Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Windsor Health And Rehabilitation during CMS and state inspections, most recent first.
Failure to Provide Behavioral Health Services: A resident with anxiety, OCD, ADHD, PTSD, MDD, and bipolar disorder had a PHQ-9 score indicating moderately severe depression and reported frequent thoughts of being better off dead or self-harm, along with loneliness and isolation. The resident requested mental health support, but the record showed only one attempted visit by a mental health provider and no further referral or communication, while staff described the resident as emotional, tearful, agitated, and socially isolated.
The facility failed to maintain 8 consecutive hours of RN coverage each day for multiple days reviewed. Staffing records showed repeated days with no RN coverage on any shift, and an LPN, the DNS, and the Regional Director of Clinical Operations all acknowledged the RN staffing requirement was not met.
Failure to provide individualized activity programs for 3 residents. Residents with preferences for independent or one-to-one activities, including interests such as music, TV, arts and crafts, reading, bingo, and going outside, had care plans and activity calendars that listed personalized opportunities, but there was no documentation they were offered or participated in them. The Activities Director acknowledged the facility lacked a meaningful program for residents unable to attend group activities, and residents reported boredom, lack of offers, and little activity in their rooms.
A facility failed to provide enough nursing staff and a licensed nurse in charge on each shift, leading to delayed care on the South Hall. A resident with diabetes, dysphagia, a pressure ulcer, and severe cognitive impairment needed two staff for transfers and close meal supervision, but staff reported morning care was delayed by admissions, wound care, smoke breaks, and other duties. Another resident with bilateral BKA reported a call light went unanswered for nearly an hour, and a third resident who required two-person mechanical-lift transfers was left waiting in bed while staff searched for help. Staff and the Administrator acknowledged call lights and resident care were not being addressed timely, and staffing was based on minimum levels and budget limits rather than acuity.
Failure to assist residents with dental services affected three residents. One resident with seizures and a TIA hx had missing teeth and reported a cancelled dental appt that was never rescheduled, with no dental documentation in the chart. Another resident with dysphagia and trigeminal neuralgia reported broken upper dentures, while staff could not locate dental notes and had no process to assess dental needs. A third resident with post-stroke hemiplegia had missing teeth and tooth decay, needed dental care, but could not transfer to the dental chair for the appt.
Failure to ensure residents understood binding arbitration agreements: three residents signed arbitration forms without clear evidence they were fully informed or that the resident/POA understood the documents. One resident had severe cognitive impairment and a POA on file, another had a POA who was unavailable during admission, and a third later said they did not recall signing and would not have signed based on the education provided. Admissions staff said they were unaware of the 30-day rescission period and did not complete follow-up conversations.
Staff failed to clean reusable mechanical lifts between resident uses, did not complete hand hygiene after handling soiled linens or after coughing and blowing a nose before touching a resident's wheelchair, and did not follow EBP when assisting a resident into bed with a mechanical lift. The IP stated lifts were to be cleaned after each use, hand hygiene was required after disposing of dirty linens and after contact with bodily fluids, and staff assisting a resident on EBP into bed were to wear gloves and a gown.
Failure to assess a resident for self-administration of medications. A resident with asthma and angina had PRN orders for nitroglycerin and an albuterol inhaler, but the record showed no self-administration evaluation or orders. The resident said he/she requested to self-administer these medications but was told it was not allowed, and the LPN Resident Care Manager confirmed the request was denied. The DNS stated residents may self-administer if able to do so safely and that staff should assess the resident and obtain orders if appropriate.
Smoking Choice Restrictions Not Clearly Defined: The facility failed to support resident self-determination related to smoking for two residents. A CNA stated supervised smokers were limited to two cigarettes during each 20-minute smoke break, while the DON/Administrator acknowledged the smoking schedule did not state a cigarette limit and that residents requiring supervised smoking were allowed to have as many cigarettes as they wanted during the break. One resident with cervical spondylosis with myelopathy and another resident with ESRD and chronic pain both stated they felt treated like children because of the two-cigarette limit.
A resident council meeting was interrupted multiple times when staff entered the dining room without knocking during the meeting. Two residents stated staff interrupted often and that the interruptions disrupted the meeting, with one resident losing their train of thought. The AD and Administrator acknowledged residents were expected to have private council meetings and staff should not interrupt.
A resident with anxiety disorder, heart failure, and hospice services received psychotropic PRN lorazepam without the ordered first use of albuterol on multiple occasions. Staff interviews showed the CNA associated the resident's hallucinations with anxiety, the CMA relied on nurses for assessment before PRN use and gave lorazepam without being told to give albuterol first, and the DNS said the order was unclear and staff should follow physician orders as written.
A resident admitted with fractures of the L femur and L humerus had an oxycodone card go missing after a room move, and it was later found behind a picture frame in the hall. Staff and the DNS reported the card had been missing for days, another oxycodone misappropriation was identified, and no further investigation was completed; police were not notified.
Unsafe discharge with incomplete wound care orders: A resident admitted with a femur fracture and a stage 2 pressure injury was discharged without home health nursing included in the orders, despite ongoing wound treatment needs. The ALF reported it was not told about the pressure injury or given updated wound care orders, and staff stated the resident had a worsening coccyx wound at discharge and that the wound care orders were changed right before discharge.
A resident with dementia was admitted to hospice, but the Significant Change MDS assessment was not completed within the required 14-day timeframe. The MDS Coordinator confirmed the assessment was still incomplete more than 3 weeks after hospice admission, and the DNS stated it should have been completed within 14 days.
A resident admitted with diabetes and receiving insulin did not have a complete baseline care plan. The TARs lacked monitoring for adverse reactions to insulin, and the revised care plan did not include diabetic focus or interventions. An LPN said the resident’s orders were believed to be complete, a CNA could not identify the resident as diabetic from the care plan, and the DNS stated diabetic care should have been included within 48 hours.
A resident with flaccid hemiplegia after a stroke reported that staff did not assist with ROM exercises. The care plan called for ROM in the morning and evening, but the chart had no documentation that ROM was completed. Multiple staff said they had not seen ROM exercises performed, one CNA said there was no time to do them, and the DNS stated moving the resident during dressing was not a substitute for ROM exercises.
A resident with lung cancer and dysphagia was found to be eating without the distant supervision recommended by SLP. The resident’s care plan did not reflect the supervision need, and staff interviews showed inconsistent understanding of what distant supervision meant, with the DNS stating the resident received the correct diet but was not supervised.
Respiratory Care Orders, Care Plan, and Monitoring Not in Place: A resident with COPD and respiratory failure had orders for CPAP while sleeping and room air when awake, but the EHR lacked orders and indications for supplemental O2 when CPAP was not used. Staff intermittently monitored O2 saturation rather than daily, and the care plan/TAR did not include the oxygen delivery system, parameters for oxygen use, or ongoing respiratory assessment. Observations showed the resident consistently receiving O2 via NC, and an LPN and the DNS acknowledged the missing orders, care plan, assessment, and monitoring.
A resident with ESRD had scheduled dialysis and required pre- and post-dialysis evaluations, but multiple required evaluations were missing. The record also showed a dialysis center instruction to increase dietary potassium that was not implemented, and the RD and DNS were unaware of the order and any follow-up communication with the dialysis center.
A resident with CHF and weakness, who was cognitively intact, did not have access to a call light overnight after receiving a bed bath. The call light was later found clipped to the top corner of the mattress and not within reach. The resident reported that no staff checked on them during the night despite needing to use the toilet and subsequently experienced fecal incontinence in bed. A CNA and an LPN confirmed the resident’s upset condition related to the inaccessible call light, and the Administrator acknowledged the lack of call light access and stated that staff were expected to check on residents at least every two hours.
A resident with a right leg fracture stabilized by an external fixator and diabetes had an order for PRN oxycodone 5 mg every four hours for pain, but the controlled substance record showed the last dose was given and the supply depleted, and the medication was not reordered in a timely manner. The resident later reported severe pain (rated nine), yet the MAR showed no oxycodone was administered and the record lacked documentation of any alternative pain interventions while staff attempted to obtain more medication from the pharmacy and the on-call provider.
A hospice resident with COPD exacerbation and respiratory failure had PRN orders for oral morphine for SOB and moderate to severe pain but, according to multiple staff interviews and record review, an LPN refused to administer the ordered morphine during a period when the resident was screaming, anxious, disoriented, and exhibiting terminal agitation and SOB. Staff reported that the LPN declined to medicate the resident due to concern about depressing respirations, would not call hospice or the physician, and refused to provide the med cart keys to another LPN who attempted to follow the physician’s orders. CNAs and another LPN described the resident as having a very bad night with ongoing pain and distress, while the hospice care manager noted frustration with ordered medications not being administered and confirmed morphine was appropriate for the resident’s symptoms.
A resident with dementia and a history of falls was repeatedly kept up in a wheelchair at the nurse’s station for most of the night by an LPN, despite the resident’s stated desire to go to bed and the absence of any care-plan directive to keep the resident up all night. CNAs reported that when they attempted to put the resident to bed after incontinence care, the LPN ordered them to get the resident back up, refilled the resident’s coffee, and positioned the resident with a blanket, coffee, and magazines at the nurse’s station, stating she did not want to complete more incident reports for falls. Other nursing staff told the LPN this was abusive, and leadership later confirmed that keeping a resident at the nurse’s station all night for staff convenience was not acceptable, constituting involuntary seclusion.
Two residents experienced alleged abuse or neglect that was not reported to the State Survey Agency as required. One resident with COPD and respiratory failure had an order for PRN morphine for shortness of breath and pain, but an LPN allegedly refused to administer the medication despite reports of screaming, dyspnea, and anxiety, and no FRI was filed despite the Administrator and a unit manager being aware. Another resident with a hip fracture and dementia was allegedly kept in a wheelchair at the nurse’s station for most of the night and repeatedly given coffee so an LPN would not have to address falls or incident reports, and the Administrator allegedly instructed staff not to submit an FRI, with no investigation or report completed.
The facility failed to investigate two separate allegations of potential abuse and neglect. In one case, a resident with COPD and respiratory failure was reportedly denied ordered pain medication by an LPN despite reports of screaming, shortness of breath, and anxiety, and no investigation or documentation was completed to determine what occurred or rule out abuse/neglect. In the second case, a resident with a hip fracture and dementia was reportedly kept in a wheelchair at the nurse’s station for most of the night and repeatedly given coffee so an LPN would not have to address falls or incident reports, and again no investigation or documentation was completed despite leadership being notified.
Two residents did not receive care according to physician orders: one did not receive ordered repeat x-rays for ongoing pain and was later found to have a fracture, while another received a narcotic pain medication on a scheduled basis instead of as needed due to a transcription error, with a delay in starting the medication. The errors were acknowledged by the Resident Care Manager.
The facility failed to ensure kitchen staff wore appropriate hair restraints during meal preparation. A cook was observed plating meals without a hair restraint, contrary to the US FDA Food Code 2022, which requires all staff to wear hair restraints regardless of hair length. This oversight placed residents at risk for unsanitary food conditions.
The facility did not complete annual performance reviews for two CNAs, which are essential for ensuring competent nurse staffing. A review of personnel records showed that one CNA, hired in 2022, had not been reviewed since early 2024, and another, hired in 2016, had not been reviewed since mid-2023. The DON confirmed the oversight, potentially risking resident care due to insufficiently assessed staff competence.
The facility failed to involve residents in the development of their comprehensive care plans. A resident with diabetes reported not being informed about medication or treatment changes, and another resident with a hip fracture did not receive a care plan copy. Staff confirmed that while initial meetings were held, no care planning meetings occurred post-comprehensive MDS, leaving residents uninvolved in their care plan development.
A resident with a hip fracture was admitted with a urinary catheter, which was supposed to be removed a week after discharge per hospital orders. Despite instructions for a trial of voiding and a urology referral, the facility did not document any attempt to remove the catheter or make the referral. The resident was observed with the catheter still in place and unaware of any removal plan. Staff confirmed the failure to follow up on the orders.
A facility failed to change a PICC dressing for a resident receiving IV antibiotics, as the dressing change was not listed on the MAR and staff were unaware of the required frequency. The dressing, last changed on March 4, was overdue for a change on March 11, leading to a deficiency in care.
A facility failed to timely implement a physician's order to reduce a resident's Trazodone dose from 150 mg to 100 mg. The order, recommended on 10/21 and confirmed on 11/5, was not executed until 1/1, placing the resident at risk for unnecessary psychotropic medication use.
Expired medications, including Healthy Eyes (Leutin) and Terbinafine, were found in a medication room, confirmed by an LPN and the DNS. These expired medications should not have been available for resident use, posing a risk for diminished treatment efficacy.
A resident with diabetes and pressure ulcers received wound care that did not follow proper infection control practices. An LPN failed to perform hand hygiene after removing contaminated gloves during a dressing change, contrary to the facility's infection control policy. The LPN acknowledged the oversight, and the infection preventionist confirmed the requirement for hand hygiene between glove changes.
A facility failed to offer a pneumonia vaccine to a resident admitted with hypertension, as revealed during an interview and record review. The resident was eligible for the vaccine, but the medical record showed no indication of it being administered or offered. The DNS confirmed the oversight upon reviewing the resident's medical record.
Failure to Provide Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for Resident 32, who was admitted with diagnoses including anxiety disorder, obsessive-compulsive disorder, attention deficit hyperactivity disorder, post-traumatic stress disorder, major depressive disorder, and bipolar disorder. The admission MDS dated 4/30/26 showed a PHQ-9 score of 19, indicating moderately severe depression symptoms, and documented that the resident had thoughts of being better off dead or hurting self 12 to 14 days out of 14, felt down, depressed, or hopeless 12 to 14 days out of 14, and often felt lonely or isolated from others. A care conference on 5/1/26 documented that Resident 32 requested to be seen by a mental health provider. A progress note on 5/5/26 showed a mental health provider attempted to see the resident, but the resident was at an appointment, and the record contained no other communication, visit, or referral to a mental health provider. A social services admission and history evaluation on 5/8/26 described the resident as very emotional and in need of additional mental health support. Staff later stated the resident made statements about wanting to die when first admitted, was tearful and yelling out during observation, and had mood changes, agitation, and social isolation. The administrator stated that if the resident requested mental health support, a mental health professional should have been contacted.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to staff a registered nurse for eight consecutive hours per day, seven days per week, for 18 of 34 days reviewed for staffing. Review of the Direct Care Staff Daily Reports dated 6/3/26 through 7/6/26 showed 18 dates with no 8 consecutive hours of RN coverage on any shift in a 24-hour period. On 7/7/26, an LPN stated the DNS did not work the floor. On 7/8/26, the DNS confirmed she was not scheduled to work the floor on days when there were no RNs scheduled and stated she was only available three hours daily to complete resident assessments as an RN because of DNS obligations. The DNS acknowledged the facility requirements for RN coverage were not met, and the Regional Director of Clinical Operations also acknowledged the facility did not meet the staffing requirement for RNs.
Failure to Provide Individualized Activity Programs
Penalty
Summary
The facility failed to provide personalized, individual, and independent activities for 3 residents who were reviewed for activities. Resident 7, admitted with diagnoses including seizures and a history of TIA, had an activity evaluation showing a preference for independent and one-to-one activities. The resident’s quarterly MDS stated it was very important to do favorite activities, and the revised care plan identified enjoyment of music and TV or movies, impaired psychosocial well-being, and visual impairment. The July activity calendar listed one-to-one visits every Wednesday at 4 PM, but no documentation was found showing Resident 7 was offered or participated in independent or one-to-one activities. Observations showed the resident spent time in bed alone, usually sleeping or lying in bed with the light off, and the resident stated no one offered activities in the room and that activity staff never offered the planned one-to-one visits. Resident 9, admitted with diagnoses including generalized anxiety disorder and adult failure to thrive, had a care conference note stating the resident was unable to get up from bed and preferred independent activities and one-to-one visits. The revised care plan identified a preference for self-directed activities in the room and interests in arts and crafts, reading, religious studies, watching TV and sports, and electronic use. The July activity calendar also listed one-to-one visits every Wednesday at 4 PM, but no documentation was found showing the resident was offered or participated in independent or one-to-one activities. The resident stated being frequently bored and that the only thing to do in the room was watch TV, and also stated activity staff never offered the planned one-to-one visits. The Activities Director acknowledged the facility did not have a meaningful activity program for residents unable to attend group activities and could not identify a personalized independent or one-to-one program aligned with the resident’s interests. Resident 33, admitted with diagnoses including COPD and hearing loss, had an activities evaluation showing a dislike of coloring, a preference for independent activities, and a liking for bingo. The admission MDS and related CAAs showed a BIMS score of 13, indicating cognitive intactness, risk for impaired communication, and that it was very important for the resident to be outside when the weather was good. Activity progress notes showed the resident was offered group activities but declined and participated in independent activities on multiple days in May and June, with only 2 days documented in July, and no additional activities were identified from 5/1/26 through 7/6/26. The revised care plan listed self-directed activities including arts and crafts, watching television, and listening to music, but the resident stated no meaningful activities were offered, that staff walked past the bed without asking about activities, and that no radio or activity supplies were in the room. Staff stated they had not thought to encourage the resident to get up for activities, that residents who remained in bed were limited to coloring and one-on-one conversations, and that documentation of conversations and personalized activity options needed improvement.
Delayed Resident Care Due to Inadequate Staffing
Penalty
Summary
The facility failed to provide adequate nursing staff each day to meet resident needs and to have a licensed nurse in charge on each shift, as shown by delayed assistance on the South Hall. Resident 2, who had diabetes, dysphagia, a pressure ulcer, and severe cognitive impairment, required two staff for transfers, one staff for dressing, and close supervision while dining due to aspiration risk. Staff reported that morning care for this resident was difficult and time-consuming, and that admissions, wound care, and competing responsibilities delayed timely assistance. On 7/8/26, Resident 2 was observed in bed with the call light on and still in a gown before staff responded and began morning care. Staff statements described repeated delays in resident care because staff were occupied with smoke breaks, meetings, admissions, and other duties. A CNA stated she had been away from resident care for 40 minutes supervising smoke breaks and could not timely attend to Resident 2’s brief change and breakfast. The DNS stated the nursing management team and many nurses were new, that staff often had more than two admissions, and that residents were waiting 30 minutes for care. Other staff stated call lights were often not answered within expected timeframes, that nurses were not always available to assist, and that the facility needed a culture change so staff would be available to help with resident care. Resident 40, who had bilateral below-the-knee amputations and required set-up assistance for toileting and dressing, reported a call light placed at 5:20 AM was not answered until 6:10 AM, and that the delay prevented morning care from being completed. Staff confirmed they were occupied with other residents and a morning meeting, and that care often took 30 minutes for some residents. Resident 4, who required two staff for mechanical-lift transfers and had pain and muscle weakness, was left waiting in bed while staff searched for a second CNA; the resident expressed discomfort and pain while waiting. The Administrator stated staffing was based on minimum CNA levels and budget limits rather than resident acuity, and acknowledged that call lights were not answered timely.
Failure to Assist Residents With Dental Services
Penalty
Summary
The facility failed to assist residents in obtaining dental services for 3 of 3 sampled residents reviewed for dental services. Resident 7, admitted in 2021 with diagnoses including seizures and a history of TIA, stated that his/her teeth were disintegrating and was observed with several missing teeth on the top and bottom. The resident reported that a dental appointment had been scheduled earlier in the year but did not occur and was not rescheduled. No documentation related to dental services was found in the resident’s electronic health record, and the Social Services Director acknowledged the dental appointment scheduled for 2/17/26 was cancelled for an unknown reason and was not rescheduled, with no follow-up completed. Resident 10, admitted in 10/2024 with diagnoses including dysphagia and trigeminal neuralgia, stated that his/her upper dentures were broken and that he/she needed to see the dentist. Staff reported the resident had seen the dentist on 1/21/26, but the Social Services Director could not locate the progress notes for that visit and stated there was no process to assess the need for dental appointments. Staff also reported the resident had told a CNA about a month earlier that the dentures were broken, and the CNA informed the charge nurse but could not recall which nurse. Resident 43, admitted in 1/2025 with right-sided hemiplegia following a stroke, was observed with missing teeth and tooth decay and stated he/she needed to go to the dentist but could not transfer to a chair alone. A progress note documented a request for dental care, and another note stated the resident could not be seen at a dental appointment because of inability to transfer to the dental chair. The Social Services Director stated there was a telehealth dental appointment on 2/6/26 but could not locate notes from that visit and stated there was no process to assess the need for dental appointments.
Failure to Ensure Residents Understood Arbitration Agreements
Penalty
Summary
The facility failed to ensure residents were fully informed and understood the binding arbitration agreement for 3 of 3 sampled residents reviewed for arbitration. Resident 2 was admitted with adjustment disorder and paranoid schizophrenia, had a BIMS score of 5 indicating severe cognitive impairment, and signed a State Arbitration Agreement despite having a durable POA on record. Staff stated they had family present when the agreement was signed, were unaware the resident had a POA at that time, did not know residents had 30 days to rescind the agreement, and did not conduct a follow-up conversation. The Administrator acknowledged the facility needed a different process to ensure the resident or representative understood the agreement. Resident 33 was admitted with COPD and symptoms involving cognitive function and awareness, had a BIMS score of 13, and signed the arbitration agreement while the resident's medical and financial POA was traveling. The resident stated they were not at their best during admission and did not recall receiving education about the agreement; the POA stated they would not have allowed the resident to sign and was unaware it had been signed. Resident 53 was admitted with anxiety and depression, had a BIMS score of 13, and signed the arbitration agreement, but later stated they did not recall signing it and would not have signed it based on the education provided. Staff stated it was difficult to ascertain cognition during admission, believed the resident could understand and sign, were unaware of the 30-day rescission period, and did not conduct a follow-up conversation.
Infection Control Lapses With Equipment Cleaning, Hand Hygiene, and EBP
Penalty
Summary
The facility failed to follow infection prevention and control practices by not cleaning reusable resident equipment between uses, not performing hand hygiene at required times, and not following Enhanced Barrier Precautions for a resident on EBP. Staff were observed removing a mechanical lift from a resident room and placing it in the hallway without cleaning it afterward, and later staff acknowledged the lift had not been disinfected after use. Staff also observed another mechanical lift being used for a resident and then left in the room without being cleaned before staff moved on to other tasks. The Infection Preventionist stated lifts were to be cleaned after each use. Staff were also observed handling soiled linens and then continuing through the facility without completing hand hygiene, and another staff member was observed coughing into his hands, blowing his nose, and then touching a resident's wheelchair handles and transporting the resident into the room without performing hand hygiene in between. In addition, two CNAs assisted a resident on Enhanced Barrier Precautions into bed using a mechanical lift without donning gowns, and one CNA stated he did not follow EBP for that task. The LPN/Infection Preventionist stated that when staff assisted any resident on EBP into bed, they were to wear gloves and a gown.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to assess a resident for self-administration of medications for 1 of 4 sampled residents reviewed for choices. Resident 31 was admitted with diagnoses including asthma and angina pectoris and had physician orders dated 6/12/26 for nitroglycerin as needed for chest pain and an albuterol inhaler as needed for difficulty breathing or shortness of breath. The record contained no evidence of a self-administration evaluation or self-administration orders for this resident. On 7/6/26, Resident 31 stated that he/she had requested to self-administer nitroglycerin and albuterol but was told that he/she could not self-administer while in the facility. The resident expressed concern about extended wait times for medications and stated that these were the two medications needed immediately when symptoms occurred. On 7/10/26, the LPN Resident Care Manager stated the resident had asked to self-administer medications and was informed that self-administration was not allowed. On 7/13/26, the DNS stated residents had the right to self-administer medications if they were able to do so safely and that staff were expected to assess a resident's ability to self-administer and request orders if the resident was found safe to do so.
Smoking Choice Restrictions Not Clearly Defined
Penalty
Summary
The facility failed to allow resident self-determination related to smoking for 2 of 4 sampled residents reviewed for choices. The resident smoking safety policy did not include any information about the number of cigarettes residents were allowed to smoke during their 20-minute smoking break. Resident 31, admitted with cervical spondylosis with myelopathy, stated that although allowed to smoke during the supervised breaks, the resident felt treated like a child because only two cigarettes were allowed during each 20-minute smoking break and wanted to smoke as many cigarettes as desired during that time. Staff 29, a CNA, stated she was trained that residents were only allowed two cigarettes during the 20-minute smoking break. The Administrator stated supervised smokers were allowed five smoking breaks daily and two cigarettes per break per the smoking policy residents signed. The Administrator later acknowledged that the smoking schedule did not state the number of cigarettes a resident was allowed to smoke during the 20-minute smoking break and acknowledged that residents who required supervised smoking were allowed to have as many cigarettes as they wanted during their 20-minute smoke break. Resident 32, admitted with end stage renal disease and chronic pain, also stated the facility treated residents like kids by only allowing two cigarettes during the 20-minute smoking break.
Resident Council Meeting Interrupted by Staff
Penalty
Summary
The facility failed to ensure residents could meet privately for a Resident Council meeting. During an observed Resident Council meeting in the dining room with four residents, including Resident 43 and Resident 15, staff entered the dining room without knocking four different times during the approximately 30-minute meeting. Resident 15 stated that staff interrupted often during the monthly Resident Council meeting, and Resident 43 stated that staff interrupted the meeting multiple times and that the interruptions caused her/him to lose her/his train of thought. The Activity Director stated staff were expected to allow residents to have a private Resident Council meeting and acknowledged staff had interrupted the meeting, though she said it was improving. The Administrator stated residents had the right to meet privately and staff were expected not to interrupt Resident Council meetings.
PRN Order Not Followed Before Psychotropic Use
Penalty
Summary
The facility failed to ensure that a non-psychotropic PRN medication was given before a psychotropic medication as ordered for one resident. Resident 8 was admitted with diagnoses including anxiety disorder and heart failure, and the record showed the resident elected hospice services due to a decline in health and heart failure. The resident received psychotropic medications for hallucinations and anxiety, and a signed hospice physician order dated 3/16/26 directed that lorazepam be given every four hours as needed and that albuterol be used first. Review of the June and July 2026 TARs showed that albuterol was not administered before lorazepam on 6/4/26, 6/16/26, 6/20/26, and 7/1/26. Staff interviews indicated the CNA stated hallucinations were not unusual for the resident and triggered anxiety, the CMA said she relied on nurses to assess before PRN administration and confirmed giving lorazepam on 6/20/26 without being told to give albuterol first, and the DNS stated the order was unclear and staff were to follow physician orders as written and contact the physician for clarification. The hospice DON stated hospice preferred the least restrictive interventions and that albuterol was intended to address the resident's shortness of breath, which was the main symptom of the resident's anxiety.
Unsafe Narcotic Storage and Missing Oxycodone Card
Penalty
Summary
The facility failed to safely store narcotics for one sampled resident who was admitted with diagnoses including a fractured left femur and a fractured left humerus. Staff and a complainant reported that a card of the resident’s oxycodone was missing after the resident was moved from the North Hall to the South Hall, and the card was later found behind a picture frame in the North Hall. An investigation dated 4/27/26 indicated the resident’s oxycodone card was missing on 4/25/26 and was found a few days later behind the back of a picture frame, and the investigation also identified misappropriation of another resident’s oxycodone. The DNS stated staff discovered the missing oxycodone card during a medication count, that the card had been missing since 4/25/26, and that no further investigation was completed to determine how it ended up behind the picture frame; police were not notified of the misappropriation.
Unsafe Discharge With Incomplete Wound Care Orders
Penalty
Summary
The facility failed to ensure a safe discharge for one resident who was admitted with a femur fracture and had a stage 2 pressure wound to the right buttock on admission. During the discharge process, the facility requested home health PT and OT orders, but home health nursing services were not included. A later treatment order in the TAR directed wound cleansing and application of medihoney with a bordered dressing daily and as needed, while the discharge summary listed only barrier cream twice daily for the resident’s buttock pressure injury. After discharge, the assisted living facility reported it had not been informed that the resident had a stage 2 pressure injury and had not received updated wound care orders. The home health director stated nursing care was not requested in the discharge orders. Staff stated the resident had a worsening wound on the coccyx at discharge, that the assisted living facility was not informed of the wound care, and that the wound care orders were changed right before discharge. The administrator stated the facility should have known to request home health nursing orders and expected all current wound care orders to be sent to the assisted living facility.
Delayed Significant Change MDS Assessment After Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change MDS assessment within the required timeframe for Resident 51, who was admitted in 2025 with diagnoses including dementia. A 6/19/26 Election of Hospice Benefit form showed the resident was admitted to hospice services on 6/19/26, but on 7/10/26 the Significant Change MDS assessment was still not completed, 22 days after hospice admission. Staff 38, the MDS Coordinator, confirmed on 7/10/26 at 2:08 PM that the Significant Change MDS had not yet been completed, and Staff 2, the DNS, stated on 7/13/26 at 10:55 AM that the assessment was to be completed within 14 days of the resident's start on hospice services.
Incomplete Diabetic Baseline Care Plan
Penalty
Summary
The facility failed to accurately complete a diabetic baseline care plan for a resident admitted with diabetes and receiving insulin. The resident was admitted in 6/2026 with diagnoses including diabetes, and the 6/18/26 admission MDS showed the resident received insulin. However, the 6/2026 and 7/2026 TARs did not include monitoring for adverse reactions to insulin administration, and a revised care plan dated 6/25/26 did not include any diabetic focus or interventions. Staff 18 stated that a Resident Care Manager was responsible for verifying orders for new residents and ensuring all treatments, orders, and monitors were in place, but believed no treatments were missing for the resident. Staff 25 reviewed the care plan and stated she could not identify the resident as diabetic, which was important for monitoring hypoglycemia. Staff 2 stated the baseline care plan was expected to include diabetic care within 48 hours, especially because the resident received insulin.
Failure to Provide Ordered ROM Exercises
Penalty
Summary
Facility failed to provide ROM for 1 sampled resident (#16) with flaccid hemiplegia of the right side following a stroke. Resident 16 was admitted in 2017 and stated on interview that he/she was unable to move the right side and that staff did not assist with ROM exercises. The revised care plan dated 5/12/25 indicated ROM was to be provided in the morning and evening, but the chart contained no documentation that ROM exercises were completed. Multiple staff members stated they had not seen ROM exercises performed with Resident 16, one CNA said there was no time to complete ROM exercises, another CNA stated the resident’s extremities were moved during dressing but ROM exercises were not completed, and the DNS stated staff were expected to complete ROM exercises while providing care and that dressing alone was not sufficient replacement for ROM exercises.
Meal Supervision Not Implemented for Resident With Dysphagia
Penalty
Summary
The facility failed to ensure appropriate supervision during meals for a resident with lung cancer and dysphagia. The resident was admitted in 5/2024, and a 1/17/26 SLP progress note indicated the resident needed distant supervision while eating. The resident’s current care plan did not include information about distant supervision during meals, and a 5/4/26 facility investigation stated the resident was eating without supervision and that the 1/17/26 recommendation for distant supervision had never been put in place. During interviews, staff described distant supervision as keeping the resident within line of sight while eating, with some stating staff should remain in the doorway or stay in the room until the resident finished eating. The DNS stated the resident received the correct diet but was not supervised, and that SLP failed to inform staff of the 1/2026 recommendation for distant supervision while eating.
Respiratory Care Orders, Care Plan, and Monitoring Not in Place
Penalty
Summary
The facility failed to ensure physician orders for respiratory care, an individualized respiratory care plan, and ongoing respiratory monitoring and assessment were in place for one resident with COPD and respiratory failure. The resident was admitted in 1/2026 with diagnoses including COPD and respiratory failure. Physician orders dated 1/30/26 indicated the resident used a CPAP machine while sleeping, and if the CPAP was removed or refused, the facility was to implement supplemental oxygen; the resident was to be on room air when awake. The 2/11/26 care plan repeated this information, but the electronic health record did not contain orders and indications for supplemental oxygen use when the resident was not wearing CPAP. The Oxygen Monitoring Task showed staff intermittently monitored oxygen saturation levels, but not daily, with gaps in monitoring from 6/25/26 through 6/28/26 and from 7/6/26 through 7/9/26. There was no information on the care plan or Treatment Activity Record about the supplemental oxygen delivery system or equipment, parameters for when to administer oxygen, how or when to monitor oxygen saturation, or documentation of ongoing assessment of the resident's respiratory status or response to supplemental oxygen use. From 7/6/26 through 7/9/26, observations showed the resident consistently received supplemental oxygen via nasal cannula from either an oxygen tank attached to the wheelchair or an oxygen concentrator in bed. Staff stated the resident received oxygen at all times, and the RCM LPN and DNS acknowledged the facility did not have orders, a care plan, assessment, or monitoring in place for the resident's supplemental oxygen use.
Dialysis communication and required evaluations were not completed
Penalty
Summary
The facility failed to ensure dialysis services were in place for a resident with end stage renal disease who was admitted in 6/2026 and had a care plan for dialysis on Mondays, Wednesdays, and Fridays. Review of the resident’s pre-dialysis and post-dialysis evaluations showed missing documentation on multiple treatment days, including no pre-dialysis evaluation on 6/26/26, 7/1/26, and 7/8/26, and no pre-dialysis or post-dialysis evaluation on 7/6/26. The record also showed no post-dialysis evaluation on 7/6/26 and 7/8/26. A 7/3/26 progress note indicated the dialysis center communicated directions to increase potassium in the resident’s diet, but the record contained no evidence that this note was implemented or that additional communication occurred with the dialysis center. The RD stated she was unaware of the note and it was not implemented, and the DNS confirmed the facility was responsible for communicating with the dialysis center and completing the pre- and post-dialysis evaluations. The DNS also confirmed the missing evaluations and stated she was unaware of the potassium increase note and of any communication to confirm the order.
Failure to Ensure Accessible Call Light Resulting in Incontinence Episode
Penalty
Summary
The facility failed to reasonably accommodate a resident’s needs and preferences by not ensuring the call light was accessible throughout the night. A cognitively intact resident with diagnoses including congestive heart failure and weakness was admitted on 2/27/26. A Facility Reported Incident dated 2/26/26 documented that the resident received a bed bath on the evening of 2/23/26 and the call light was not accessible until the following morning. The resident reported that no one checked on them during the night and that they needed to use the toilet. On the morning of 2/24/26 at approximately 7:40 AM, a CNA found the resident’s call light button clipped to the top corner of the mattress and untucked from under the pillow, and the resident was very upset after experiencing fecal incontinence in bed because they were unable to call for assistance. An LPN confirmed being informed that the resident was upset after the incontinence episode due to the inaccessible call light, and the Administrator acknowledged that the resident did not have access to the call light and experienced fecal incontinence. The Administrator also stated that staff were expected to check on residents at least every two hours during the shift.
Failure to Provide Ordered PRN Pain Medication After Supply Depletion
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident with significant pain needs. The resident was admitted with a right tibia and fibula fracture stabilized with an external fixator and had diabetes. A physician’s order dated 10/23/25 directed that the resident receive oxycodone 5 mg every four hours as needed for pain. The admission MDS Pain CAA indicated that pain interventions were to be administered per provider orders. The controlled substance record showed the last oxycodone dose was given on 10/25/25 at 7:35 PM, with zero tablets remaining afterward. On 10/27/25 at 6:00 AM, the Treatment Administration Record documented the resident reported a pain level of nine, yet the Medication Administration Record showed no oxycodone 5 mg was administered that day. On 10/27/25, an LPN documented that the resident complained of pain and requested oxycodone 5 mg, but the facility was out of the medication. The LPN contacted the pharmacy to reorder and requested a Cubex pull code, which the pharmacy denied because remaining oxycodone from the original prescription was already packaged for delivery and a new prescription was required for further refills. The LPN left a voicemail for the on-call provider, and later documented that the provider faxed a new prescription and that three additional tablets would be delivered, with approval to pull from Cubex if needed. The medical record contained no documentation of when the oxycodone was actually delivered and no documentation of any additional pain-management interventions provided to the resident after the reported pain level of nine. A pharmacy technician later stated that four tablets of oxycodone 5 mg were delivered to the facility on 10/27/25 at 3:55 PM, and the DNS confirmed the resident’s oxycodone supply had been depleted on 10/25/25 and was not reordered timely.
Failure to Administer Ordered Morphine for Hospice Resident in Distress
Penalty
Summary
The deficiency involves the facility’s failure to protect a hospice resident with COPD exacerbation and respiratory failure from neglect when ordered morphine for pain and shortness of breath was not administered. The resident had a physician’s order for morphine sulfate 0.25 ml by mouth every hour as needed for shortness of breath and/or moderate to severe pain. Progress notes documented that the resident experienced COPD exacerbation, groaning, difficulty breathing, thirst, distress, rapid breathing, anxiety, and difficulty swallowing. The medication administration record showed the resident received one dose of morphine on 11/6/25 at 8:38 PM, with no further doses given that day despite ongoing symptoms. Multiple staff interviews indicated that the LPN assigned to the resident’s care refused to administer the ordered morphine despite reports from other staff that the resident was screaming, anxious, short of breath, disoriented, and exhibiting terminal agitation behaviors such as pulling off clothes, screaming, and crying. Staff reported that the LPN stated she did not want to depress the resident’s breathing and would not listen to other staff, would not call hospice or the physician, and refused to give the medication cart keys to another LPN who attempted to medicate the resident per orders. CNAs and another LPN described the resident as having a very bad night, being in pain and distress the whole shift, and stated they believed the resident was being neglected. The hospice care manager reported hospice staff were frustrated with medication administration not being done as ordered and confirmed that morphine was appropriate for shortness of breath and could benefit the resident by slowing rapid breathing. The LPN later stated she did not remember if she gave the medication and did not provide further documentation or explanation.
Resident Kept at Nurse’s Station Overnight Against Wishes to Avoid Fall Reports
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from involuntary seclusion by keeping the resident up in a wheelchair at the nurse’s station for most of the night against the resident’s expressed wishes. The resident was admitted in 2025 with diagnoses including a hip fracture and dementia, and the care plan dated 12/2025 did not include any intervention to keep the resident at the nurse’s station all night to prevent falls. Despite this, on at least one night, the resident was kept at the nurse’s station until approximately 2:00–2:30 AM, provided incontinence care, and then returned to the nurse’s station and kept there until 5:00 AM, even though the resident requested to go to bed and did not usually stay up at night. Multiple staff interviews described that an LPN insisted on keeping the resident up at the nurse’s station because the resident had a history of falls and the LPN did not want to complete additional incident reports. CNAs reported that when they attempted to put the resident to bed after incontinence care, the LPN intervened and directed them to get the resident back up, despite the resident stating a desire to remain in bed. Staff observed the resident’s coffee cup being repeatedly refilled at night, which they stated was not normal for this resident, and the resident was positioned at the nurse’s station with a table, coffee, and magazines while being kept awake. Other nursing staff reported that on more than one night the LPN attempted to keep the resident up at the nurse’s station, tucking a blanket around the resident in the wheelchair and leaning the chair back while the resident stated being tired and wanting to go to bed. Staff stated they informed the LPN that forcing the resident to remain in the chair at the nurse’s station instead of allowing the resident to go to bed was abusive. The LPN acknowledged keeping the resident up at the nurse’s station due to concerns about falls and incident reports, and facility leadership confirmed that residents could be monitored at the nurse’s station but not for the entire night and not for staff convenience. This conduct resulted in the resident being subjected to involuntary seclusion and not being allowed to go to bed when requested.
Failure to Report Allegations of Abuse and Neglect to State Agency
Penalty
Summary
The facility failed to timely report allegations of abuse or neglect to the State Survey Agency for two residents. For one resident with COPD, acute exacerbation, and respiratory failure, a physician order dated 11/4/25 directed administration of morphine sulfate 0.25 ml by mouth every hour as needed for shortness of breath and/or moderate to severe pain. A former staff member reported that on 11/6/25, an LPN assigned to this resident refused to administer the ordered pain medication despite other staff reporting the resident was screaming, short of breath, and very anxious. The former staff member stated the Administrator was aware of the incident and spoke with the LPN, but no Facility Reported Incident (FRI) was submitted. The Administrator later acknowledged there was no FRI submitted, and the LPN/Unit Manager also confirmed awareness of the incident and that no FRI was reported. For another resident admitted with a hip fracture and dementia, a former staff member reported being notified that an LPN forced the resident to remain in a wheelchair at the nurse’s station for most of the night and continuously gave the resident coffee because the LPN did not want to deal with the resident falling and any potential incident reports. The former staff member stated she informed the Administrator of this incident and was told not to submit an FRI because it was handled in-house. The DNS stated there should have been an investigation of this incident and clarified that while residents may be monitored at the nurse’s station, it should not be for the entire night or for staff convenience. The Administrator acknowledged there was no FRI submitted to the State Survey Agency for this incident.
Failure to Investigate Allegations of Abuse and Neglect Involving Two Residents
Penalty
Summary
The facility failed to thoroughly investigate allegations of potential abuse and neglect involving two residents. For one resident with COPD with acute exacerbation and respiratory failure, a former staff member reported that on a specific date an LPN assigned to the resident refused to administer ordered pain medication despite reports from other staff that the resident was screaming, short of breath, and very anxious. The former staff member stated she was not informed of the incident at the time and therefore did not investigate it. The Administrator later acknowledged that no investigation was completed, could not provide any documentation showing an investigation or how abuse/neglect was ruled out, and stated she felt the incident was handled by the facility. The LPN involved stated she did not remember if she gave the medication and would need to check the medical record, but did not provide further information or documentation. Another LPN/Unit Manager confirmed awareness of the allegation that the LPN refused to give the resident morphine despite being told the resident was distressed, and also acknowledged that no investigation was completed. For a second resident with a hip fracture and dementia, a former staff member reported being notified that an LPN forced the resident to stay up in a wheelchair for most of the night at the nurse’s station and continuously gave the resident coffee because the LPN did not want to deal with the resident falling and any potential incident reports. The former staff member reported that she notified the Administrator of this incident. The DNS stated there should have been an investigation for this allegation and clarified that while residents could be monitored at the nurse’s station, this should not occur for the entire night or for staff convenience. The Administrator again acknowledged that no investigation was completed for this incident, could not provide any documentation of an investigation, and stated she felt the incident was handled by the facility.
Failure to Follow Physician Orders for X-rays and Medication Administration
Penalty
Summary
The facility failed to follow physician orders for two residents. One resident with peripheral vascular disease was admitted in February 2017 and had a physician order for a right hand x-ray on September 10, 2024. Although the initial x-ray was negative for fracture, the resident continued to experience pain and limited range of motion, prompting repeat x-ray orders on September 18 and September 24, 2024, which were not completed. The resident was later found to have a right wrist fracture during a hospital visit on October 10, 2024. The Resident Care Manager confirmed that the ordered x-rays were not obtained as directed. Another resident, admitted in September 2024 with kidney failure, had a physician order for hydrocodone/acetaminophen 5-325 mg to be given three times daily as needed (TID PRN). The medication was started four days after the order was received and was administered on a scheduled basis (TID) rather than as needed, due to a transcription error. This error was identified in a provider note, which indicated that the incorrect administration may have contributed to the resident's increased confusion. The Resident Care Manager acknowledged the delay in starting the medication and the incorrect administration schedule.
Failure to Ensure Kitchen Staff Wore Hair Restraints
Penalty
Summary
The facility failed to ensure that kitchen staff wore appropriate hair restraints during meal preparation, as observed on March 12, 2025. Specifically, a cook was seen plating meals without a hair restraint, which is a violation of the US FDA Food Code 2022. The Dietary Manager initially stated that there was no requirement for hair restraints for staff with hair less than half an inch long. However, upon reviewing the food code, it was confirmed that all staff, regardless of hair length, are required to wear hair restraints to prevent hair from contacting exposed food. This oversight placed residents at risk for unsanitary food conditions.
Failure to Complete Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to ensure that annual performance reviews were completed for two Certified Nursing Assistants (CNAs) out of a sample of five, which was necessary for assessing sufficient and competent nurse staffing. Specifically, the personnel records review on March 14, 2025, revealed that Staff 9, hired on December 5, 2022, had not received a performance review since January 10, 2024. Similarly, Staff 12, hired on May 26, 2016, had their last performance review on June 8, 2023. This oversight was confirmed by the Director of Nursing, who acknowledged that the annual performance reviews for these staff members were not completed, potentially placing residents at risk due to a lack of competent staff.
Failure to Involve Residents in Care Plan Development
Penalty
Summary
The facility failed to involve residents in the development of their comprehensive care plans, as evidenced by the experiences of three residents. Resident 15, admitted with a diagnosis of diabetes, reported that no one discussed medication or treatment changes with them, and they did not have a care planning meeting. Staff 16, the Interim Social Services, confirmed that while a 72-hour care meeting was conducted upon admission, no care planning meeting was held after the initial comprehensive MDS was completed. Staff 17, the Interim MDS Coordinator, admitted to only asking about pain and not involving residents in the care plan development. Staff 2, the DNS, stated that while she updated the care plan as needed, the MDS staff were responsible for updates post-comprehensive MDS, and residents were not involved in the development process. Similarly, Resident 32, also with a diagnosis of diabetes, stated they did not have a care planning meeting, did not receive a copy of their care plan, and were not involved in discharge decisions. Resident 42, readmitted with a hip fracture, also reported not having a care planning meeting or receiving a copy of their care plan. Staff 16, 17, and 2 provided consistent accounts of the lack of resident involvement in care plan development, confirming that the facility did not conduct care planning meetings with residents after the comprehensive MDS was completed, thus failing to include them in the process.
Failure to Assess and Follow Up on Urinary Catheter Removal
Penalty
Summary
The facility failed to ensure proper assessment and follow-up for the removal of a urinary catheter for a resident admitted with a hip fracture. The hospital discharge order specified that the catheter should be removed one week after discharge, and a progress note indicated a trial of voiding should be attempted when acute symptoms improved, with a referral to a urologist for further evaluation. However, the medical record lacked documentation of any attempt to remove the catheter or to make a urology referral. On observation, the resident still had the catheter in place and was unaware of any plan for its removal. Staff confirmed the oversight, acknowledging that the catheter removal and urology referral were not attempted as ordered.
Failure to Change PICC Dressing as Scheduled
Penalty
Summary
The facility failed to complete IV dressing changes for a resident who was receiving antibiotics through a PICC line. Resident 39, admitted with an abdominal wall abscess, had a physician's order for zoxyn, an IV antibiotic, every six hours. The resident also had an unscheduled order for PICC line care, with the next dressing change due on January 27, 2025. On March 14, 2025, an LPN stated she did not change the PICC dressing because it was not listed on the MAR and was unaware of the frequency for changing PICC dressings. Another LPN, the Resident Care Manager, confirmed that PICC dressings should be changed weekly and as needed but could not find the last recorded dressing change for the resident. Upon observation, the dressing was dated March 4, 2025, indicating it was overdue for a change on March 11, 2025.
Failure to Implement Timely Dose Reduction of Psychotropic Medication
Penalty
Summary
The facility failed to ensure the gradual dose reduction of psychotropic medications as ordered for one of the sampled residents. Resident 2, who was admitted with a diagnosis including diabetes, had a physician's order on 9/26/24 for Trazodone 150 mg, which was later discontinued on 12/31/24. A recommendation was made on 10/21/24 to reduce the Trazodone dose to 100 mg, and the provider responded with an order to implement this reduction on 11/5/24. However, the facility did not implement the order until 1/1/25, as confirmed by Staff 2 (DNS) during a review on 3/12/25. This delay in implementing the physician's order placed the resident at risk for unnecessary psychotropic medication use.
Expired Medications Found in Facility's Medication Room
Penalty
Summary
The facility failed to ensure that medication rooms were free of expired biologicals, which was observed in one of the two sampled medication rooms. During an inspection, two expired medications, Healthy Eyes (Leutin) and Terbinafine (an antifungal medication), were found in the medication storage room. Staff 13, an LPN, confirmed the presence of these expired medications and acknowledged that they should not be administered to residents. Additionally, Staff 2, the Director of Nursing Services (DNS), also confirmed that the medications were expired and should not be given to residents. This oversight placed residents at risk for diminished treatment efficacy.
Inadequate Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to adhere to proper infection control practices during wound care for a resident with pressure ulcers. The resident, admitted in February 2017 with a diagnosis of diabetes, had a physician's order dated March 5, 2025, for wound care on the buttocks. On March 11, 2025, during an observed dressing change, an LPN performed hand hygiene, donned gloves, cleaned the wound, but then failed to perform hand hygiene after removing the contaminated gloves before applying new ones. The LPN acknowledged the omission, stating that hand hygiene was completed only at the beginning and end of the dressing change. The facility's infection preventionist confirmed that hand hygiene should be performed every time gloves are removed.
Failure to Offer Pneumonia Vaccine to Resident
Penalty
Summary
The facility failed to ensure that a resident was offered a pneumonia vaccine, which was identified during an interview and record review. The deficiency involved a resident who was admitted to the facility in December 2024 with a diagnosis of hypertension. Upon reviewing the resident's medical record, it was found that the resident was eligible for a pneumonia vaccine but was not offered one. On March 13, 2025, at 11:11 AM, the Director of Nursing Services (DNS) confirmed that there was no indication in the medical record that the pneumonia vaccine was administered prior to admission or offered after admission to the facility.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Salem
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tierra Rose Care Center | 2.4 mi | ★★★★★ | 2 | 0 |
| Keizer Nursing And Rehabilitation | 2.7 mi | ★★★★★ | 3 | 0 |
| Avamere Court At Keizer | 3.7 mi | ★★★★★ | 0 | 0 |
| Avamere Transitional Care At Sunnyside | 3.9 mi | ★★★★★ | 0 | 0 |
| Salem Transitional Care | 4.8 mi | ★★★★★ | 11 | 0 |
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