review.
Failure to Include Residents in Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to ensure residents and/or their responsible parties were included in and offered the opportunity to participate in quarterly care plan meetings. This deficiency affected five residents, all of whom had not been involved in care planning meetings as required. Resident #13, with diagnoses including COPD, muscle weakness, and paranoid schizophrenia, had not been involved in care planning since September 2023. The Social Service Designee (SSD) confirmed that care plan meetings were not performed timely or on a quarterly schedule for this resident. Resident #18, who had severe cognitive impairment and required hands-on assistance with bathing, had not had a care plan meeting since admission. The resident's guardian confirmed that they had not been contacted for any care plan meetings despite requesting one. Similarly, Resident #25, who was cognitively intact and non-compliant with treatments, had not had a care plan meeting since November 2023. The SSD confirmed the lack of timely care plan meetings for this resident as well. Resident #56, who was cognitively intact and required assistance with transfers and showers, had not had a care plan meeting since admission. The SSD confirmed the lack of timely care plan meetings and scheduled an upcoming meeting. Resident #42, who was cognitively intact and required substantial assistance with daily activities, had not had a care plan meeting since September 2023. The SSD and the facility's Administrator and Director of Nursing confirmed that quarterly care plan meetings had not been conducted for this resident.
Failure to Obtain Proper Authorization for Managing Resident Funds
Penalty
Summary
The facility failed to obtain written and witnessed authorizations to manage resident funds, affecting four residents. Resident #18, who had severe cognitive deficits and a court-appointed guardian, had a fund management authorization form signed by the resident without a witness or guardian signature. Resident #34, with severe cognitive impairment, had no signed authorization for the facility to manage personal funds. Resident #38, with mild cognitive impairment, had a fund management authorization form signed without a witness signature. Resident #291, who was cognitively intact, also had no signed authorization for the facility to manage personal funds. Interviews with the Business Office Manager (BOM) confirmed the lack of proper signatures and witness verification. The BOM stated that witness signatures were only obtained when a resident signed with an X, which was not in compliance with the required procedures for managing resident funds. This oversight affected the financial management of the residents involved, as proper authorization and verification were not obtained as required.
Failure to Maintain Clean, Safe, and Comfortable Environment
Penalty
Summary
The facility failed to ensure a clean, safe, and comfortable environment for several residents. Resident #12's room was observed multiple times with a dirty floor, foul odor, and missing plaster on the wall. Despite daily and monthly cleaning protocols, the room remained unclean, and the housekeeper and housekeeping manager were unaware of any resident refusals for cleaning. The missing plaster was not reported to maintenance for repair, indicating a lapse in communication and follow-up on maintenance issues. Residents #48 and #71 had broken window blinds in their rooms, which were not reported to maintenance for repair. Resident #48 confirmed that the blinds had been broken since admission, and both the housekeeper and state-tested nurse aide verified the broken blinds. This demonstrates a failure in the facility's process for identifying and addressing disrepair in resident rooms. Residents #54 and #64 experienced uncomfortable room temperatures, with wall and floor temperatures recorded at 67 and 65 degrees Fahrenheit, respectively. Resident #54 was observed wearing a coat indoors, and Resident #64's mother confirmed the room was cold and that the facility had not acted on a proposal to add an additional heating unit. The facility's Vice President of Operations acknowledged the ongoing heating issue but did not take action as the existing unit was deemed functional. The facility lacked a policy for maintaining a comfortable environment, contributing to the residents' discomfort.
Failure to Update Care Plans According to Physician's Orders
Penalty
Summary
The facility failed to ensure resident care plans were updated to reflect the physician's orders, affecting two residents. For Resident #42, who had significant diagnoses including congestive heart failure, edema, diabetes mellitus type II, and chronic kidney disease, the care plan included monitoring intake and output per facility policy. However, there were no intake and output records available in the medical record, and the Director of Nursing (DON) confirmed that this intervention was no longer ordered by the physician but remained in the care plan from 2020. Similarly, for Resident #66, who had significant diagnoses including chronic obstructive pyelonephritis, chronic kidney disease stage III, and dependence on renal dialysis, the care plan included monitoring intake and output. However, there were no intake and output records available in the medical record. The DON confirmed that the intake and output intervention was carried over from previous care plans and was no longer ordered by the physician. Both residents were cognitively intact, as indicated by their BIMS scores of 15 out of 15.
Ineffective Antibiotic Stewardship Program
Penalty
Summary
The facility did not ensure they had an effective antibiotic stewardship program that monitored antibiotic use, including reducing the risk of adverse effects and the development of antibiotic-resistant organisms from unnecessary or inappropriate antibiotic use. This deficiency affected 28 residents out of 34 residents identified as ordered antibiotics during the months of February 2024 and March 2024. The facility census was 86. The report revealed that a significant number of residents receiving antibiotics did not meet the McGreer criteria for antibiotic use, indicating inappropriate or unnecessary antibiotic administration. The review of the facility's records showed that for February 2024, 27 occurrences of residents requiring antibiotic use were documented, and 25 of these did not meet the McGreer criteria. Similarly, in March 2024, there were 21 occurrences of residents requiring antibiotic use, and 14 of these did not meet the criteria. The Infection Control Preventionist (ICP) reviewed all residents on antibiotics and completed individual McGreer Criteria forms to determine if the antibiotics met the criteria. However, if the criteria were not met, no further action was taken, such as contacting the medical director, physician, or pharmacist, or discussing it with the Administrator or Director of Nursing (DON). Interviews with the ICP revealed that the lack of documentation in nursing notes was a significant reason why many residents did not meet the criteria for antibiotic use. Despite identifying this issue, the ICP did not bring it to the attention of the DON or Administrator, nor did they in-service the nurses on the importance of documentation. The Administrator and DON were unaware that most residents receiving antibiotics did not meet the McGreer criteria and acknowledged that there would be changes moving forward. The facility's policy on Antibiotic Stewardship, dated February 2019, emphasized the use of McGreer's criteria when considering the initiation of antibiotics and required monthly data compilation and interpretation by the ICP, which was not effectively implemented.
Failure to Provide Blanket to Resident
Penalty
Summary
The facility did not ensure Resident #80 was treated in a dignified and respectful manner after he requested a blanket from staff because he was cold, and the blanket was not provided. Resident #80, who was cognitively intact and had multiple diagnoses including chronic respiratory failure, COPD, and pneumonia, requested a blanket from an Agency LPN. The LPN checked the linen closet and found no blankets, only a sheet, which she offered to the resident. The resident expressed frustration and used profanity, stating that this was a recurring issue. Both the Agency LPN and an STNA acknowledged that there was often a shortage of linen, including blankets, and did not attempt to check other units or the laundry room for a blanket. Further observation revealed that the Agency LPN and STNA remained at the nursing station without making additional efforts to find a blanket. The resident continued to express his frustration and remained cold with only sheets. An inspection of the laundry room later revealed approximately a dozen blankets available. Interviews with the Director of Housekeeping and the Administrator confirmed that staff had access to the laundry room and should have checked there to accommodate the resident's request. The facility's policy on Resident Rights emphasized the importance of treating residents with dignity and respect, which was not upheld in this instance.
Failure to Convey Resident Funds and Notify of Account Balances
Penalty
Summary
The facility failed to ensure that funds were conveyed within 30 days upon the death of Resident #292. The resident was admitted with significant diagnoses including metabolic encephalopathy, adult failure to thrive, anxiety, and acute respiratory failure. Despite the resident's discharge on 11/10/23, a check for the remaining funds was not issued until 12/31/23, which was more than 30 days after the resident's death. This was confirmed through an interview with the Business Office Manager (BOM) #710 on 03/27/24. Additionally, the facility did not notify two residents when their personal funds account balance was within two hundred dollars of the state-allowed limit. Resident #8, who had a court-appointed guardian and was on Medicaid, had a balance of $2405.63 as of 03/27/24. The BOM admitted that she only makes phone calls to notify residents or their guardians about the need to spend down funds but does not provide written notifications. Similarly, Resident #34, who had severe cognitive impairment and was his own guarantor, had an account balance of $2321.45. There was no signed authorization for the facility to manage his personal funds, and the BOM confirmed that she does not give written notifications for spend down needs.
Failure to Implement and Access Baseline Care Plans
Penalty
Summary
The facility failed to ensure staff were knowledgeable about locating baseline care plans and utilizing Kardexes for newly admitted residents, leading to inadequate care for two residents. Resident #82, admitted with multiple diagnoses including myelodysplastic syndrome and diabetes, did not have a baseline care plan or Kardex in place from the date of admission. This resulted in the resident not receiving necessary interventions to prevent pressure ulcers and proper ADL care, such as oral hygiene. Interviews and observations revealed that staff were unaware of how to locate the baseline care plan in the electronic medical record, and the resident's toothbrush remained unused in his nightstand, indicating a lack of oral care since admission. Similarly, Resident #76, admitted with diagnoses including cerebral infarction and a pressure ulcer, also lacked a baseline care plan and Kardex interventions for pressure ulcer prevention and ADL care. The resident's Kardex only included seizure precautions, and staff interviews confirmed they did not know how to access baseline care plans. The DON admitted to not being familiar with the electronic medical record system and had not educated the nurses on locating baseline care plans, resulting in the absence of necessary care interventions for the resident. The facility's failure to have a care planning policy and the staff's lack of knowledge on accessing baseline care plans led to significant deficiencies in resident care. Both residents did not receive appropriate interventions for pressure ulcer prevention and ADL care, as evidenced by the lack of oral hygiene for Resident #82 and the absence of pressure ulcer prevention measures for Resident #76. The DON's unfamiliarity with the electronic medical record system and the lack of staff training contributed to these deficiencies, highlighting a systemic issue within the facility's care planning process.
Failure to Address Resident's Hearing Aid Request
Penalty
Summary
The facility did not ensure that a resident's concern regarding hearing and request for hearing aids were timely met. Resident #53, who had a history of diabetes, hypertension, congestive heart failure, and chronic obstructive pulmonary disease, was identified as having a risk for communication problems related to a hearing deficit. Despite an audiogram completed on 06/16/23 recommending a hearing aid for the left ear, there was no documented follow-up for a hearing aid from 06/16/23 to 10/10/23. The resident continued to experience hearing loss and ringing in his ears, and multiple progress notes and physician orders indicated the need for a hearing aid and further audiology consults, but these were not timely addressed by the facility. The resident expressed frustration over the delay and missed appointments, which were attributed to facility oversight and management turnover. Interviews with the Social Service Designee and the Director of Nursing revealed a lack of clarity and follow-through regarding the resident's request for a hearing aid. The Social Service Designee was unsure of the status of the resident's hearing aid request, and the Director of Nursing, who started in February 2024, confirmed that the resident had been waiting since 06/16/23 for a hearing aid. The resident had an appointment scheduled for 02/21/24, which was missed due to lack of transportation, and the next appointment was set for 04/12/24. The facility did not have a policy regarding hearing, which contributed to the delay in addressing the resident's needs. The Ombudsman had an ongoing open case since 03/28/23 regarding the resident's complaint of hearing loss and request for a hearing aid. The Ombudsman documented multiple attempts to follow up with the facility's management, including the former Director of Nursing and Administrator, but received limited responses and updates. The Ombudsman noted that the turnover in management staff affected the follow-through of the concern. Despite the resident's repeated complaints and the Ombudsman's efforts, the facility failed to provide timely and adequate follow-up for the resident's hearing aid request, resulting in prolonged communication difficulties for the resident.
Failure to Timely Change Oxygen Tubing
Penalty
Summary
The facility failed to change nasal cannula oxygen tubing in a timely manner for two residents. Resident #6, who has chronic obstructive pulmonary disease, morbid obesity, diabetes mellitus, and heart failure, was observed with oxygen tubing dated 02/07/24, despite orders to change the tubing weekly. The resident's Treatment Administration Record indicated the tubing was last changed on 03/20/24, but the observation on 03/25/24 revealed outdated tubing. An STNA confirmed the date on the tubing during the observation. Similarly, Resident #289, who has acute respiratory failure, chronic obstructive pulmonary disease, cryptogenic organizing pneumonia, and pulmonary fibrosis, was observed with undated oxygen tubing. The resident's medical record also indicated a weekly change order for the tubing. An LPN verified the absence of a date on the tubing and acknowledged that it should be changed weekly. The facility's policy on oxygen administration did not specify the frequency for changing oxygen tubing.
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 427 citations issued within 25 miles in the last 12 months — including the 7 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 Warren
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Gillette Nursing Home | 0.4 mi | ★★★★★ | 6 | 0 |
| Shepherd Of The Valley Howland | 1.1 mi | ★★★★★ | 0 | 0 |
| Washington Square Healthcare Center | 2.8 mi | ★★★★★ | 26 | 0 |
| Community Skilled Healthcare | 3 mi | ★★★★★ | 36 | 1 |
| White Oak Manor | 3.3 mi | ★★★★★ | 3 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Warren Nursing & Rehab.
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.