Below average — CMS composite of the measures below.
The next survey window likely opens around September 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 Blue Mountain Care Center during CMS and state inspections, most recent first.
Failure to Follow Transfer Care Plan: A resident with a hip fx had a care plan requiring use of a [NAME]-steady for transfers, but an LPN transferred the resident from a recliner to a w/c without using the device. The resident reported the staff member used a bear hug/stand-pivot method instead, and the LPN stated he was unaware of the transfer requirement and did not follow the care plan.
Failure to address a resident’s alcohol use and substance use disorder concerns. A cognitively intact resident with stroke, malnutrition, a G-tube, and an NPO diet was observed with signs of intoxication, and staff found alcohol in the room and documented that the resident admitted sneaking alcohol into the facility daily. The care plan did not include the resident’s alcohol use or any interventions, and multiple staff reported there were no documented interventions related to monitoring for intoxication or substance use.
The facility failed to ensure an LPN/RN was on duty for one of two reviewed days. The former DNS stated there was one night shift when no nurse was working, and the Administrator later confirmed the facility did not have a nurse on the night shift. Staffing records for the dates reviewed could not be located.
The facility failed to ensure RN coverage for at least 8 consecutive hours on 3 of 17 days reviewed. Direct care staff daily reports showed no required RN coverage on multiple days, and the Administrator acknowledged the missing coverage.
Incomplete and inaccurate staffing postings were identified when the facility could not locate required Direct Care Staff Daily Reports for multiple periods and the available reports had blank, crossed-out, or inaccurate entries. The forms were missing or incorrect for the daily census and number of working staff, and the Administrator acknowledged the reports were incomplete and inaccurate.
Facility administration failed to ensure required care planning participation, abuse reporting and investigation, face-to-face MD visits, qualified infection prevention oversight, and adequate nursing/CNA staffing. The administrator acknowledged that residents were not offered care conferences, an abuse allegation was not reported or thoroughly investigated, tele-health visits were used instead of required in-person MD visits, no certified infection preventionist was in place, and staffing records were missing or inaccurate with multiple shifts lacking required RN and CNA coverage.
The facility failed to submit required PBJ staffing data based on payroll and other verifiable and auditable records. Review of the staffing data for two quarters showed the required information was not submitted, and the Administrator confirmed the PBJ had not been submitted.
Infection prevention and control failures involved a community use glucometer and the facility’s water management program. An LPN and an RN did not consistently disinfect the glucometer between resident CBG checks, and the RN used the same meter for two residents without cleaning it first. The facility also had a Legionella water management policy but had not developed or conducted a risk analysis assessment for areas where water-borne pathogens could grow and spread.
The facility failed to have a qualified and trained IP in place for the infection prevention and control program. Staff reported that the IP had started the role but had not completed the required training, and the former IP had been assisting until leaving the facility. The Administrator confirmed the facility did not have a certified IP in place after the former IP’s departure.
Failure to obtain and document advance directive information for 4 sampled residents. A resident with diabetes stated they did not know what an advance directive was and had never been offered information, while another resident with depression had no record of an advance directive being reviewed or offered. One resident with heart failure had a form indicating an advance directive existed, but the facility did not obtain a copy, and another resident with heart failure and depression had a care plan for quarterly advance directive education that was not reflected in the record. Social Services stated a POLST was completed on admission and could not explain the process for offering or completing advance directives.
Physician Visits Not Completed Face-to-Face: The facility failed to ensure that three residents received required in-person physician visits every 90 days. The residents had diagnoses including dementia, muscle weakness, HTN, and DM, but their physician encounters were completed via telehealth, with the last documented face-to-face visits occurring months earlier. The Administrator stated she believed telehealth visits were acceptable and acknowledged the last in-person visit dates.
Failure to Obtain Consent for Psychotropic Medications: A resident admitted with depression and insomnia had orders for trazodone, sertraline, and bupropion, but the record showed no evidence that the risks and benefits were reviewed or that consent was obtained. The Administrator stated she could not locate any documentation showing informed consent for the three antidepressant medications.
Failure to involve residents in care planning: Four sampled residents, including residents with diabetes, depression, and heart failure, had no record of being offered or having a care conference since admission. Residents stated they had not been given the opportunity to review their care plans and wanted to attend, while Social Services confirmed there was no process in place to involve residents in their plan of care.
Failure to Report Allegation of Abuse: A cognitively intact resident with a hx of stroke and weakness reported that an LPN would not let the resident back into the building after going outside, and witnesses described the LPN locking the door and making a rude comment. The DNS did not interview the resident, did not complete an investigation, and did not report the allegation of abuse/verbal abuse to the SA; the Administrator was aware of the concern but the incident was still not reported.
Failure to Thoroughly Investigate Allegation of Abuse: A cognitively intact resident with a history of stroke and weakness reported being locked out of the facility by an LPN during night shift and having to wait until day shift to re-enter. Witnesses reported the LPN would not open the door and made a dismissive comment, causing the resident to cry. The DNS did not specifically interview the resident or another involved resident and did not complete an investigation; the Administrator stated the incident was not investigated.
The facility failed to discard an expired Humalog insulin vial used for a resident and failed to document medication refrigerator temperatures for two dates in a medication room and treatment cart area. An LPN observed preparing the insulin acknowledged it was past the 28-day discard date, and the refrigerator logs were blank even though insulin and other meds were stored inside.
Failure to provide routine dental services for a resident with HF. The resident reported it had been about a year since the last dental visit and said there were problems finding a dentist who could accommodate wheelchair use. The record showed no dental appointment had been made since admission, and Social Services could not provide information about when the resident's dental status was reviewed.
Failure to provide dental services for one resident was identified during record review and interview. A resident with heart failure, diabetes, and severe cognitive impairment had only three natural teeth remaining, and the family member stated the resident had not received routine dental cleaning in the past year. No dental cleaning history was found in the chart, and the Social Services staff member could not provide information about the resident’s last routine dental service.
Failure to provide ordered SLP services for a resident with dementia, severe cognitive impairment, dysphagia, weight loss, and recent lung CA. The resident had choking concerns and was awaiting SLP eval, but the facility lacked a consistent process for arranging ST, had no record of the hospital therapist’s evaluation, and did not follow up on the therapist’s recommendations or therapy authorization.
A resident receiving hospice services died in the facility, but the LPN did not notify hospice in a timely manner. The resident had vascular dementia and adult failure to thrive, and the chart lacked progress notes documenting the time of death or hospice notification. Hospice records showed the death was reported about 2 hours after the resident died, and the hospice RN stated staff were expected to notify hospice upon death so the family could be contacted timely.
A facility failed to maintain a medication error rate below five percent, resulting in a 19 percent error rate. Multiple residents with diabetes were administered insulin without priming the pens as per manufacturer instructions. Additionally, a resident with atrial fibrillation did not receive diltiazem despite meeting the parameters for administration. The involved RNs acknowledged their lack of awareness regarding the priming requirement.
A facility failed to follow professional standards, leading to delayed implementation of physician orders for a resident with post-surgical care needs and untimely skin assessments for another resident with a new wound. The DNS did not implement admission orders for three days, and a wound assessment was delayed by five days due to the absence of the RNCM.
Two residents requiring assistance with ADLs did not receive adequate nail care, as observed by surveyors. One resident with kidney disease and another with dementia had long, untrimmed nails, despite care plans indicating the need for regular nail care. Staff acknowledged the lack of specific documentation for nail care and confirmed the expectation for routine checks and trimming.
A resident readmitted for post-surgical care did not receive prescribed medications due to the facility's failure to implement physician orders. The DNS received the orders but did not implement them before leaving, despite the administrator's request. As a result, the resident missed doses of doxycycline, losartan, and pravastatin for three days.
The facility failed to assess and monitor pressure ulcers for two residents, leading to discrepancies in wound documentation and care. One resident developed a Stage 2 pressure ulcer on the buttock and forearm, while another had a Stage 4 ulcer with inconsistent measurements. The absence of the RNCM responsible for assessments contributed to the oversight.
Two residents did not receive timely doses of prescribed antibiotics due to a breakdown in the medication reordering process. One resident with chronic kidney disease missed multiple doses of Keflex, while another with diabetes experienced a delay in receiving cephalexin. The DNS was unable to verify medication availability, and the facility administrator acknowledged the reordering issue.
The facility failed to timely address pharmacy recommendations for three residents, leading to prolonged unnecessary medication use and unaddressed monitoring for potential heart risks. Despite pharmacy reviews suggesting medication changes and monitoring, physician responses were delayed, and staff acknowledged the lack of timely follow-up.
The facility failed to maintain accurate medical records for two residents with pressure ulcers, resulting in discrepancies in wound measurements. One resident had conflicting measurements recorded by the DNS on the same day, while another resident's measurements varied between a progress note, a Weekly Wound Observation Tool, and handwritten notes by an RN. These inconsistencies could impact the accuracy of resident care.
Failure to Follow Transfer Care Plan
Penalty
Summary
The facility failed to follow Resident 4’s comprehensive care plan for transfers. Resident 4 was admitted in 2026 with diagnoses including a hip fracture, and the 4/13/26 care plan directed that the resident be transferred using a [NAME]-steady sit-to-stand transfer device. An email from the OT on 5/12/26 stated Resident 4 reported being transferred from a recliner to a wheelchair by an LPN without using the [NAME]-steady, and the email noted the resident was not to be transferred any other way than by using the device. On 5/27/26, the OT stated Resident 4 reported being transferred by stand pivot instead of using the [NAME]-steady. The resident stated an LPN assisted by grabbing the resident and transferring the resident from the recliner to the wheelchair, with the resident placing hands on the staff member’s shoulders, and that the staff member did not ask about transfer status. The LPN stated he assisted the resident by giving a bear hug and having the resident stand and pivot on his or her own, assumed the resident was a one-person assist based on therapy observations, and was not aware the resident required the [NAME]-steady. The LPN acknowledged he did not follow the resident’s care plan for transfers, and the DNS and RNCM acknowledged the care plan was not followed.
Failure to Address Resident Alcohol Use and Substance Use Disorder
Penalty
Summary
The facility failed to implement interventions related to substance use disorder for a resident who was admitted with diagnoses including stroke and malnutrition and who was receiving tube feeding through a gastrostomy tube with a current NPO diet order. The resident had a BIMS of 15 and was cognitively intact. On 4/14/26, an RN observed the resident ambulating with an unsteady gait, red/glossy eyes, increased drooling from baseline, and an odor of alcohol, and found a bottle of whiskey that was about 60% gone in the resident’s room. The resident admitted to sneaking alcohol every day since admission and refused transfer to the hospital for further evaluation, so hourly monitoring was initiated. A physician progress note on 4/15/26 documented that the resident admitted being an alcoholic and sneaking alcohol into the facility daily despite the NPO order and facility policies, and the risks of aspiration were reviewed. The care plan contained no information related to the resident’s noncompliance with the NPO diet order and alcohol consumption, and no interventions were implemented, including monitoring for signs and symptoms of substance use disorder. Multiple staff members later stated they found empty alcohol containers or observed signs consistent with alcohol use, but reported there were no interventions in place related to the resident’s alcohol use, and the DNS acknowledged the medical record needed to include interventions such as signs and symptoms of intoxication.
Licensed Nurse Not on Night Shift
Penalty
Summary
The facility failed to ensure a licensed nurse was on duty for 1 of 2 days reviewed for licensed nurse staffing. During interview, the former DNS stated there was one occasion on 8/6/25 or 8/7/25 when there was no nurse working the night shift. The Administrator requested the Direct Care Staff Daily Reports and daily staff assignment sheets for 8/6/25 and 8/7/25, but the Quality Coordinator was unable to locate the assignment sheets and the Administrator was unable to locate the Direct Care Staff Daily Reports. The Administrator later stated the facility did not have a nurse working the night shift on 8/7/25.
RN Coverage Not Maintained
Penalty
Summary
The facility failed to ensure a registered nurse was available for at least eight consecutive hours on 3 of 17 days reviewed for RN coverage. Review of the Direct Care Staff Daily Reports for 9/1/25 and 10/1/25 through 10/16/25 showed no required RN coverage on 9/1/25, 10/6/25, and 10/7/25. On 10/16/25 at 4:53 PM, Staff 1, the Administrator, acknowledged the dates without the required RN coverage.
Incomplete and Inaccurate Staffing Postings
Penalty
Summary
The facility failed to post accurate and complete nurse staffing information and failed to retain required staff postings. On 10/15/25, the Administrator was asked for the Direct Care Staff Daily Reports from 8/1/25 through 10/14/25, and later stated that the reports for 8/1/25 through 8/31/25 and 9/2/25 through 9/30/25 could not be located. A review of the Direct Care Staff Daily Reports from 10/1/25 through 10/16/25 showed that all 16 of 16 days had portions of the form left blank, crossed out, or inaccurate, including the daily census and the number of working staff. On 10/16/25, the Administrator acknowledged that the Direct Care Staff Daily Reports were incomplete and inaccurate for the identified dates.
Facility Administration Failed to Ensure Required Care Processes, Reporting, Staffing, and Infection Prevention Oversight
Penalty
Summary
The facility administration failed to use resources effectively and efficiently to attain or maintain residents’ highest practicable physical, mental, and psychosocial well-being. The report identified multiple deficiencies involving care planning, abuse reporting and investigation, physician visits, infection prevention staffing, and staffing levels and records. The facility did not offer the resident or representative opportunities to participate in the care planning process through care conferences for four residents, and the administrator acknowledged this had not been done for the identified residents. The facility also failed to report an allegation of abuse to the State Agency and did not thoroughly investigate the allegation for one resident; the administrator stated she was unaware of what a FRI was and acknowledged the allegation was not reported or thoroughly investigated. In addition, face-to-face physician visits did not occur as required for three residents, with the administrator stating she believed tele-health visits were acceptable. The facility did not have a qualified and trained infection preventionist in place, and staffing deficiencies were identified, including no nurse on one night shift, no RN coverage on several dates, insufficient CNA staffing on multiple shifts, and missing or inaccurate Direct Care Staff Daily reports for August, September, and multiple days in October.
Failure to Submit Required Payroll-Based Journal Staffing Data
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information based on payroll and other verifiable and auditable data. Review of the Payroll Based Journal Staffing Data for Fiscal Year Quarter 1 and Quarter 2 of 2025 showed that the required data for both quarters was not submitted. On 10/15/25 at 2:40 PM, Staff 1, the Administrator, confirmed that the Payroll-Based Journal was not submitted.
Infection Prevention and Control Program Deficiencies
Penalty
Summary
The facility failed to ensure a community use glucometer was properly cleaned and sanitized between resident uses. The blood glucose monitoring system manufacturer instructions indicated the meter was to be disinfected with EPA-registered wipes, and the facility’s 4/4/25 policy and procedure stated glucometers were to be cleaned according to manufacturer instructions and/or with an EPA approved germicidal disposable cloth. On 10/14/25, Staff 3, an LPN, was observed administering insulin to Resident 11 and stated she had checked the resident’s CBG previously. Later that day, Staff 3 stated she sometimes used alcohol wipes to clean glucometers. On 10/16/25, Staff 16, an RN, was observed checking Resident 5’s CBG with a community use glucometer and placing the glucometer in a basket in the medication cart without cleaning it. Staff 16 then used the same glucometer for Resident 11 before the State Surveyor intervened. Staff 16 returned to the medication cart and cleaned the glucometer with an EPA approved wipe, and acknowledged she had not cleaned the community use glucometer between resident uses and was unaware of the cleaning policy. The facility also failed to develop and conduct a risk analysis assessment for potential areas of growth and spread of water-borne pathogens. The facility’s 8/7/25 Legionella Water Management Policy stated the purpose of the program was to identify areas in the water system where Legionella bacteria can grow and spread and reduce the risk of Legionnaires’ disease, but Staff 18, the Maintenance Director, and Staff 19, Maintenance, stated the facility had not developed and conducted a risk analysis assessment for potential areas of growth and spread of water-borne pathogens in the main water system. The Administrator stated she was unaware the facility did not have a risk analysis assessment in place.
Unqualified Infection Preventionist
Penalty
Summary
The facility failed to have a qualified and trained infection preventionist in place for its infection prevention and control program. Surveyors requested documentation on 10/13/25 showing that an infection preventionist was in place. On 10/16/25, Staff 14 stated she began the IP role in October 2024 but had not completed the required training to become qualified, and she reported that Staff 15 had been assisting with the Infection Prevention and Control Program until recently. Human Resources documentation provided on 10/16/25 showed Staff 15’s last day at the facility was 10/5/25. On 10/17/25, the Administrator stated she was unaware of the required qualifications and training for the infection preventionist and confirmed the facility did not have a certified infection preventionist from 10/6/25 to the present.
Failure to Obtain and Document Advance Directive Information
Penalty
Summary
The facility failed to obtain information related to advance directives and health care decisions for 4 of 4 sampled residents reviewed for advance directives. The facility’s admission packet included a Philosophy Statement form with questions about whether a resident already had an advance directive, whether information was provided, and whether it was accepted or declined, with a signature line for the resident or responsible party. However, the clinical record for Resident 5, admitted with diabetes, showed no indication that an advance directive was reviewed or offered, and the resident stated she/he did not know what an advance directive was and had never been offered or provided any information about it. Resident 6, admitted with depression, also had no indication in the record that an advance directive was reviewed or offered. Resident 3, admitted with heart failure, had a Philosophy Statement form in the clinical record indicating an advance directive existed, but there was no indication the facility obtained a copy of it. Resident 12, admitted with heart failure and depression, had a care plan directing staff to offer education to the resident and legal representative regarding an advance directive quarterly at care conferences and as needed, but the clinical record and care conference documentation showed no indication that an advance directive was reviewed or offered quarterly. Staff 4 from Social Services stated a POLST was completed upon admission and there was no one to ask regarding the process for offering and completing an advance directive with residents.
Physician Visits Not Completed Face-to-Face
Penalty
Summary
The facility failed to ensure that long term residents received physician visits every 90 days for 3 of 4 sampled residents reviewed for unnecessary medications and nutrition. Resident 1, admitted in 8/2023 with diagnoses including dementia and muscle weakness, received telehealth physician visits, and the last in-person physician visit documented in the record was on 2/18/25. Staff 13, the former Administrator, stated that physician visits were completed via telehealth, and Staff 1, the Administrator, stated she believed only telehealth physician visits were acceptable and acknowledged the resident's last face-to-face physician visit was on 2/18/25. Resident 8, admitted in 11/2024 with diagnoses including dementia and hypertension, also received telehealth physician visits, with the last face-to-face physician visit documented on 1/21/25. Resident 11, admitted in 2023 with diagnoses including diabetes and dementia, likewise received telehealth physician visits, and the last face-to-face physician visit documented for that resident was on 1/21/25. Staff 13 stated physician visits were completed via telehealth, and Staff 1 stated she believed telehealth physician visits were acceptable and acknowledged the last face-to-face physician visit dates for Residents 8 and 11.
Failure to Obtain Consent for Psychotropic Medications
Penalty
Summary
The facility failed to inform a resident and/or the resident's responsible party of the risks and benefits of psychotropic medications and failed to ensure consent was obtained for their use. Resident 6, admitted in 2025 with diagnoses including depression and insomnia, had physician orders dated 8/19/25 and 9/25/25 for trazodone for insomnia, sertraline for depression, and bupropion for depression. Review of the clinical record showed no indication that the risks and benefits of the antidepressant medications were reviewed or that consent was obtained from Resident 6. On 10/15/25 at 12:00 PM, the Administrator stated she was unable to locate any information showing that the risks and benefits were reviewed or that consent was obtained for the three identified medications.
Failure to Involve Residents in Care Planning
Penalty
Summary
The facility failed to offer the resident or representative the opportunity to participate in the development and implementation of the person-centered plan of care for 4 of 5 sampled residents reviewed for care planning. Resident 5, admitted with diabetes, had no indication in the clinical record that a care conference was offered or completed since admission. Resident 5 stated on interview that no care conference had ever been held to review the care plan and that he or she would be interested in attending one if offered. Staff 4 from Social Services stated she could not locate any documentation that care conferences were completed to review residents' care plans and acknowledged there was no process in place to involve residents in their plan of care. Resident 6, admitted with depression, also had no indication in the clinical record that an initial care conference was offered or completed since admission. Resident 6 stated he or she did not know what a care conference was and had never been offered one to review the care plan, but would be interested if offered. Resident 3, admitted in 9/2024 with heart failure, and Resident 13, admitted in 11/2024 with heart failure, likewise had no indication in the record that they were offered a care conference since admission. Both residents stated they wanted to attend a care conference and did not recall one being held. Staff 4 again stated there was no process in place to involve residents in their plan of care and acknowledged Residents 3, 6, and 13 were not involved in their care planning.
Failure to Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency within the required timeframe for one resident. Resident 10 was admitted in 2/2021 with diagnoses including stroke and weakness, and the 7/28/25 Quarterly MDS showed a BIMS of 15, indicating the resident was cognitively intact. On 10/16/25, Witness 1, Witness 2, and Witness 3 reported concerns that Staff 12, an LPN, locked the door when Resident 10 went outside and did not allow the resident to re-enter the building. Witness 3 stated Staff 12 told Resident 10, “You are not the most important resident here. We can't stop what we are doing and open the door,” and said the resident began crying after the incident. Resident 10 stated that about a month earlier, when leaving the facility at 4:40 AM, Staff 12 did not let the resident back in and the resident had to wait until day shift arrived at 7:00 AM to re-enter. Staff 2, the DNS, stated staff reported that Staff 12 did not let Resident 10 in when the resident knocked and called, but Staff 2 did not specifically interview the resident, did not complete an investigation, and did not report the incident to the State Agency. Staff 2 stated she was unaware she needed to report the incident and any allegation of verbal abuse to the State Agency. Staff 1, the Administrator, stated she was aware of Resident 10’s concerns about getting in and out of the facility when Staff 12 worked, and stated the incident was not reported to the State Agency.
Failure to Thoroughly Investigate Allegation of Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a cognitively intact resident with a history of stroke and weakness. Resident 10, admitted in 2/2021, had a 7/28/25 Quarterly MDS showing a BIMS of 15. On 10/16/25, Witness 1, Witness 2, and Witness 3 reported concerns that Staff 12, an LPN, locked the door when Resident 10 went out of the facility and did not allow the resident to re-enter. Witness 3 stated Staff 12 told the resident, "You are not the most important resident here. We can't stop what we are doing and open the door." Resident 10 began crying and the incident was reported to the DNS. Resident 10 stated that about a month earlier, while Staff 12 was working night shift, the resident left the facility at 4:40 AM and was not allowed back in until day shift arrived at 7:00 AM. The resident stated being upset after the incident and described Staff 12 as rude. The DNS stated the report involved Staff 12 not letting Resident 10 in when the resident knocked and called during night shift a couple weeks earlier, but she did not specifically ask Resident 10 about being locked out, did not interview Resident 12, and did not complete an investigation. The Administrator later stated she was aware Resident 10 had concerns about getting in and out of the facility at night when Staff 12 worked, and that the incident was not investigated.
Expired Insulin and Missing Refrigerator Temperature Logs
Penalty
Summary
The facility failed to ensure expired biologicals were discarded and failed to monitor medication refrigerator temperatures for 1 treatment cart and 1 medication room reviewed. During observation, Staff 3 (LPN) was seen preparing Humalog insulin for Resident 11, and the open date on the medication showed it had exceeded the manufacturer’s 28-day discard timeframe. Staff 3 acknowledged that the Humalog was expired and had not been discarded after 28 days of opening. In addition, review of the medication refrigerator logs with Staff 3 showed no recorded temperatures for two dates, even though the refrigerator contained insulin and other medications. Staff 3 stated night shift was responsible for completing the temperature logs and acknowledged that the logs were blank for those dates.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to ensure routine dental services were provided for 1 of 2 sampled residents reviewed for dental care needs. Resident 3 was admitted in 9/2024 with diagnoses including heart failure. During an interview on 10/14/25 at 9:27 AM, Resident 3 stated it had been one year since a dentist appointment and reported issues finding a dentist that accommodated residents who required wheelchairs. Review of the clinical record found no evidence that a dental appointment had been made since the resident's admission. On 10/16/25 at 2:08 PM, Staff 4 from Social Services stated she had started at the end of September 2025, was still learning her role, was not involved in dental services, and could provide no additional information about when Resident 3's dental status was reviewed.
Failure to Provide Dental Services
Penalty
Summary
Provide or obtain dental services for each resident was not met for one of two sampled residents reviewed for dental services. Resident 12 was admitted in 2015 with diagnoses including heart failure and diabetes, and the 7/28/25 Quarterly MDS showed a BIMS score of 4, indicating severe cognitive impairment. On 10/14/25, the resident’s family member stated the resident had three natural teeth remaining and had not received routine dental cleaning in the past year, and that she wanted the resident to receive routine dental cleanings. No evidence was found in the clinical record regarding the resident’s dental cleaning history. On 10/16/25, the Social Services staff member stated she had started at the end of September 2025, was still learning her role, was not involved in dental services, and could provide no additional information regarding the resident’s last routine dental service.
Failure to Provide Ordered SLP Services
Penalty
Summary
The facility failed to provide therapy services for one resident who was reviewed for nutrition concerns. The resident was admitted with diagnoses including dementia and muscle weakness, and the annual MDS indicated a BIMS score of four, severe cognitive impairment, and swallowing problems including loss of liquids and/or solids from the mouth during eating or drinking and coughing or choking during meals. Nutrition at Risk notes documented concern for increased choking risk, and tele-health physician notes documented a recent lung cancer diagnosis, dysphagia, weight loss, and that the resident was awaiting an SLP evaluation. A tele-health physician note later stated that a free initial SLP evaluation had been completed and that further follow-up was needed, but the resident's medical record contained no notes related to that evaluation. Staff stated the facility did not have an on-site speech therapist and used one through the local hospital as outpatient therapy, but the process for setting up speech therapy was not consistent. Staff also stated a hospital speech therapist performed a screening note rather than a full SLP evaluation, and the facility did not follow up on the recommendations or document follow-up on therapy authorization. The administrator was unaware of the recommendations and orders for therapy services for the resident.
Delayed Hospice Notification After Resident Death
Penalty
Summary
The facility failed to notify hospice services of a resident’s death in a timely manner for 1 of 1 sampled resident reviewed for hospice services. The resident was admitted with diagnoses including vascular dementia and adult failure to thrive, and the admission MDS showed the resident received hospice services while in the facility. The care plan stated the facility would collaborate with hospice and the resident’s family to meet the resident’s needs, and the facility’s hospice policy required the facility to coordinate with the state-recognized hospice program and communicate when changes were indicated to the plan of care. A complaint alleged the facility did not notify hospice of the resident’s death in a timely manner. The resident’s medical record contained no progress notes documenting the date and time of death or notification to hospice. The death record showed the resident died at 7:30 PM, and hospice documentation showed the LPN notified hospice at 9:45 PM, with hospice notifying the family at 9:50 PM. A hospice RN stated the LPN contacted hospice at approximately 9:30 PM to report the death and that staff were expected to notify hospice upon death so hospice could follow its protocol by calling the family timely. The Administrator stated she expected facility staff to communicate timely with the hospice provider upon the resident’s death.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a 19 percent error rate. This was observed through multiple incidents involving the improper administration of insulin to residents. Resident 164, who was admitted with diabetes, was supposed to receive Novolin R insulin, but the administering RN did not prime the insulin pen as required by the manufacturer's instructions. Similarly, Resident 8, also with diabetes, was administered insulin lispro without priming the pen, despite the manufacturer's instructions. Both RNs involved acknowledged their lack of awareness regarding the need to prime the insulin pens. Additionally, Resident 1, with chronic kidney disease and diabetes, was administered Lantus insulin without the pen being primed. The RN involved admitted to not knowing the priming requirement. Another incident involved Resident 3, who was prescribed diltiazem for atrial fibrillation. The RN held the medication despite the resident's blood pressure and heart rate being within the parameters for administration. These errors highlight a significant deficiency in medication administration practices at the facility.
Failure to Implement Physician Orders and Conduct Timely Skin Assessments
Penalty
Summary
The facility failed to ensure professional standards were followed by a Registered Nurse (RN) in the administration of medications and management of pressure ulcers, placing residents at risk for adverse outcomes. Specifically, Resident 164 was readmitted to the facility with post-surgical care needs following a toe amputation. The Director of Nursing Services (DNS), identified as Staff 2, received the resident's admission physician orders but did not implement them before leaving the facility for the day. This resulted in a delay of three days before the orders were implemented, as confirmed by the facility's Administrator, identified as Staff 1. Additionally, the facility failed to conduct timely skin assessments for Resident 8, who was admitted with diagnoses including diabetes and a sacral fracture. A new wound was identified on the resident's left buttock, but Staff 2 did not assess the wound until five days later. Staff 3, the RN Case Manager, was responsible for skin assessments but was on vacation, and it was expected that Staff 2 would complete these assessments in her absence. This lack of timely assessment and intervention for pressure ulcers further highlights the facility's failure to adhere to professional standards of care.
Failure to Provide Adequate Nail Care to Residents
Penalty
Summary
The facility failed to provide adequate nail care to two residents who required assistance with activities of daily living (ADLs). Resident 10, admitted in 2021 with kidney disease, was observed on two occasions with long, curved fingernails. The resident's care plan indicated a need for ADL assistance, but there was no documented evidence of when nail care was provided. Staff 6, a CNA, stated that nail care was supposed to be done on shower days and as needed, but acknowledged there was no specific documentation for when it was completed. The DNS confirmed the expectation for nursing staff to perform nail care, even for non-diabetic residents, and acknowledged the resident's nails needed trimming. Similarly, Resident 11, admitted in 2023 with dementia and moderate cognitive impairment, also required assistance with ADLs. The care plan included interventions to check and trim nails on bath days and as needed, yet there was no documentation of nail care being provided. The resident expressed that their nails were not trimmed often enough and could not recall the last time they were trimmed. Staff 6 confirmed the expectation for routine nail checks and acknowledged the resident's nails were longer than appropriate. The DNS reiterated the expectation for nursing staff to complete nail care and acknowledged the need for trimming.
Failure to Implement Admission Physician Orders
Penalty
Summary
The facility failed to implement physician orders upon admission for a resident who was readmitted with diagnoses including post-surgical care for a toe amputation. The hospital discharge orders specified that the resident was to receive doxycycline, losartan, and pravastatin. However, on the day following admission, the resident missed doses of all three medications. The Medication Administration Record (MAR) and progress notes confirmed the missed doses. A progress note indicated that a registered nurse was unable to resume many medications and documented the medications given. Another progress note revealed that there were no orders in the resident's chart. The Director of Nursing Services (DNS) received the admission physician orders but did not implement them before leaving the facility for the day. The facility administrator had requested the DNS to review and implement the orders prior to the resident's arrival, but the DNS left the building without doing so. Consequently, the admission physician orders were not implemented for three days, resulting in the resident not receiving the prescribed medications.
Failure to Assess and Monitor Pressure Ulcers
Penalty
Summary
The facility failed to properly assess and monitor pressure ulcers for two residents, leading to a deficiency in care. Resident 8 was admitted with conditions including diabetes and a sacral fracture, and initially, no wounds were noted. However, a wound care order was implemented for a wound on the left buttock, which was later identified as a Stage 2 pressure ulcer. There were discrepancies in wound measurements and assessments, with Staff 2 acknowledging a lack of recent wound care training and failing to conduct timely assessments. Additionally, four Stage 2 pressure ulcers were identified on the resident's left forearm, which were not initially documented. Resident 6, who had a Stage 4 pressure ulcer on the sacral region, also experienced a lack of consistent wound assessments. The Weekly Wound Observation Tool was not completed after a certain date, and discrepancies were found in the wound measurements recorded by different staff members. Staff 5, who conducted a dressing change, noted inconsistencies between her handwritten notes and the official records. The absence of the RNCM, who was responsible for skin assessments, contributed to the oversight, as floor nurses were not typically tasked with these assessments.
Failure to Administer Timely Medications
Penalty
Summary
The facility failed to provide timely pharmaceutical services for two residents, resulting in missed doses of prescribed antibiotics. Resident 1, who was admitted in 2018 with chronic kidney disease, had a physician order dated 8/9/24 for Keflex 500 mg three times daily for a urinary tract infection (UTI). However, the medication administration record (MAR) indicated that Resident 1 did not receive the medication on multiple occasions between 8/10/24 and 8/12/24. Staff 2, the Director of Nursing Services (DNS), acknowledged the missed doses and was unable to verify the availability of Keflex in the electronic medication dispensing system, mistakenly believing that medications were automatically refilled by the pharmacy. The facility administrator identified a breakdown in the medication reordering process by nursing staff. Similarly, Resident 7, admitted in 2023 with diabetes, was discharged from the hospital with a UTI and a prescription for cephalexin 500 mg four times daily. The MAR showed that Resident 7 did not receive the first dose until 8/13/24 at 5:00 PM, despite being readmitted to the facility earlier. Staff 2 confirmed the delay in administering the first dose and demonstrated a lack of knowledge in checking medication inventory. The administrator again cited a failure in the medication reordering process as the cause of the delay.
Delayed Response to Pharmacy Recommendations
Penalty
Summary
The facility failed to address pharmacist recommendations in a timely manner for three residents, leading to the risk of unnecessary medication administration. Resident 8, diagnosed with depression, was recommended by the pharmacy to discontinue mirtazapine on July 8, 2024. However, the physician did not agree to this recommendation until August 6, 2024, resulting in the resident continuing to receive the medication for 29 days beyond the recommendation. Staff acknowledged that the expectation was for the physician to address such recommendations within two weeks. Similarly, Resident 6, with an anxiety disorder, had a pharmacy recommendation on June 26, 2024, to change diazepam to lorazepam due to the high risk of adverse reactions in older adults. This recommendation was not signed by the physician until July 31, 2024, 35 days later. Additionally, Resident 12, with heart disease, bipolar disorder, and depression, had a pharmacy recommendation on June 26, 2024, to monitor for heart-related symptoms and conduct an EKG every six months due to the potential risk of QT interval prolongation. Although the physician agreed to these recommendations on July 3, 2024, there was no documented evidence that the recommendations were addressed, as acknowledged by the staff.
Inaccurate Wound Measurements for Residents with Pressure Ulcers
Penalty
Summary
The facility failed to ensure the accuracy of medical records for two residents with pressure ulcers, leading to discrepancies in wound measurements. Resident 8, who was admitted with diagnoses including diabetes and a sacral fracture, had conflicting wound measurements recorded on the same day. A progress note by the Director of Nursing Services (DNS) indicated a Stage 2 pressure ulcer on the left inner gluteal area with specific measurements, while a Weekly Wound Observation Tool completed later by the same staff member showed different measurements and did not specify which wound it referred to. When questioned, the DNS stated that the progress note was the most accurate. Similarly, Resident 6, who was readmitted with a Stage 4 pressure ulcer of the sacral region, also had inconsistent wound measurements recorded. A progress note by a registered nurse (RN) documented one set of measurements, while the Weekly Wound Observation Tool indicated different dimensions. Upon review, the RN acknowledged discrepancies between the progress note, the observation tool, and her handwritten notes, which contained yet another set of measurements. These inconsistencies in documentation could lead to inaccurate assessments and care for the residents.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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