Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Graduate Post Acute during CMS and state inspections, most recent first.
Two residents experienced unresolved grievances related to missing personal items when the facility did not promptly investigate and resolve complaints as required by its personal property policy. One resident reported missing personal care products that disappeared during a night shift, and although the issue was documented as resolved, the items had not yet been replaced and no inventory sheet could be located. Another resident's representative reported an ongoing pattern of missing clothing despite multiple items being brought in, with inventory records showing reduced numbers of garments and only a few missing items later found, while the grievance remained unresolved.
A resident with a history of stroke, dysphagia, failure to thrive, and moderate protein-calorie malnutrition was discharged home while receiving specialized enteral feedings, but the facility did not ensure that necessary enteral feeding supplies were provided or properly documented at discharge. The RD confirmed an ordered enteral feeding regimen, yet the discharge summary completed by the ADON only listed a walker and omitted enteral needs and other equipment. After discharge, it was documented that required bolus/gravity feeding supplies were not provided, even though the resident’s son had been trained. The DON later confirmed that a mechanical lift and sling were ordered but not recorded in the clinical record, and invoices showed multiple orders and cancellations of enteral supplies and formula without explanation. The ADON stated that the home health agency could not supply the specific enteral formula brand, and responsibility for ensuring correct enteral feeds was inconsistently attributed to the SW despite the discharge summary indicating nursing responsibility.
A resident with complex GI and renal conditions had inaccurate and incomplete documentation in the medical record. The SNF/NF to hospital transfer form contained conflicting information, listing one transfer date and family notification date while recording VS and the signature on a different date. In addition, although the resident was on a heart-healthy, full liquid diet with intake to be tracked by nursing assistants, the "amount eaten at meal" task form lacked documented percentages for multiple breakfasts and lunches. The RD and DON confirmed both the intended documentation process and that the transfer form and meal intake records were not accurately or fully completed.
A resident with asthma, HTN, anxiety, morbid obesity, and quadriplegia was reported as not receiving needed assistance to get out of bed since admission, while the DON stated that staff reported the resident was refusing to get out of bed when offered. However, review of clinical notes over several months showed no documentation by nursing staff of any refusals, and the person-centered care plan contained no problem, goals, or interventions related to refusals to get out of bed, despite facility policy requiring measurable objectives, time frames, and documentation of services not provided due to resident refusal.
Food was not stored, prepared, distributed, and served in accordance with professional standards. A hole in the dish room ceiling had been open for about two weeks, flies were observed in the dish room, and a severe foul odor was present. Dry storage items were stacked to the ceiling with no clearance, and flies and gnats were seen in the main kitchen area while an uncovered trash container sat by the tray line during food prep. The FSD confirmed the findings and said flies were entering from the outside receiving area near the trash room.
The facility failed to complete annual performance reviews for five of five nurse aide personnel files reviewed. When surveyors requested the evaluations from the NHA and DON, the facility could not produce records for the five nurse aides, and the evaluations were not submitted before or at the exit conference.
A resident had repeated PRN Lorazepam orders for anxiety that were renewed beyond the initial 14-day limit. The record contained no prescriber documentation explaining the clinical rationale for continuing the psychotropic medication or stating the duration for continued use, and the DON confirmed there was no such justification.
Failure to use interpreter and communication supports: A resident whose primary language was not English was observed trying to communicate needs by gestures, but staff did not use the interpreter line or communication board during interactions. The resident’s care plan required interpreter services, yet staff were unaware of the resident’s preferred language and the facility’s interpreter line, and the communication board was not accessible when the resident had difficulty communicating basic needs and preferences.
Failure to obtain ordered weights for nutritional monitoring. A resident had a physician order for monthly weights, but weights were not consistently obtained and several months had no documented weights. The resident experienced significant weight loss, and a reweight to confirm the loss was still pending when the Dietician confirmed the missing weights and lack of reweight.
The facility failed to properly assess, monitor, and maintain a resident’s midline catheter. The resident had a right upper extremity midline with a dressing that had not been changed within the required interval, and the record lacked evidence of a physician order for midline care or documented midline assessments for complications. An LPN and the DON confirmed the findings and expected practice.
Missing Physician Orders for Oxygen Administration: The facility failed to obtain physician orders for oxygen for two residents reviewed for respiratory care. One resident with diagnoses including type 2 DM with peripheral angiopathy and gangrene and panlobular emphysema was observed receiving 3 L of oxygen without an order in the chart, and an LPN confirmed no order was present. Another resident was observed receiving oxygen via nasal cannula at 1 L/min, but active orders reviewed by surveyors did not show an oxygen order.
Failure to provide trauma-informed and culturally competent care was identified for two residents with PTSD. One resident had diagnoses including subarachnoid hemorrhage, MDD, and PTSD, and another had diagnoses including muscle wasting and atrophy, HF, and PTSD. In both cases, the care plans did not address the residents’ trauma history or possible triggers that could cause re-traumatization, and the DON confirmed the omissions.
A resident’s chart showed delayed follow-through on consultant pharmacist recommendations involving Wellbutrin timing and crushing instructions. The pharmacist noted that Wellbutrin was being given at bedtime and suggested moving it to 9:00 a.m., but the change was not implemented until after the survey team requested the pharmacy review. A separate recommendation to add a DO NOT CRUSH statement for meds that should not be crushed was acknowledged, yet the order was not updated for weeks, and the ER tablet was still being given half without a documented reason for not following the pharmacist’s guidance.
Improper disposal of garbage and refuse was observed in the trash room and receiving area. Trash bins were exposed and overflowing, dirty gloves, debris, and food were scattered on the floor, and a severe foul odor was present. In the receiving area, uncovered trash bins were filled with trash, a foul white liquid was pooling across the floor from the construction trash container, kitchen trash was placed in the construction bin, and flies were observed throughout the area.
Failure to provide ADL assistance for grooming and bathing: two residents did not receive needed care as planned. One resident with dialysis dependence, heart failure, PVD, and legal blindness reported that his teeth had not been brushed in weeks and was observed with oral odor, dirty fingernails, and uncombed hair; staff also noted he received only partial bathing and no oral care after dialysis. Another resident with muscle wasting and kidney cancer reported being left in a chair for hours because a second staff member was unavailable and said he had not had a shower in about a month; he was observed with greasy hair and facial hair, and task records showed missed scheduled showers.
A resident with diabetes, gangrene, and a surgical amputation did not receive ordered wound care for a left foot wound and a right toe wound on multiple scheduled days, and the wound dressing was found dated several days earlier. In a separate finding, a resident with orthostatic hypotension received Midodrine late and was given the medication even when systolic BP was above the ordered hold parameter; an LPN confirmed the medication was administered outside the order.
A resident did not receive ordered Oxycontin ER 20 mg q12h for pain on multiple scheduled doses. The resident reported severe pain and said staff told her the medication was not available from the pharmacy. An RN confirmed the ordered pain med was not given as prescribed.
A resident with cognitive impairment and a history of falls exited the facility unsupervised after staff failed to recognize her as a resident and did not follow LOA and visitor sign-out protocols. The resident left through the front entrance while the receptionist was distracted, and was later found over a mile away. This lapse in supervision and protocol adherence placed the resident at high risk for injury.
A resident with a history of falls and cognitive deficits, requiring staff assistance for ambulation and without a physician order for leave, was able to exit the facility unsupervised. The resident left through the front entrance after being mistaken for a visitor by the receptionist, who did not follow sign-out or visitor badge protocols. The resident was found two hours later, 1.2 miles away, after staff realized the resident was missing.
A resident with moderate cognitive impairment and a history of falls exited a facility unsupervised, walking 1.2 miles away. The receptionist, distracted by personal activities, mistook the resident for a visitor and allowed them to leave without following protocol. The resident was found two hours later, highlighting a failure in supervision and adherence to facility policies.
A resident with a history of falls and cognitive deficits left an LTC facility unsupervised due to inadequate management and protocol lapses. The resident exited behind visitors, with the receptionist failing to recognize them as a resident. The resident was found 1.2 miles away, highlighting non-compliance with leave of absence and visitation protocols, resulting in Immediate Jeopardy.
The facility did not ensure an effective pest control program, as evidenced by a rodent observed in a resident room and confirmation from an LPN who reported frequent rodent sightings. Two residents also reported seeing rodents and expressed concerns about ongoing infestation, with mouse traps proving ineffective.
A resident with multiple medical conditions did not receive several scheduled medications at the prescribed time, as a nurse administered them over two hours late. The nurse confirmed the delay, which resulted in noncompliance with physician orders.
A resident with a diagnosis requiring supplemental oxygen was observed receiving oxygen at 6 L/min via nasal cannula, despite a physician order specifying 2 L/min. This deviation from the prescribed oxygen flow rate was confirmed by an RN and did not align with facility policy requiring adherence to physician orders.
A resident with a recent hip fracture, requiring staff assistance for ADLs, was not provided or offered a scheduled shower as indicated in the care plan. Review of documentation and resident interview confirmed the omission, with no evidence of bathing assistance being given on the scheduled day.
A resident with a physician's order for Cannabidiol Oral Solution for pain and seizures was not informed prior to admission that the facility prohibited cannabis administration. As a result, the resident did not receive the prescribed medication, and the order was discontinued due to facility policy. Staff and the resident's representative confirmed that the no-cannabis policy was not communicated before or at admission, and the facility could not provide documentation of the policy.
A resident with cognitive impairments and a history of schizophrenia eloped from an LTC facility due to inadequate supervision and failure to properly check the functionality of a wander management device. The resident was missing for over 24 hours, highlighting deficiencies in the facility's elopement prevention policy and procedures.
A resident with a history of stroke and schizophrenia eloped from an LTC facility due to inadequate supervision and management by the Nursing Home Administrator and DON. Despite having an elopement care plan, the resident exited the facility and was missing for over 24 hours. A wander guard was applied but not properly tested, contributing to the incident.
A facility failed to document a prescribed wound care regimen for a resident who underwent foot surgery. Despite a physician's order for daily wound care, there was no record of the care being performed, as confirmed by the facility administrator. This lack of documentation indicates a failure to maintain accurate medical records.
The facility failed to employ a qualified Food Service Director (FSD) as required. The FSD, responsible for food service operations, lacked necessary certifications and did not receive frequent consultations from a qualified dietician. A corporate RD covered the facility part-time, but there was no evidence of regular guidance for the FSD.
The facility was found to be non-compliant as it lacks a qualified professional to direct the activities program. Interviews with the NHA and the Director of Guest Services confirmed the absence of an activities director. Resident council meeting minutes from June and July indicated discussions on activities, but no qualified oversight was mentioned.
The facility failed to ensure nursing staff had necessary competencies, as three employees lacked documented training in key areas such as resident rights, person-centered care, and infection control. This deficiency was confirmed with the facility's administration.
The facility's pest control program on the fifth floor was ineffective, as evidenced by multiple mice and pest sightings. Despite a policy requiring a pest-free environment, interviews with staff and residents, along with documentation, revealed ongoing issues. The pest control company's reports and a log book recorded numerous sightings, and residents reported frequent encounters with mice and other pests.
The facility did not provide a Notice Of Medicare Non-Coverage (NOMNC) to a resident transitioning from Medicare to Medicaid pending status. Despite multiple requests during a survey, the facility could not produce the NOMNC, confirmed by the facility's Social Services.
A nurse aide in an LTC facility misappropriated funds from two residents by using their EBT and debit cards to purchase food for herself. The residents, one with moderate cognitive impairment and the other with intact cognition but communication difficulties, admitted to giving their cards to the aide. Despite receiving training on the facility's abuse policy, the aide claimed ignorance of her actions being misappropriation. The facility's investigation confirmed the allegations, but the extent of the misappropriation remains unknown.
A facility failed to thoroughly investigate the misappropriation of funds involving two residents and a nurse aide. The aide used residents' EBT and debit cards to purchase items for herself and at the residents' request. Despite residents admitting consent, the investigation lacked comprehensive evidence, including staff statements and interviews with other residents. One resident had moderate cognitive impairment, highlighting the need for a thorough investigation.
A resident with HIV, paraplegia, and a stage 4 pressure ulcer experienced a decline in ROM and ADL, requiring more assistance. The facility failed to conduct a significant change MDS assessment despite these changes, as confirmed by the RN Assessment Coordinator.
A facility failed to develop a baseline care plan within 48 hours for a resident with COPD and a tracheostomy requiring oxygen therapy. The resident was observed on oxygen via a tracheostomy collar, but the care plan was not initiated until several days after admission, contrary to facility policy.
A facility failed to develop and implement a comprehensive care plan for a resident with an indwelling urinary catheter. Despite having a physician's order for catheter management, there was no documented care plan addressing the resident's urinary catheter. The resident, with diagnoses including hemiplegia and urinary retention, had a catheter in place, confirmed by observation and interview, yet lacked a documented care plan.
The facility failed to update care plans for three residents, leading to deficiencies in addressing their specific medical needs. One resident's care plan did not reflect the need for supervision of a visitor providing unauthorized medical care. Another resident experienced significant weight loss and abnormal bleeding without care plan updates. A third resident was signed onto hospice care, but their care plan was not updated to reflect this change, including the updated advance directive.
A resident with COPD and a tracheostomy was not receiving the prescribed oxygen level of 6 liters per minute, as the concentrator was set to 3 liters per minute. This discrepancy was observed on two occasions and confirmed by a nurse, who then adjusted the oxygen level to the correct setting.
A facility failed to follow infection control practices for a resident with multiple pressure injuries. The resident's room lacked EBP signage and a PPE disposal bin. A nurse performed wound care without a gown, despite drainage from the wounds. Staff interviews revealed a misunderstanding of the EBP policy, leading to non-compliance with CDC guidelines.
The facility failed to provide palatable food and drink at appropriate temperatures for residents. Resident council minutes and interviews revealed dissatisfaction with food quality and service. A test tray evaluation showed food temperatures did not meet standards, and the presentation was unappealing, confirmed by the Food Service Director.
The facility failed to maintain an effective pest control program, with multiple sightings of mice and other pests across all nursing units. Despite a policy for a pest-free environment, logs and resident notes reported frequent pest sightings, including mice and roaches. Staff interviews confirmed the inadequacy of pest control measures, with missed treatments contributing to the issue.
A resident, who was at high risk for falls and moderately cognitively impaired, experienced falls on two occasions. The facility failed to notify the resident's representative as required by their policy. Documentation errors led to the resident being incorrectly listed as their own responsible party, and staff interviews confirmed the oversight.
A facility failed to update a resident's care plan to include fall risk precautions despite the resident's high fall risk and history of falls. The resident, with moderate cognitive impairment and a history of falls, experienced two unwitnessed falls without new interventions being developed. The Interim DON confirmed the lack of fall risk precautions.
The facility did not provide the required transfer notices to the State Office of the LTC Ombudsman for three months. This was confirmed through a review of clinical records and staff interviews, revealing that the facility failed to send copies of transfer or discharge notices to the Ombudsman as required.
The facility failed to maintain a comfortable temperature in the dialysis center, affecting residents receiving dialysis treatment. The cooling system was in disrepair, leading to temperatures above the recommended range. Temporary cooling units were insufficient, and the issue persisted due to delays in obtaining necessary parts for repair. Residents and staff reported discomfort, and the facility was non-compliant with CMS temperature requirements.
The facility failed to report allegations of abuse and neglect for four residents to the state survey agency. Grievances included a resident left in feces, another not receiving care over a weekend, a third experiencing disrespectful behavior from a nurse aide, and a fourth not receiving toileting assistance. These grievances were not reported as required by the facility's policy.
The facility failed to conduct thorough investigations into allegations of abuse and neglect for four residents. Grievances included reports of inadequate care, confrontational behavior by staff, and lack of assistance with toileting. Despite the facility's policy requiring prompt reporting and investigation, no evidence of complete investigations was provided, as confirmed by discussions with the DON and Regional Nurse.
Failure to Promptly Resolve Grievances Regarding Missing Personal Property
Penalty
Summary
The facility failed to promptly resolve resident grievances related to missing personal items for two interviewed residents. Facility policy on Personal Property, dated 2001, states that the facility will promptly investigate any complaints of misappropriation or mistreatment of resident property. One resident filed a grievance reporting that personal care items, including Johnson's Baby Lotion (pink), Aveeno Skin Relief (small bottle), and Dove antiperspirant, went missing during a night shift. The facility met with the family the same day to document the missing items and the family requested replacement of those products. The grievance form recorded the issue as resolved eight days after the grievance was filed, but the facility later confirmed that the replacement items had not yet been obtained by that time and that there was no inventory sheet available for this resident. Another resident's representative submitted a grievance reporting an ongoing concern that the resident's personal clothing, including at least eight pairs of pants and approximately fifteen shirts brought in over time, had been continually going missing each week. The grievance form documented the issue as resolved within six days of the grievance, but an inventory sheet from earlier in the year listed only a limited number of shirts, undershirts, pajama pants, and sweatpants, and a subsequent inventory sheet showed even fewer shirts and sweatpants. An email from the resident's family later provided a detailed list of missing items, of which only two were located. The Administrator confirmed that this grievance had not yet been resolved, as only a few items had been found and the facility still needed to speak with night shift staff before any reimbursement of the missing items could occur.
Failure to Provide Enteral Feeding Supplies and Proper Discharge Documentation
Penalty
Summary
The facility failed to ensure that a discharged resident receiving enteral nutrition had necessary enteral feeding supplies and appropriate documentation at the time of discharge. The resident had diagnoses including cerebral infarction due to small artery occlusion, adult failure to thrive, dysphagia, and moderate protein calorie malnutrition, and was receiving specialized enteral feedings per a physician order, along with some oral intake. The Registered Dietitian confirmed the ordered enteral feeding regimen. The social worker documented that the resident and family requested an early discharge and stated they had everything in place for the resident to go home. However, the discharge summary completed by the Assistant Director of Nursing only documented a walker as needed equipment and did not include the resident’s enteral feeding needs or other equipment. After discharge, a social worker progress note documented that supplies needed for bolus and/or gravity feeding were not provided, and that the resident’s son had been trained on both methods. The facility’s DON later confirmed that a Hoyer lift and sling were ordered but not documented in the clinical record or discharge summary. Invoices showed that a hydraulic patient lift and commode were ordered and delivered on the discharge date, while irrigation kits, bolus supplies, and enteral formula were ordered and then canceled on two later dates, with no explanation for the multiple orders or cancellations. The Assistant DON acknowledged that the resident was receiving specialized enteral feedings and that the accepting home health agency did not have the specific brand and could not provide the supply. When the family reported post-discharge that they did not have supplies, the facility provided a packet of supplies, but responsibility for ensuring correct enteral feeds and brand was inconsistently attributed to the social worker despite the discharge summary indicating nursing responsibility.
Inaccurate Hospital Transfer Documentation and Incomplete Meal Intake Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident with diagnoses including intestinal obstruction of unclear severity, colostomy malfunction, ileostomy, and kidney failure. The resident’s closed clinical record showed hospitalizations on two separate dates, including one on March 30, 2026. Review of the SNF/NF to Hospital Transfer Form revealed conflicting and inaccurate information: the form listed the transfer date and family notification as March 4, 2026, at 9:06 a.m., while the vital signs recorded on the same form were dated March 30, 2026, and the form itself was signed on March 30, 2026. The DON confirmed that the Transfer to the Hospital form did not reflect accurate information for March 30, 2026. The resident was on a heart-healthy, full liquid diet, and intake was to be tracked by nursing assistant staff using an “amount eaten at meal” task form. Review of this documentation showed missing recorded percentages for breakfast and lunch on multiple dates in March 2026, specifically the 18th, 21st, 22nd, 23rd, 25th, and 27th. The RD confirmed that intake was to be documented in this manner, and the DON confirmed that the “amount eaten at meal” task form had not been completed for those meals on the identified dates. These omissions and inaccuracies demonstrated that the facility did not maintain medical records in accordance with accepted professional standards.
Failure to Care Plan and Document Resident Refusals to Get Out of Bed
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan addressing a resident’s reported refusals to get out of bed. Facility policy, revised in March 2022, requires that comprehensive care plans include measurable objectives, time frames, and a description of services that would otherwise be provided but are not, due to a resident exercising the right to refuse care. For one resident with diagnoses including asthma, hypertension, anxiety, morbid obesity, and quadriplegia, the facility reported concerns to the State Survey Agency that the resident had not been receiving needed assistance to get out of bed since admission in late December 2025. Review of the resident’s clinical record from December 2025 through March 2026 showed no documentation by nursing staff, including nurse aides, that the resident refused to get out of bed when offered assistance. The resident’s person-centered care plan also lacked any care plan problem, goals, or interventions related to refusals to get out of bed. During an interview, the DON stated that the resident refuses to get out of bed when offered and that staff had notified her of this, but there was no corresponding documentation of these refusals in the clinical notes or care plan. This lack of documentation and care planning for the resident’s refusals resulted in noncompliance with multiple cited state regulatory requirements for resident care policies, care planning, and nursing services.
Food Service Sanitation and Storage Deficiencies
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards for food service safety. During observation of the dish room, a hole was seen in the ceiling, and the administrator confirmed the opening had been exposed for about two weeks after a pipe was removed. Flies were observed in the dish room, and a severe foul odor was present. In the dry storage area, boxes and food items were stored all the way to the ceiling with no clearance between the top shelf and the ceiling. In the main cooking area, flies and gnats were observed, and a gray trash container was standing uncovered by the tray line while food was being prepared. The Food Service Director confirmed these findings and stated that flies were coming into the kitchen area from the outside receiving area where the trash room was located.
Missing Annual Performance Reviews for Nurse Aides
Penalty
Summary
The facility failed to complete annual performance reviews for nurse aide staff as required for five of five nurse aide personnel files reviewed, including Employees E11, E12, E13, E14, and E15. During an interview on September 25, 2025, at 10:00 a.m., annual performance evaluations for these nurse aide staff were requested from the NHA and DON. In a later interview with Regional Staff, Employee E10, on September 25, 2025, at 10:48 a.m., the facility did not have records of performance evaluations for Employees E11 through E15, and the facility did not submit the requested performance evaluations prior to or at the time of the exit conference.
PRN Psychotropic Order Continued Without Required Prescriber Documentation
Penalty
Summary
The facility failed to ensure that the rationale and duration for continuing PRN psychotropic medication orders beyond 14 days were documented by the prescribing practitioner for one resident, R123. Record review showed multiple PRN orders for Lorazepam 2 mg by mouth every six hours as needed for anxiety, each entered for a 14-day period: August 27, 2025 through September 10, 2025; September 8, 2025 through September 22, 2025; and an active order on September 16, 2025 through September 30, 2025. Further review found no documentation from the prescriber giving a clinical rationale or justification for continuing PRN Lorazepam beyond the initial 14-day limit, and no indication of the duration for continued use as required. The DON confirmed in interview that the medication order was renewed after 14 days of the initial order and that there was no justification for the continuation or indication of duration for continued use.
Failure to Use Interpreter and Communication Supports
Penalty
Summary
The facility failed to ensure effective communication interventions were implemented for a resident whose primary language was not English. On September 23, 2025, Resident R84 was observed unable to speak English and pointing toward a brief to indicate a need for assistance, but there was no evidence that an interpreter line or communication board was used during the interaction. A nurse aide stated that the resident just uses gestures and confirmed that neither the interpreter line nor the communication board was utilized. Review of the resident’s care plan, dated March 31, 2025, showed that interpreter services were required because the resident’s primary language was not English, with interventions including Video Remote Interpretation services or Language Link as needed to provide adequate communication. On September 24, 2025, the resident was again observed frustrated while trying to operate the television remote and unable to communicate which channel she wanted. The nurse aide stated, "I try different things until we figure it out," and also said it was sometimes really hard to understand the resident. At that time, the communication board was stored on the closer door and not accessible to the resident, and the Director of Memory Care Services stated, "we hung up the communication board yesterday." Staff were also unaware of the facility’s interpreter line or the resident’s preferred language.
Failure to Obtain Ordered Weights for Nutritional Monitoring
Penalty
Summary
The facility failed to ensure that Resident R7’s ordered weights were obtained to monitor nutritional status. The record showed that the physician recommended weight monitoring on June 3, 2025, and again on July 11, 2025, when a monthly weight order was placed for the 15th of every month. The resident’s weight documentation showed no weights recorded for June 2025, July 2025, or August 2025 as ordered. The resident weighed 137.6 lbs. on May 7, 2025, and 116 lbs. on September 18, 2025, reflecting a 15.7% weight loss over the period. A nutritional progress note dated September 19, 2025, documented that the resident triggered for significant weight loss of -21.8 lb (15.8%) over 5 months and noted that a reweight to confirm the loss was pending and that the weight loss was unplanned/unfavorable. No reweights were documented as of September 24, 2025, and the Dietician confirmed that the ordered weights were not consistently obtained and that no reweight had been completed to confirm the weight loss.
Midline Catheter Care Not Properly Assessed or Maintained
Penalty
Summary
The facility failed to provide adequate treatment, assessment, and monitoring for the care and maintenance of a midline catheter for one resident. The resident had a right upper extremity midline catheter observed on September 22, 2025, at 1:06 p.m., and the dressing on the midline was documented as last changed on September 12, 2025. An LPN present during the observation confirmed the finding. Review of the resident’s clinical record showed no evidence that the facility obtained a physician order for midline catheter care and assessment, and no evidence that the facility completed midline assessments for complications related to the midline. The record also showed no evidence that the facility completed the midline catheter dressing change every seven days as required. The DON confirmed that staff were expected to provide and document midline assessment and change the midline dressing every seven days.
Missing Physician Orders for Oxygen Administration
Penalty
Summary
The facility failed to obtain physician orders for oxygen administration for two residents reviewed for respiratory care. Facility policy stated that oxygen is administered by licensed staff with a physician's order, and that in an emergency oxygen may be administered with an order obtained as soon as possible. Review of the clinical record for one resident showed diagnoses including surgical amputation, type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene, and panlobular emphysema. On observation, that resident was receiving 3 liters of oxygen, but the clinical record contained no physician order for oxygen, and an LPN confirmed there was no order. A second resident was observed in bed receiving oxygen via nasal cannula at 1 L/min, but review of active physician orders showed no evidence that the facility had obtained an order for oxygen administration. The DON later confirmed that there was a physician order to administer oxygen to that resident. The deficiency was identified based on clinical record review, staff interviews, and direct observations of the residents receiving oxygen without documented physician orders in the record reviewed by surveyors.
Failure to Address PTSD Triggers in Care Plans
Penalty
Summary
Failure to provide trauma-informed and culturally competent care was identified for two residents with PTSD. Resident R4 was admitted with diagnoses including non-traumatic subarachnoid hemorrhage, major depressive disorder, and PTSD. The resident’s care plan, dated September 25, 2025, did not include a plan for the resident’s history of traumatic events and did not address possible triggers that could cause re-traumatization. Resident R104 was admitted with diagnoses including muscle wasting and atrophy, heart failure, and PTSD. Review of R104’s care plan showed that no care plan was developed for the resident’s PTSD or for possible triggers that could cause re-traumatization. The DON confirmed in interview that both residents’ care plans did not include PTSD and possible triggers that may cause re-traumatization.
Delayed Response to Pharmacist Medication Recommendations
Penalty
Summary
The facility failed to ensure a timely response to the consultant pharmacist’s recommendations for one resident, R7, related to potentially unnecessary medications and medication administration instructions. A June 20, 2025 pharmacy consultant recommendation stated that Wellbutrin was being given at bedtime and could contribute to difficulty sleeping, and suggested changing the dose time to 9:00 a.m.; although the recommendation was acknowledged and signed, there was no evidence it was implemented until September 24, 2025, after the survey team requested the pharmacy review. A July 30, 2025 pharmacy consultant recommendation stated that the physician order indicated medications may be crushed even though the resident was receiving medications that should not be crushed, and requested the orders be updated to include a DO NOT CRUSH statement; this recommendation was also acknowledged and signed, but the physician order did not include the DO NOT CRUSH statement until August 31, 2025. Further review showed the medication continued as an extended-release tablet and was given half, and there was no documented reason for not following the pharmacist recommendation.
Improper Disposal of Garbage and Refuse
Penalty
Summary
Garbage and refuse were not disposed of properly in the trash room and receiving area. During observations, the trash room door was open and the trash bins were exposed; two large trashcans were overflowing with refuse exposed to open air, and a severe foul odor was present. Dirty gloves, debris, and food were scattered on the floor around the trash bins. In the receiving area, four uncovered grey trash bins were exposed and filled with trash, and a foul white milky liquid was pooling across the floor, appearing to leak from the construction trash container and spreading into multiple walking and delivery zones used by staff to transport food into the facility. Trash from the kitchen was observed placed in the construction trash bin, and flies were seen in the receiving area, the trash room, the construction trash container, and at the receiving entrance door. The Food Service Director confirmed the observations during the tour.
Failure to Provide ADL Assistance for Grooming and Bathing
Penalty
Summary
The facility failed to provide necessary assistance with ADLs to maintain proper grooming for two residents. One resident with diagnoses including anterior spinal artery compression syndrome, cervical region, dependence on renal dialysis, heart failure, peripheral vascular disease, and legal blindness had care planned for staff assistance with bathing, grooming, and oral care. During interview, the resident stated that his teeth had not been brushed in weeks and reported that because he goes to dialysis early in the morning, his teeth were not brushed. He was observed with a strong oral odor, covering his mouth, and later was observed with dirty fingernails, noticeable oral odor, and uncombed hair. The nurse aide assigned to the resident stated she had not yet provided his care for the day, and the Administrator confirmed the observations. The resident was later observed returning from dialysis after receiving only a face wash and partial bath, with oral care still not provided and oral odor remaining. A second resident with muscle wasting and atrophy, malignant neoplasm of the left kidney, and need for assistance with personal care had a care plan indicating dependence on staff for bathing and assistance with ambulation. The resident reported that therapy had taken him out of bed, but staff could not place him back because a second person was not available, leaving him sitting in a chair for two and a half hours. He also stated that showers were very important to him and that the last shower he received was about a month ago. The resident was observed with greasy hair and facial hair, and a licensed nurse confirmed those observations. Task documentation showed the resident was scheduled for showers twice weekly, but multiple scheduled showers were not completed.
Missed wound care and improper medication administration
Penalty
Summary
The facility failed to provide ordered wound care for a resident with a surgical amputation, type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene, and panlobular emphysema. The resident reported that wound dressings had not been changed for 2 days, and observation showed the left foot wound dressing was dated September 20, 2025. The physician order required negative pressure wound therapy dressing changes every 3 days and as needed on every day shift for the left foot wound, but the September 2025 TAR showed the resident did not receive wound care on September 19 and September 22 as ordered. The resident also had an order dated September 12, 2025 for daily treatment to the right 4th toe wound, including cleansing, Santyl, calcium alginate, an ABD pad, and Kling wrap, but the TAR showed missed wound care on September 18, September 21, and September 22. An LPN confirmed the resident did not receive wound care on the dates identified based on the TAR and the wound dressing date. In a separate finding, a resident with osteomyelitis of the vertebra, malignant neoplasm of the bronchus or lung, and orthostatic hypotension reported that medications were not given timely. Observation showed the resident receiving the scheduled 9:00 a.m. medication at about 11:00 a.m., and the MAR showed Midodrine was administered even when systolic blood pressure was above 120, contrary to the order to hold the medication when systolic BP was greater than 120. An LPN confirmed the medication was administered when the resident's systolic BP was above 120.
Failure to Provide Ordered Pain Medication
Penalty
Summary
The facility failed to ensure that pain management was provided consistently as ordered by the physician for Resident R123. The resident stated during interview that she was not receiving her pain medication and reported pain at a level of 10 out of 10, adding that staff told her the medication ordered by the physician was not available from the pharmacy. The physician order dated September 4, 2025, directed Oxycontin extended release 20 mg every 12 hours for pain, but the Medication Administration Record showed the resident did not receive the medication on September 20, 2025 at 9:00 p.m., September 21, 2025 at 9:00 a.m., and September 21, 2025 at 9:00 p.m. The RN confirmed that Resident R123 did not receive the pain medication as ordered.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Protocol Lapses
Penalty
Summary
A deficiency occurred when a resident with a history of repeated falls, difficulty walking, pelvic fracture, and cognitive impairment was able to leave the facility without a physician's order for a leave of absence (LOA) and without staff supervision. The resident, who required one-person assistance for ambulation and had a moderately impaired cognitive status as indicated by a BIMS score of 10, exited the third floor via elevator and walked out the front entrance using a walker. The resident was not identified as having an LOA order in the clinical records, and there was no documentation of staff being notified or a sign-out process being followed. Facility policy required that residents at risk for wandering or elopement have care plans with specific interventions and that staff intervene if a resident attempts to leave. However, the receptionist on duty did not recognize the resident as a facility resident, mistaking her for a visitor due to her appearance. The receptionist was distracted by personal computer use and failed to follow the protocol of ensuring all residents and visitors sign out and wear visitor badges. Surveillance footage confirmed that the receptionist opened the door for the resident, who then left the premises unchallenged. Staff interviews revealed that the assigned nursing assistant was aware the resident wanted to walk but did not clarify the resident's intentions or monitor her whereabouts. The resident was later found approximately 1.2 miles away in a busy area after being missing for about two hours. The failure to provide adequate supervision and to follow established LOA and visitation protocols resulted in the resident leaving the facility unsupervised, placing her at high risk for injury.
Removal Plan
- Resident was assisted back to the Center and assessed by RN Supervisor for injuries.
- The Center completed a headcount of all residents and compared it to the midnight census to ensure all residents were accounted for.
- The Nursing Administration held huddles with staff to discuss residents who go on frequent LOAs and signs and symptoms that may indicate risk for leaving the Center without staff notification.
- Shift RN Supervisor provided immediate education to receptionist on duty.
- RN Supervisors were educated on the completion of headcount of all residents compared to midnight census and the immediate reporting of any discrepancy to the Director of Nursing/designee.
- Staff were educated on signs and symptoms that may indicate a risk of elopement.
- Reception/security staff were educated on the process of each visitor receiving a badge that must be returned prior to door being opened and visitor leaving the premise.
- Staff educated on elopement/missing person policy and procedure including code yellow announcement to notify staff in Center, search both on the premises and the surrounding areas, notification processes including local police department.
- Staff educated on elopement drills including how often and expected response.
- All the training above will be added to our general orientation schedule for all new future employees.
- Residents with a current unsupervised LOA order were re-educated on the LOA policy/agreement and understood the sign out process with both the nursing staff on the unit.
- Auditing census compared to headcount every 4 hours for 3 days then every shift for 14 days then daily. All variances will be reported to the QAPI Committee monthly.
- Random audit of five visitors to ensure compliance with the visitor pass system two times daily for 14 days then daily for two months. All variances will be reported to the QAPI Committee monthly.
- Daily audit of LOA log to ensure reception/security staff are checking for clearance to leave the Center. The audit will be completed daily for three weeks with all variances reported during the clinical meeting.
- The QAPI Committee will make recommendations to ensure continued compliance. Upon sustained compliance, the QAPI Committee will recommend the reduction or resolution of the audits and the reception/security staff.
Failure to Supervise Resident Results in Unsupervised Exit and Elopement
Penalty
Summary
The Nursing Home Administrator (NHA) and Director of Nursing (DON) failed to effectively manage the facility to ensure adequate supervision for a resident with a history of repeated falls, difficulty walking, pelvic fracture, and cognitive communication deficit. The resident's care plan required one-person staff assistance for ambulation, and there was no physician order for a leave of absence. Despite these requirements, the resident was able to exit the third floor via elevator, leave through the front entrance, and was not noticed missing until later in the shift. Facility documentation and staff interviews revealed that the nursing assistant assigned to the resident was told by the resident that they needed to walk, but the assistant assumed this meant walking on the unit. When the resident was later found missing, a Code Yellow was announced. Surveillance footage showed the resident, dressed appropriately and using a walker, leaving the building behind a group of visitors. The receptionist, who was distracted by personal activities on the computer, did not recognize the resident as a resident and allowed them to exit without following sign-out or visitor badge protocols. The resident was located approximately 1.2 miles away in a busy area after being missing for about two hours. The facility's investigation confirmed that the resident did not have a physician order for a leave of absence and should not have been allowed to leave unaccompanied. The failure to follow established protocols for supervision, leave of absence, and visitor management directly contributed to the resident's unsupervised exit and subsequent elopement.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to a resident who did not have a leave of absence (LOA) order, resulting in the resident exiting the third floor via elevator and walking out the front entrance of the facility. The resident was located two hours later, approximately 1.2 miles away from the facility in a busy urban area. This incident was identified as an Immediate Jeopardy past non-compliance, placing the resident at high risk for injury. The resident, who was admitted with a history of repeated falls, difficulty walking, fracture of the pelvic bone, and cognitive communication deficit, had a BIMS score indicating moderate cognitive impairment. The resident's care plan required one-person staff assistance for ambulation, and there was no documented evidence of a physician order for a leave of absence. Despite this, the resident managed to leave the facility without staff intervention, as the receptionist mistook the resident for a visitor and allowed them to exit. The facility's policies on wandering and elopements, as well as resident leaves of absence, were not followed. The receptionist, distracted by personal activities on the computer, failed to recognize the resident and did not adhere to the protocol of ensuring visitors and residents sign out and wear visitor badges. This oversight, combined with the lack of supervision and failure to identify the resident's risk of elopement, led to the resident's unsupervised departure from the facility.
Removal Plan
- Resident left the Center to take a walk. The resident had walked to her previous address and was visiting neighbors. The Center staff spoke with her friend, and she was assisted back to the Center. Upon return, RN Supervisor assessed, and no injuries were noted.
- The Center completed a headcount of all residents and compared it to the midnight census to ensure all residents were accounted for and resting comfortably.
- The Nursing Administration held huddles on all floors with staff on duty to discuss the current residents which go on frequent LOAs as well as the signs and symptoms that may indicate the risk for leaving the Center without staff notification. No variances were noted, and no current residents were identified as an elopement risk.
- Shift RN Supervisor provided immediate education to receptionist on duty.
- RN Supervisors were educated on the completion of headcount of all residents compared to midnight census and the immediate reporting of any discrepancy to the Director of Nursing/designee.
- Staff were educated on signs and symptoms that may indicate a risk of elopement. 100% completion.
- Reception/security staff were educated on the process of each visitor receiving a badge that must be returned prior to door being opened and visitor leaving the premise. 100% completion.
- Staff educated on elopement/missing person policy and procedure including code yellow announcement to notify staff in Center, search both on the premises and the surrounding areas, notification processes including local police department. 100% completed.
- Staff educated on elopement drills including how often and expected response. 100% completion.
- All the training above will be added to our general orientation schedule for all new future employees.
- Residents with a current unsupervised LOA order were re-educated on the LOA policy/agreement and understood the sign out process with both the nursing staff on the unit.
- Auditing census compared to headcount every 4 HRS (hours) for 3 days then every shift for 14 days then daily. All variances will be reported to the QAPI (Quality Assurance Improvement Program) Committee monthly.
- Random audit of five visitors to ensure compliance with the visitor pass system two times daily for 14 days then daily for two months. All variances will be reported to the QAPI Committee monthly.
- Daily audit of LOA log to ensure reception/security staff are checking for clearance to leave the Center. The audit will be completed daily for three weeks with all variances reported during the clinical meeting.
- The QAPI Committee will make recommendations to ensure continued compliance. Upon sustained compliance, the QAPI Committee will recommend the reduction or resolution of the audits.
Resident Elopement Due to Inadequate Supervision and Protocol Lapses
Penalty
Summary
The deficiency involved the failure of the Nursing Home Administrator and Director of Nursing to effectively manage the facility, resulting in a resident, identified as Resident R1, exiting the facility unsupervised. Resident R1, who had a history of repeated falls, difficulty walking, and cognitive communication deficit, was admitted to the facility with a care plan indicating the need for one-person staff assistance for ambulation. Despite this, Resident R1 was able to leave the facility without a physician order for leave of absence, which was not documented in the resident's records. On the day of the incident, a nursing assistant was informed by Resident R1 of the need to walk, but the assistant assumed it was within the unit. Later, the resident was found missing, prompting a Code Yellow for elopement. Surveillance footage showed Resident R1 leaving the facility behind a group of visitors, with the receptionist, Employee E9, failing to recognize the resident and allowing the exit without intervention. The receptionist was distracted by personal activities on the computer and did not follow the facility's protocol for visitor sign-out and badge return, contributing to the oversight. The resident was located 1.2 miles away in a busy urban area, having walked to a friend's apartment. The facility's investigation confirmed that the resident should not have been allowed to leave without supervision or a physician order. Interviews with facility staff, including the Regional Vice President of Operations, confirmed the non-compliance with leave of absence and visitation protocols, placing the resident at risk for serious injury. This situation was identified as an Immediate Jeopardy of past non-compliance.
Plan Of Correction
This Plan of correction constitutes this facility's written allegation of compliance for the deficiencies cited. This submission of this plan of correction is not an admission or agreement with the deficiencies or conclusions contained in the Department's inspection report. Resident has been re-educated on the LOA on the process and is not currently at risk of elopement from the center. A full house audit was completed to identify any other residents similarly affected. All variances were updated and discussed with the physician. Care plans were updated to address safety and supervision. RDO reviewed with NHS/DON respective job descriptions. The job descriptions state that they will maintain and develop written policies and procedures that govern the operations of the center to include Resident Leave of Absence, Wandering and Elopements Procedure - Missing Resident. RDO reviewed with LNHA and DON his/her respective job description which includes that the purpose of the position was to plan, organize, develop and direct the overall operation of the nursing services department in accordance with the current federal, state, and local standards, guidelines and regulations that govern our center and as may be directed by the NHA and MD to ensure the highest degree of quality care is maintained at all times. The NHA and DON delegate the administrative authority, responsibility and accountability necessary for carrying out assigned duties. RDO will complete weekly audits for 12 weeks to ensure administrative enforcement of visitor badge process is being adhered to.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program as required by its own policy, resulting in the presence of rodents on the 2nd floor unit. During an observation, a rodent was seen in a resident room, and this finding was confirmed by a licensed nurse. The nurse reported observing rodents one to two times during each working shift. Additionally, interviews with two residents revealed that they had seen rodents in their rooms and expressed concerns about a persistent rodent infestation, noting that mouse traps placed in the room were ineffective.
Failure to Administer Medications Timely According to Physician Orders
Penalty
Summary
A deficiency was identified when a registered nurse failed to administer scheduled medications to a resident at the prescribed time. According to the resident's physician orders and Medication Administration Record (MAR), several medications, including acetaminophen, allopurinol, amiodarone, apixaban, gabapentin, ferrous sulfate, and a multivitamin, were scheduled to be given at 9:00 a.m. However, observation revealed that these medications were not administered until 11:12 a.m. The nurse involved confirmed during an interview that the medications were not given at the scheduled time. The resident in question had multiple medical conditions, including atrial fibrillation, gout, neuropathy, and anemia, for which the medications were prescribed. The failure to administer medications as ordered constituted noncompliance with physician orders and facility policy.
Failure to Follow Physician Orders for Oxygen Administration
Penalty
Summary
A deficiency was identified when a resident, who was diagnosed with dependence on supplemental oxygen, did not receive respiratory care in accordance with the physician's orders. The resident had a documented order for oxygen administration at 2 liters per minute via nasal cannula to be provided continuously for shortness of breath. However, during an observation, the resident was found to be receiving oxygen at 6 liters per minute via nasal cannula, which was not consistent with the physician's order. This discrepancy was confirmed by a registered nurse at the time of the observation. The facility's policy requires nurses to follow physician orders when administering oxygen, but this was not adhered to in this instance.
Failure to Provide Scheduled Bathing Assistance to Dependent Resident
Penalty
Summary
A deficiency was identified when a resident, who was alert, oriented, and required assistance with activities of daily living (ADLs) due to a recent hip fracture, did not receive the necessary support for personal hygiene. The resident's care plan specified the need for one-staff assistance with bathing, transferring, dressing, and toileting, and the facility maintained a shower schedule indicating the resident was to receive a shower on Saturdays. On the scheduled shower day, the resident reported not being offered or provided a shower. Review of the nursing kardex and the resident's clinical record showed no documentation that a shower or bathing was provided or offered as per the care plan. The lack of documentation and the resident's statement confirmed that the required assistance with bathing was not delivered as scheduled.
Failure to Inform Resident of No-Cannabis Policy Resulted in Missed Medication
Penalty
Summary
The facility failed to inform a resident and their representative of its policy prohibiting the administration of cannabis products prior to admission. The admission documentation did not include any information regarding the facility's stance on medical cannabis use. The resident, who had a physician's order for Cannabidiol Oral Solution to manage pain and seizures, was admitted without being notified that the facility would not permit the administration of this medication. As a result, the prescribed medication was not administered from the time of admission, and the order was later discontinued due to facility policy. Interviews with facility staff and the resident's representative confirmed that neither the resident nor their representative was made aware of the no-cannabis policy before or at the time of admission. The staff member responsible for reviewing medication lists at admission did not ensure that only medications permitted by facility policy were included. Additionally, when requested, the facility administrator was unable to provide a copy of the no-cannabis use policy during the survey.
Resident Elopement Due to Inadequate Supervision and Device Checks
Penalty
Summary
The facility failed to provide adequate supervision to a resident at risk for elopement, resulting in the resident exiting the third floor via elevator and leaving through the front entrance doors. The resident was not located for over 24 hours, which placed them at high risk for injury. The facility's policy on 'Wander Management and Elopement Prevention' was not effectively implemented, as routine checks for placement and functionality of the wander management system devices were not conducted as required. The resident, who was admitted with a history of stroke, schizophrenia with prior psychosis, and cognitive dysfunction, was determined not to have decisional capacity and was assigned a legal guardian. Despite these conditions, the admission evaluation incorrectly indicated that the resident was not at risk for elopement. A care plan identifying the resident as at risk for elopement was only developed after admission, highlighting a delay in recognizing and addressing the resident's needs. Interviews with staff revealed that the wander guard device was not properly tested for functionality, and there was no documented evidence of its placement or functionality checks. The facility lacked a 'tester box' to verify the device's operation, and there was no order for the wander guard in the resident's clinical record. These oversights contributed to the resident's ability to leave the facility undetected, leading to an Immediate Jeopardy situation.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The deficiency involved the failure of the Nursing Home Administrator and Director of Nursing to effectively manage the facility, resulting in inadequate supervision of a resident at risk for elopement. The resident, who had a history of stroke, schizophrenia with prior psychosis, and cognitive dysfunction, was admitted to the facility and identified as being at risk for elopement. Despite the development of an elopement care plan, the resident managed to exit the facility and was missing for over 24 hours. The resident was last seen by staff in the afternoon and was discovered missing later that evening. The facility's search efforts were unsuccessful, and the resident was eventually located at another center 2.2 miles away, in a busy urban area. The resident was returned to the facility and assessed for respiratory concerns, which required a visit to the emergency room. Upon return, the resident was placed under one-to-one supervision. Interviews with staff revealed that a wander guard was applied to the resident upon admission, but there was no documented order for it, nor evidence that it was tested for functionality. The facility lacked a tester box to verify the wander guard's operation, which was on order. This oversight contributed to the resident's ability to elope, highlighting a significant lapse in the facility's management and adherence to federal and state guidelines.
Plan Of Correction
This Plan of Correction constitutes this facility's written allegation of compliance for the deficiencies cited. This submission of this plan of correction is not an admission of or agreement with the deficiencies or conclusions contained in the Department's inspection report. Resident has been assessed and identified as elopement risk. Resident is being maintained on 1:1 supervision 24/7. A full house audit was completed to identify any other residents similarly affected. All variances were updated and discussed with the physician. Care plans were updated to address safety and supervision. RDO reviewed with the NHA his respective job description that includes "Equipment and Supply Function" section stated that the NHA are to ensure that the Center is maintained in a clean and safe manner for residents' comfort and convenience by assuring that necessary equipment and supplies are maintained to perform such duties/services. Ensure that adequate supplies and equipment are on hand to meet the day-to-day operations needs of the Center and residents. NHA reviewed with DON her respective job description which includes that the purpose of the position was to plan, organize, develop and direct the overall operation of the nursing service department in accordance with current federal, state and local standards, guidelines and regulations that govern our Center and as may be directed by the Administrator and the Medical Director, to ensure that the highest degree of quality care is maintained at all times. The Director of Nursing Services delegates the administrative authority, responsibility and accountability necessary for carrying out assigned duties.
Incomplete Documentation of Wound Care
Penalty
Summary
The facility failed to maintain complete and accurately documented clinical records for a resident who was admitted for skilled nursing care following a surgical procedure on the right plantar foot. The resident's clinical record included a physician's order dated December 25, 2024, which specified a wound care regimen to be performed daily during the night shift. However, upon review, there was no documentation in the resident's clinical record to confirm that the wound care was carried out as ordered by the primary care physician. An interview with the facility administrator on January 23, 2025, confirmed the absence of both electronic and written documentation verifying the completion of the prescribed wound care. This lack of documentation indicates a failure to adhere to the physician's orders and maintain accurate medical records, as required by regulatory standards. The deficiency was identified during a review of clinical records and interviews with residents and staff.
Plan Of Correction
The resident no longer resides in the facility. An audit was completed to identify residents with physician orders for wound treatments to ensure accurate documentation. Variances were addressed and recorded on the audit. The licensed nurses were educated on The Wound Treatment Policy with emphasis on adherence to physician's orders and documenting accordingly. DON/Designee will perform 10 random weekly audits for 4 weeks, then monthly for 3 months to ensure that physician's orders are being followed, and wound treatments are being adhered to and documented on. Trends will be reported to the QAPI committee for recommendations as warranted.
Failure to Employ Qualified Food Service Director
Penalty
Summary
The facility failed to employ a qualified director of food and nutrition services, as required by regulations. During an observation tour, the Food Service Director (FSD), who had been working at the facility for one and a half years, stated his responsibilities included oversight of ordering, receiving, storing, preparation, and service of food. However, upon interview, the FSD confirmed that he was not a certified dietary manager, certified food manager, nor did he have a national certification for food service management and safety, or an associate's or higher degree in food service management or hospitality from an accredited institution. Additionally, the FSD had not received frequently scheduled consultations from a qualified dietician. A review of the FSD's credentials confirmed that he did not meet the statutory qualifications for his role. Further interviews revealed that a corporate Registered Dietician (RD) covered the building two days per week, but the facility was unable to provide evidence that the FSD was receiving the necessary frequent consultations from a qualified dietician to ensure adequate guidance for the dietary department.
Lack of Qualified Activities Program Director
Penalty
Summary
The facility was found to be non-compliant with the requirement to have a qualified professional directing the activities program. During an interview with the nursing home administrator on November 19, 2024, it was revealed that the facility currently lacks an activities program director. This was further confirmed by the Director of Guest Services on November 20, 2024, who stated that the facility does not have a qualified activities director. Additionally, a review of resident council meeting minutes from June and July 2024 indicated discussions on activities such as outdoor engagements and birthday celebrations, but there was no mention of a qualified professional overseeing these activities.
Deficiency in Nursing Staff Competency Training
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary competencies and skills to adequately care for residents, as evidenced by the review of personnel files and staff interviews. Specifically, three out of five personnel files reviewed showed deficiencies in skill competency training. Employee E9, a licensed nurse hired on October 1, 2024, lacked documented training in critical areas such as resident rights, person-centered care, communication, basic nursing skills, restorative services, skin and wound care, medication management, pain management, infection control, identification of changes in condition, and cultural competency. Similarly, Employee E18, a nurse aide hired on August 21, 2024, and Employee E16, a nurse aide hired on June 21, 2024, also did not have documented competency training in the same essential areas. These findings were confirmed with the facility's Nursing Home Administrator and Director of Nursing, indicating a systemic issue in ensuring that staff are adequately trained to meet the needs of residents, as required by the relevant Pennsylvania Code sections.
Deficiency in Pest Control Program on Fifth Floor
Penalty
Summary
The facility failed to maintain an effective pest control program on the fifth floor, as evidenced by multiple mice and pest sightings. The facility's policy, revised in January 2024, mandates a pest-free environment through a contract with a pest control vendor for periodic services. Despite this, interviews with staff and residents, along with a review of facility documentation, revealed ongoing pest issues. Employee E14, the Unit Manager of the fifth floor, confirmed multiple mice sightings and the existence of a log to document these occurrences, which the pest control company uses to treat affected areas. The pest control company's reports indicated thirteen sightings from mid-October to the end of October 2024, and fourteen sightings from early November to mid-November 2024. Additionally, the pest sighting log book recorded 32 sightings from May to November 2024. Interviews with several residents revealed frequent sightings of mice and other pests, with one resident reporting seeing a large roach in their room. These findings demonstrate a significant deficiency in the facility's pest control measures, impacting the living conditions on the fifth floor.
Failure to Provide NOMNC to Resident
Penalty
Summary
The facility failed to provide a Notice Of Medicare Non-Coverage (NOMNC) to one of the three residents reviewed, specifically Resident R20. The review of facility documentation titled 'Medicare A Patients Cut from Skilled Care with Benefits Days Remaining' indicated that Resident R20 was transitioning from Medicare to Medicaid pending status effective August 19, 2024. Despite multiple requests during the survey conducted from November 20, 2024, through November 22, 2024, the facility was unable to produce the NOMNC for Resident R20. This deficiency was confirmed through an interview with the facility's Social Services, Employee E11, and is a violation of 28 Pa Code 201.29(f) regarding resident rights.
Misappropriation of Resident Funds by Nurse Aide
Penalty
Summary
The facility failed to protect residents from misappropriation and exploitation of property, specifically involving the unauthorized use of residents' funds. Two residents, identified as R1 and R22, were involved in incidents where a nurse aide, Employee E16, used their EBT and debit cards to purchase food items for herself. The residents admitted to giving their cards to Employee E16, with Resident R1 having moderate cognitive impairment and Resident R22 having intact cognition but with communication difficulties due to a stroke. The facility's policy on abuse prohibition, last revised in October 2022, clearly defines exploitation and misappropriation of resident property. Despite this, Employee E16, who had received training on the facility's abuse policy, claimed to be unaware that her actions constituted misappropriation. The facility's investigation confirmed that the allegations were substantiated, as the residents had given consent for the purchases, but the aide's actions still fell under misappropriation. The Director of Nursing reported the incident to the State Agency, and the facility's investigation revealed that the extent of the misappropriation, including the duration and total amount spent, was unknown. The residents involved had varying levels of cognitive function, with Resident R1 having a BIMS score indicating moderate cognitive impairment, while Resident R22 had a BIMS score indicating intact cognition but with some communication challenges due to aphasia.
Inadequate Investigation of Misappropriation of Resident Funds
Penalty
Summary
The facility failed to conduct a thorough investigation into the alleged misappropriation of resident funds involving two residents. The facility's policy on abuse prohibition, which includes the prevention and investigation of misappropriation of resident property, was not adequately followed. The investigation did not include pertinent information such as staff statements, interviews with other residents cared for by the implicated employee, or the amount of funds used. This lack of thoroughness in the investigation process led to the deficiency. The incident involved a nurse aide, Employee E16, who was reported by two staff members for using residents' EBT and debit cards to purchase food items for herself and at the residents' request. The residents involved, identified as Resident R1 and Resident R22, admitted to giving their cards to Employee E16 and consenting to her purchasing items for herself. Despite this admission, the facility's investigation was incomplete, as it did not gather comprehensive evidence or assess the full extent of the misappropriation. Resident R1, who was cognitively assessed with a BIMS score of 12, indicating moderate cognitive impairment, was one of the residents involved. The facility's failure to conduct a complete investigation, including the lack of interviews with other residents and staff statements, resulted in a deficiency in addressing the misappropriation of resident funds. The facility's actions were insufficient to rule out the possibility of misappropriation, as required by their abuse prohibition policy.
Failure to Conduct Significant Change MDS Assessment
Penalty
Summary
The facility failed to conduct a significant change Minimum Data Set (MDS) assessment for a resident who experienced a deterioration in range of motion (ROM) and activities of daily living (ADL). The resident, identified as R67, was admitted with diagnoses including HIV, paraplegia, and a stage 4 pressure ulcer. Initially, the resident's MDS assessments indicated no impairment in both upper and lower extremities and required limited assistance for bed mobility and transfers. However, subsequent assessments showed a need for extensive assistance in these areas, indicating a significant decline in the resident's condition. Despite these changes, the facility did not complete a significant change assessment as required. The Resident Assessment Instrument (RAI) Manual specifies that a significant change in a resident's status, which impacts more than one area of health and requires interdisciplinary review, necessitates such an assessment. An interview with the Registered Nurse Assessment Coordinator confirmed that a significant change assessment should have been conducted when the changes were identified during the quarterly MDS assessment.
Failure to Develop Timely Baseline Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a resident requiring oxygen therapy. The resident, who was admitted with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and a tracheostomy, was observed receiving oxygen via a tracheostomy collar connected to an oxygen concentrator. The physician's orders specified that the oxygen concentrator should be set to 6 liters per minute, but the baseline care plan was not developed and initiated until more than 48 hours after the resident's admission. Observations conducted during a tour of the unit revealed that the resident was on oxygen therapy, yet there was no documented evidence of a baseline care plan being developed within the required timeframe. The facility's policy mandates the creation of a person-centered care plan within 48 hours of admission, but this was not adhered to, as evidenced by the care plan for COPD being initiated several days post-admission.
Failure to Develop Comprehensive Care Plan for Urinary Catheter
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident with an indwelling urinary catheter. The facility's policy requires a comprehensive individualized care plan to be developed within seven days after the completion of a comprehensive assessment and to be reviewed and revised after each assessment. However, there was no documented evidence that a care plan addressing the resident's urinary catheter was developed and implemented, despite the resident having a physician's order for an indwelling urinary catheter and specific instructions for its management. The resident, who was admitted with diagnoses including hemiplegia, hemiparesis, chronic kidney disease, and urinary retention, had a physician's order dated March 13, 2024, for a 16 F indwelling urinary catheter with a 10cc balloon. The order also specified that the urinary catheter drainage bag should be emptied at least once every eight hours or when it becomes 1/2 to 2/3 full. An observation conducted on November 19, 2024, confirmed the presence of the urinary catheter, with the urine bag containing 350 cc of yellowish clear liquid. An interview with the resident at the time of observation confirmed the presence of the urinary catheter, yet no care plan was documented in the resident's clinical record.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to update care plans for three residents, leading to deficiencies in addressing their specific medical needs. For one resident, the care plan did not reflect the need for supervision of a visitor who was providing unauthorized medical care, such as administering over-the-counter medications and performing oral hygiene, which posed risks of aspiration and tube occlusion. Despite repeated education and counseling, the visitor continued these interventions, and the care plan was not updated to address this issue. Another resident experienced significant weight loss and had a history of abnormal bleeding, yet their care plan lacked updates and interventions to address these conditions. The resident's medical records indicated a decrease in weight from 120 pounds to 101 pounds over several months, and there was no evidence that the care plan was revised to manage these health concerns. A third resident, who was admitted with heart failure, end-stage renal disease, and intestinal obstruction, was signed onto hospice care, but their care plan was not updated to reflect this significant change, including the updated advance directive. The resident's care plan did not include the transition to hospice care, and the resident eventually expired at the facility without these updates being made.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to administer oxygen as ordered by the physician for a resident diagnosed with Chronic Obstructive Pulmonary Disease (COPD) with a tracheostomy. The resident was admitted with a physician's order for an oxygen concentrator set to 6 liters per minute, to be administered during both day and night shifts. However, during observations conducted on two separate occasions, it was found that the resident's oxygen concentrator was set to only 3 liters per minute, contrary to the physician's order. The deficiency was confirmed during an interview with a licensed nurse, who acknowledged that the oxygen was running at a lower rate than prescribed. The nurse reviewed the physician's order and confirmed the discrepancy, subsequently adjusting the oxygen level to the correct setting of 6 liters per minute. This failure to adhere to the physician's order for oxygen administration was a violation of the facility's policy and the resident's care plan, which specified the need to administer oxygen as ordered.
Inadequate Infection Control Practices for Resident with Pressure Injuries
Penalty
Summary
The facility failed to maintain effective infection control practices related to barrier precautions and personal protective equipment (PPE) for a resident with multiple pressure injuries. The facility's policy on Enhanced Barrier Precautions (EBP) was not followed, as there was no signage indicating EBP outside the resident's room, and no bin was available for discarding used PPE. During an observation, a licensed nurse performed wound care on the resident without donning a gown, despite the presence of drainage from the wounds, which contradicts the facility's policy and CDC guidelines. The resident in question was admitted with several medical conditions, including cervical disc disorders and type 2 diabetes with diabetic neuropathy. The resident had multiple stage 4 pressure injuries with moderate serous drainage, requiring specific wound care orders. Interviews with staff, including the infection preventionist and the director of nursing, revealed a misunderstanding or misapplication of the facility's EBP policy, as they believed gowns were not necessary for wounds without drainage, despite evidence to the contrary.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility failed to provide food and drink that was palatable and served at appropriate temperatures for five residents. Resident council minutes from June and August 2024 indicated complaints about the quality and temperature of food, as well as issues with beverage availability and service delays. An interview with a resident revealed dissatisfaction with the food, particularly for a diabetic resident receiving regular ginger ale and finding the pork chops too hard to chew. A test tray evaluation conducted with the Dietary Director showed that the food temperatures did not meet the required standards, with hot foods below 135 degrees Fahrenheit and cold beverages above 41 degrees Fahrenheit. Additionally, the presentation of the food was unappealing due to a lack of color variety, which was confirmed by the Food Service Director.
Ineffective Pest Control Program in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program across all four nursing units, as evidenced by multiple sightings of mice and other pests. The facility's pest control policy, revised in January 2024, mandates a pest-free environment, yet pest logs and resident council notes indicate frequent sightings of mice and roaches in various rooms and hallways on the 2nd, 3rd, 4th, and 5th floors. Specific incidents include mice sightings in rooms and hallways, with reports of mice running under furniture and into air conditioning units. Additionally, there were reports of bedbugs, with a resident bitten on the neck, and roaches seen running in certain areas. Interviews with facility staff, including the Assistant Maintenance Director and the Interim Director of Nursing, confirmed the presence of pests and acknowledged the inadequacy of the current pest control measures. The pest control company was scheduled to provide treatments twice a week, but records show that several treatments were missed or only partially completed during August and September 2024. This lapse in regular pest control treatments contributed to the ongoing pest issues, as documented in the pest logs and corroborated by staff interviews.
Failure to Notify Resident's Representative of Falls
Penalty
Summary
The facility failed to ensure that a resident's representative was informed of falls sustained by the resident. The facility's policy, titled 'Change in Condition: Notification,' requires immediate notification of the patient's representative in the event of a change in condition. However, for Resident R1, who was at high risk for falls and had a history of repeated falls, the facility did not notify the resident's representative after falls occurred on two separate occasions. Resident R1, who was moderately cognitively impaired with a BIMS score of 12, experienced falls on August 28, 2024, and September 4, 2024. Despite having two representatives listed in their profile, the facility's documentation incorrectly noted the resident as their own responsible party. Interviews with facility staff, including the Social Worker and Interim Director of Nursing, confirmed that the representatives should have been informed of the falls, but were not.
Failure to Update Care Plan for Fall Risk Precautions
Penalty
Summary
The facility failed to update and revise a resident's care plan to reflect specific care needs, particularly concerning fall risk precautions. The resident, who was moderately cognitively impaired with a BIMS score of 12, had a history of difficulty walking, repeated falls, dementia, restlessness, and agitation. Despite being identified as high risk for falls with a score of 16 on a risk assessment, the care plan did not include specific fall risk precautions. The resident experienced an unwitnessed fall on August 28, 2024, and another on September 3, 2024, yet no new interventions were developed to address the increased fall risk. The Interim Director of Nursing confirmed that fall risk precautions were neither developed nor implemented for the resident. A care conference was held on September 6, 2024, to discuss the recent falls, but the family requested the resident be transferred to the hospital. The facility's failure to develop and implement appropriate fall risk precautions for the resident was a deficiency noted in the report.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide the required transfer notices to the State Office of the Long-Term Care Ombudsman for three consecutive months: July, August, and September 2024. This deficiency was identified through a review of clinical records and staff interviews. On September 18, 2024, a request was made for evidence of all residents' transfer notices provided to the Ombudsman for the specified months. However, during an interview with the Interim Director of Nursing and the Regional Clinical Lead Nurse, it was confirmed that the facility did not send a copy of the transfer or discharge notices to the Ombudsman as required by regulations.
Failure to Maintain Comfortable Temperature in Dialysis Center
Penalty
Summary
The facility failed to maintain a comfortable air temperature in the dialysis center, affecting four residents receiving dialysis treatment. The Home Hemodialysis Coordination Agreement indicated that the facility was responsible for providing a safe and sanitary environment, including maintaining the HVAC system. However, the cooling system in the dialysis center, located in the basement, was in disrepair, leading to high temperatures. Observations and interviews revealed that the temperatures in the dialysis center were consistently above the recommended range of 72 to 75 degrees Fahrenheit, with recorded temperatures reaching as high as 97 degrees Fahrenheit. Temporary cooling units were used but were insufficient to maintain the appropriate temperature. The issue with the cooling system was first reported in June 2024, but temperature monitoring did not begin until July 17, 2024. The Director of Maintenance confirmed that the cooling system required parts that were unavailable and had to be manufactured, with an estimated repair date set for September 9, 2024. During this period, residents and staff reported discomfort due to the high temperatures, and the dialysis nurse noted that maintaining the room at the appropriate temperature range was crucial for the effectiveness of dialysis solutions. The facility's failure to address the cooling system issue promptly resulted in non-compliance with the CMS requirement for maintaining a comfortable temperature for dialysis patients.
Failure to Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to report allegations of abuse and neglect to the state survey agency for four residents. The facility's policy requires immediate reporting of suspected abuse, mistreatment, or neglect to the appropriate authorities within specified timeframes, depending on the severity of the incident. However, grievances submitted on behalf of Residents R1, R2, R3, and R4 were not reported as required. Resident R1's grievance, dated August 14, 2024, stated that he was left sitting in feces all day without assistance from the nurse aides. Resident R2's grievance, submitted by her daughter on July 22, 2024, alleged that the resident did not receive care over a weekend, was left in the same clothes, and experienced confrontational behavior from nurse aides. Resident R3's grievance, dated July 28, 2024, described an incident where a nurse aide was allegedly disrespectful and did not properly assist the resident. Resident R4's grievance, dated August 14, 2024, claimed that aides were not assisting with toileting, forcing the resident to manage independently. The facility's failure to report these grievances to the state survey agency was confirmed during a discussion with the Director of Nursing and the Regional Nurse. The facility's reporting system showed no evidence of notification or investigation results being reported to the state survey agency, as required by the facility's policy and state regulations.
Failure to Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to conduct a complete and thorough investigation regarding allegations of abuse and neglect for four residents. The facility's policy requires that upon receiving information about suspected abuse, the Administrator or designee must report the allegations to the appropriate authorities within specified timeframes and initiate an investigation within 24 hours. However, the facility did not provide evidence of thorough investigations for the grievances submitted on behalf of Residents R1, R2, R3, and R4. Resident R1's grievance reported that he had been left sitting in feces all day without assistance, and the morning nurse aides told him he had to wait for the next shift. Although the Director of Nursing (DON) ensured that staff provided care, no further investigation details were documented. Resident R2's grievance, submitted by her daughter, alleged that the resident did not receive care over two days, had unchanged clothes, and experienced confrontational behavior from nurse aides. An undated statement from a nurse aide was obtained, but no additional investigation information was provided. Resident R3's grievance included allegations of inappropriate behavior by a nurse aide and missing medication, with no further investigation details documented. Resident R4's grievance alleged that aides were not assisting with toileting, forcing the resident to manage independently. The facility did not provide evidence of a complete investigation to rule out abuse or neglect for any of these residents. Discussions with the DON and Regional Nurse confirmed the lack of thorough investigations.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 1,789 citations issued within 25 miles in the last 12 months — including the 23 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Philadelphia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Logan Square Rehabilitation And Healthcare Center | 1 mi | ★★★★★ | 26 | 0 |
| Fox Subacute At South Philadelphia | 1.3 mi | ★★★★★ | 6 | 0 |
| Tucker House Nursing And Rehabilitation Center | 1.5 mi | ★★★★★ | 25 | 0 |
| University City Rehabilitation And Healthcare Ctr | 1.6 mi | ★★★★★ | 11 | 0 |
| Rittenhouse Post Acute | 2.1 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.