Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 Liberty Pointe Rehabilitation And Healthcare Ctr during CMS and state inspections, most recent first.
Unsafe and Poorly Maintained Resident Areas: Surveyors observed multiple environmental deficiencies across Station 1, Station 2, and Station 3. Findings included dust and a black substance on dining room ceiling tiles, a door that would not latch, a toilet that ran continuously, a loose bathroom doorknob, chipped paint on a half wall by the nurses' station, and several resident room issues such as dark stains, chipped paint, a hole in the ceiling, a blind that would not close, missing curtain coverage, cracks and stains, and peeling paint and wallboard damage.
A resident with metabolic encephalopathy and diabetes had an intact cognitive status on MDS and required extensive ADL assistance, but the facility did not document an interdisciplinary assessment for self-administration of an antifungal cream. Surveyors observed an unsecured jar of zinc oxide ointment and antifungal cream on the bedside table, and the resident stated she self-administered the antifungal cream daily while staff applied the zinc oxide. The DON confirmed the resident was not assessed to self-administer medications and the medications should not have been in the room.
A resident with hemiplegia, a stroke history, limited ROM, and chronic pain had a care plan directing staff to keep the call bell within reach, but observations showed the call bell tied to the side rail on the paralyzed side and not accessible. The resident said he wanted to use the call button but did not know where it was, and the DON confirmed it was not in reach.
Failure to Include Identified Needs in Care Plans: The facility did not document care plan interventions for three residents' assessed needs. One resident with diabetic retinopathy had a vision problem identified in the CAA, another resident with COPD had dental needs and urinary incontinence identified, and a third resident with hemiplegia and no teeth had dental needs identified, but the current care plans did not include interventions for these issues.
Improper Food Storage in Resident Nourishment Rooms: Surveyors found multiple unlabeled resident food items stored in the freezer and refrigerator on two nursing units, including meals, popsicles, yogurt, juice, jelly, and other snacks. One dish of pasta and meat sauce was also dated well past the listed date, and an Administrator confirmed the nourishment rooms were for resident foods only and that staff should store their food elsewhere.
Failure to Implement Enhanced Barrier Precautions: The facility failed to follow EBP for two residents. One resident with ESBL in urine had a care plan requiring gloves and gowns for high-contact care, but no EBP sign was posted outside the room. Another resident with ESRD and a hemodialysis catheter required gloves and gowns for toileting, but a NA was observed assisting with toileting without wearing a gown; the NA stated a gown should have been worn, and the DON confirmed the signage and gown use were required.
The facility failed to maintain the fire resistance rating of fire doors on the first floor due to the absence of a bottom latching device. This issue was initially observed and confirmed during an inspection in December and remained unresolved during a follow-up revisit in February.
The facility's building exceeds the maximum allowable story height for its Type V(III) protected wood frame construction, which is fully sprinklered. The building is three stories high, while the construction type permits only one story when sprinklered. This deficiency was confirmed during a document review and interview, and remains unresolved as of a follow-up visit.
The facility's dietary department was found to have several sanitation and food storage deficiencies. Observations included a large hole in the recycling area paneling, soiled convection ovens with grease and burnt debris, improper storage of a metal scoop in a flour bin, debris on the floor near the steamer and dry goods bins, a brown substance inside the ice machine, and cracked floor tiles near the utility hallway entrance.
The facility failed to maintain the fire resistance rating of fire doors, as observed when a fire door on the first floor lacked bottom latching. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director.
The facility failed to maintain clear means of egress as required by NFPA 101 standards. The headroom clearance of Exit Stairway Five was below the required minimum, and obstructions were found in exit pathways on two floors, including storage and trash on landings. These deficiencies were confirmed during an exit interview with the facility's administration.
The facility did not maintain and inspect portable fire extinguishers as required, specifically missing monthly inspections for the extinguisher on the first floor next to a resident room. This was confirmed during an exit interview with the Administrator and Maintenance Director.
The facility failed to ensure that corridor doors were properly latched, affecting fire safety and smoke containment. Observations revealed that doors on the first and second floors, including the Housekeeping Closet, Employee Storage Room, Nourishment Room, and Storage Room near resident room 106, failed to latch. These deficiencies were confirmed during an exit interview with the Administrator and Maintenance Director.
The facility did not maintain the smoke resistance of smoke barriers, as observed by an open penetration by a data wire in the smoke barrier on the third floor near a resident room. This was confirmed during an exit interview with the Administrator and Maintenance Director.
The facility did not maintain the smoke resistance of smoke barrier doors on the third floor, as holes were found in the door frame. This issue was confirmed during an exit interview with the Administrator and Maintenance Director.
The facility failed to maintain fire resistance in soiled linen and trash chutes, with doors on the third and second floors failing to close and latch. This was confirmed during an exit interview with the Administrator and Maintenance Director.
A resident with dementia and other health conditions did not have physician-ordered compression stockings applied as required. Observations over two days showed the resident without the Tubigrips, despite orders for daily application during morning care. Both an LPN and the DON confirmed the oversight.
Two residents experienced issues with the call bell system, as one resident's call bell did not activate the light outside her door, and another's produced no sound or light, requiring him to yell for help. Observations confirmed these deficiencies in the call bell system.
The facility was found to have a building classified as a three-story, Type V(III), protected wood frame construction, which is fully sprinklered. This classification exceeds the maximum allowable story height for this type of construction by one story, affecting the entire component of the facility.
A resident with dementia, difficulty walking, and osteoporosis experienced a fall, resulting in increased pain levels. Despite the facility's policy requiring notification of changes in clinical condition, the resident's physician was not informed of the increased pain following the fall.
A resident with dementia and osteoporosis was not properly assessed for pain medication effectiveness after a fall. Despite worsening pain, the resident was given acetaminophen without notifying the physician for additional pain management. The DON confirmed the lack of documentation on medication effectiveness.
The facility failed to monitor weight changes for two residents as per policy and physician orders. One resident with dementia and diabetes was not weighed weekly as required, and another with dementia and dysphagia lacked a documented weight schedule and weekly monitoring. The DON confirmed the absence of required documentation.
The facility failed to provide food that was palatable and at appetizing temperatures on three of five nursing units. Residents reported that the food was often cold and not palatable. A test tray audit confirmed that food temperatures were significantly below the required 130 degrees Fahrenheit, and further interviews indicated that this issue was consistent across both room service and dining room meals.
Unsafe and Poorly Maintained Resident Areas
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment on three of five nursing units, including Station 1, Station 2, and Station 3. Survey observations found dust and a black substance on the Station 1 dining room ceiling tiles, an activities room door that did not latch, and a central bathroom toilet that ran continuously. In room [ROOM NUMBER], the bathroom had a loose doorknob. On Station 2, the half wall by the nurses' station had chipped paint along the length of the top of the wall. Additional observations included a ceiling with dark stains and chipped paint in room [ROOM NUMBER], a hole in the ceiling in room [ROOM NUMBER], a window blind that did not close and no curtain on the window in room [ROOM NUMBER], a ceiling over wardrobes with cracks and stains in room [ROOM NUMBER], and peeling paint and wallboard damage over the bed with a black stain on the ceiling in room [ROOM NUMBER].
Failure to Assess Self-Administration of Medications
Penalty
Summary
The facility failed to assess Resident 121’s capability to self-administer medications. The resident had diagnoses including metabolic encephalopathy and diabetes, and the Minimum Data Set assessment dated December 22, 2025, indicated that the resident’s cognitive ability was intact and that extensive staff assistance was required for activities of daily living. Facility policy stated that a resident could self-administer medications only after the interdisciplinary team determined which medications could be safely self-administered and documented the assessment in the medical record. Observations on January 13, 14, and 15, 2026, found a 16-ounce jar of zinc oxide ointment and an antifungal cream unsecured on the bedside table in Resident 121’s room. During an interview, Resident 121 stated that she self-administered the antifungal cream daily and that staff applied the zinc oxide to her sacral area after incontinence care. There was no documentation showing that the facility assessed Resident 121 for the ability to self-administer the antifungal cream, and the medications were not secured in the room. The DON confirmed that Resident 121 was not assessed to self-administer medications and that the medications should not have been in the room.
Call Bell Not Within Resident’s Reach
Penalty
Summary
The facility failed to ensure the call bell was accessible for one resident with hemiplegia and hemiparesis, a history of stroke, limited range of motion, and chronic pain. The resident’s MDS showed he was alert and oriented, able to communicate needs to staff, and had limited range of motion to the left arm and leg. His care plan identified him as at risk for falls due to a history of falls and required a two-person assist with transfers, mobility, and activities of daily living, with an intervention for staff to keep the call bell within reach. However, observations on multiple occasions showed the call bell was not within the resident’s reach and was tied to the left side rail on the side with paralysis. During interview, the resident stated he wanted to use his call button but did not know where it was, and the DON confirmed the call bell was not in reach and should have been.
Failure to Include Identified Needs in Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans that addressed individual resident needs identified in the comprehensive assessment for three sampled residents. For Resident 20, who was admitted with end stage renal disease, diabetic retinopathy, and diabetes, the MDS completed on December 11, 2025 indicated the resident was alert and had diabetic retinopathy. The CAA summary noted that the resident's vision problem was to be addressed in the care plan, but there was no evidence that interventions for the vision problem were included in the current care plan. For Resident 24, who was admitted with chronic obstructive pulmonary disease, the MDS completed on December 3, 2025 indicated the resident was alert, had likely carious teeth, and was occasionally incontinent of urine. The CAA summary noted that the resident's dental needs and urinary incontinence were to be addressed in the care plan, but there was no evidence that interventions for either issue were included in the current care plan. For Resident 147, who was admitted with hemiplegia and muscle weakness, the MDS completed on September 16, 2025 indicated the resident was alert and had no teeth. The CAA summary dated September 18, 2025 noted that the resident's dental needs were to be addressed in the care plan, but there was no evidence that interventions for those dental needs were included in the current care plan.
Improper Food Storage in Resident Nourishment Rooms
Penalty
Summary
The facility failed to store food in a sanitary manner on two nursing units, Station 2 and Station 5. Review of the facility policy, Food: Safe Handling for Foods from Visitors, dated February 13, 2025, showed that staff were to label foods intended for later consumption with the resident's name. During observation of the Station 2 resident nourishment room on January 14, 2026, at 12:25 p.m., surveyors found one shrimp scampi meal and five popsicles in the freezer without a resident name. In the refrigerator, there was a dish of pasta and meat sauce dated December 25, 2025, along with a store-bought container of chicken strips, an opened bottle of vegetable juice, and a container of beef and beans that were not labeled with a resident's name. During observation of the Station 5 resident nourishment room on January 14, 2026, at 8:40 a.m., surveyors found an opened bottle of water, an opened container of ice cream cake, a bottle of green vegetable juice, and an opened package of frozen fruit bars in the freezer, all without a resident's name. The freezer also contained an empty storage bag with crumbs in the door. In the refrigerator, there were three yogurts with use-by dates of December 29, 2025, January 7, 2026, and January 11, 2026, none labeled with a resident's name, as well as one can of purchased coffee, an opened jar of jelly, an opened jar of eggplant ratatouille, a box of wafer cookies, and a box of snack cakes that were not labeled with a resident's name. There was also a large Styrofoam cup containing an unknown thick substance that was not labeled or dated. In an interview on January 15, 2026, at 2:15 p.m., the Administrator confirmed the resident nourishment rooms were for resident foods only and that staff should store their food elsewhere.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement infection prevention and control interventions for two residents who required Enhanced Barrier Precautions. Resident 7 was admitted with diagnoses including abnormal findings in the urine, urinary tract infection, diabetes, and muscle weakness. The MDS indicated the resident was alert and oriented, always incontinent of urine, required extensive staff assistance for toileting, and was dependent on staff for bathing. The care plan identified the resident as requiring Enhanced Barrier Precautions due to ESBL in the urine, with staff to wear gloves and gowns during all high-contact activities. However, observations on January 13, 14, and 15, 2026, showed no sign posted on the resident’s door indicating that Enhanced Barrier Precautions were in place. Resident 20 was admitted with diagnoses including end stage renal disease, diabetes, and muscle weakness. The MDS indicated the resident was alert and required extensive staff assistance for toileting. The care plan stated that the resident required Enhanced Barrier Precautions and had a hemodialysis catheter on the right side of the chest, with staff to wear gloves and gowns while assisting with toileting. During an observation on January 13, 2026, a nurse aide was seen entering the resident’s room and assisting with toileting without wearing a gown. During the observation, the nurse aide stated that a gown should have been worn. The DON later confirmed that signage should have been in place for Resident 7 and that staff should have worn a gown to assist Resident 20 with toileting.
Fire Door Deficiency Due to Lack of Bottom Latching
Penalty
Summary
The facility failed to maintain the fire resistance rating of fire doors, specifically on the first floor, where the fire door did not have a bottom latching device. This deficiency was initially observed on December 12, 2024, during an inspection at 10:00 a.m. The absence of the bottom latching was confirmed during an exit interview with the Administrator and Maintenance Director at 10:30 a.m. on the same day. During a follow-up onsite revisit conducted on February 4, 2025, between 08:15 a.m. and 11:00 a.m., it was determined that the issue had not been resolved. The component separation fire door on the first floor still lacked a bottom latching device, as confirmed in an exit interview with the Administrator at 11:00 a.m.
Plan Of Correction
The first-floor fire door bottom latching has been repaired. Maintenance staff to be educated on the importance of maintaining fire resistance rating of fire doors. Maintenance to monitor monthly or until compliance is met. Findings will be brought to the QAPI committee.
Building Construction Type and Height Deficiency
Penalty
Summary
The facility was found to be non-compliant with building construction requirements as per NFPA 101 standards. During a document review and interview on December 12, 2024, it was revealed that the building is classified as a three-story, Type V(III), protected wood frame construction, which is fully sprinklered. However, this construction type is only permitted to have a maximum of one story when sprinklered, indicating that the facility exceeds the allowable story height by two stories. An onsite revisit conducted on February 4, 2025, confirmed that the issue of exceeding the maximum story height allowance had not been resolved. The Administrator acknowledged the deficiency and is in the process of obtaining a Fire Safety Evaluation System (FSES) to address the non-compliance. The deficiency affects the entire component of the building, as the construction type and story height do not meet the required standards.
Plan Of Correction
I am requesting the Department of Health do the FSES in this case. Facility is consulting Lenhardt Rodgers Architecture to assist with this citation. Facility will also be requesting a TLW.
Sanitation and Food Storage Deficiencies in Dietary Department
Penalty
Summary
The facility failed to maintain sanitary conditions and proper food storage in the dietary department. During an environmental tour, a large hole was observed in the paneling on the back wall of the recycling area. The convection ovens were found to be soiled, with the insides of the oven doors coated with grease and the bottom of the top oven covered with burnt debris and food crumbs. A large metal scoop was improperly stored inside a bin containing flour. Debris was present on the floor near the steamer and dry goods bins. Additionally, a brown substance was noted on parts of the lid and the left inside wall of the ice machine. There were also five cracked floor tiles near the entrance of the utility hallway within the dietary department.
Plan Of Correction
1) The hole in the back wall of the recycling area has been repaired. Convection ovens were cleaned & grease to top & bottom ovens removed & area cleaned. Metal scoop was removed from the flour bin. Debris was removed from wall near the steamer. Ice machine was cleaned. Cracked floor tiles near the entrance of the kitchen was repaired. 2) All residents have the potential to be affected by the failure to maintain sanitary conditions & storing food properly in the dietary department. 3) Dietary staff to be educated on importance of maintaining sanitary conditions & proper food storing in the dietary department. 4) Audits will be completed weekly x4 & then monthly x2 or until compliance is met to ensure that sanitary conditions & proper food storing in the dietary department is maintained. Findings will be brought to the QAPI committee.
Fire Door Deficiency Due to Lack of Bottom Latching
Penalty
Summary
The facility failed to maintain the fire resistance rating of fire doors, which is a requirement for ensuring safety in multiple occupancies. During an observation on December 12, 2024, at 10:00 a.m., it was noted that a fire door on the first floor lacked bottom latching. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director at 10:30 a.m. on the same day.
Plan Of Correction
The first-floor fire door bottom latching was repaired. Maintenance staff to be educated on the importance of maintaining fire resistance rating of fire doors. Maintenance to monitor monthly or until compliance is met. Findings will be brought to the QAPI committee.
Failure to Maintain Clear Means of Egress
Penalty
Summary
The facility failed to maintain the means of egress in compliance with NFPA 101 standards, as evidenced by two specific deficiencies. Firstly, during a document review, it was found that the headroom clearance of Exit Stairway Five leading to the attic was approximately 6'3", which is below the required minimum of 6'8". This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director. Secondly, observations revealed obstructions in the exit pathways on two different floors. On the second floor, storage was found on the lower landing of the exit stairwell by the RNAC Office. Additionally, trash was observed on the landing of the exit stairwell next to resident room 216, and storage was found on the lower landing of the exit stairwell near resident room 108 on the first floor. These obstructions were also confirmed during the exit interview with the facility's administration.
Plan Of Correction
I am requesting the Department of Health do the FSES in this case. Facility is consulting Lenhardt Rodgers Architecture to assist with this citation. The second-floor exit stairwell by the RNAC Office was cleaned from storage on the lower landing. Maintenance staff to be educated on the importance of maintaining means of egress. Maintenance to monitor monthly or until compliance is met. Findings will be brought to the QAPI committee. Trash was cleaned from landing on the second-floor exit stairwell next to room 216. Storage was removed from the exit stairwell lower landing near room 108. Maintenance staff to be educated on the importance of maintaining means of egress. Maintenance to monitor monthly or until compliance is met. Findings will be brought to the QAPI committee.
Failure to Inspect Portable Fire Extinguishers
Penalty
Summary
The facility failed to maintain and inspect portable fire extinguishers as required by NFPA 10, affecting one of three levels in the component. During an observation on December 12, 2024, at 9:52 a.m., it was noted that the portable fire extinguisher located on the first floor next to resident room 161 was missing its monthly inspections. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director on the same day at 10:30 a.m.
Plan Of Correction
Facility completed a monthly inspection for portable fire extinguisher next to resident room 161. Maintenance staff to be educated on how to maintain and inspect portable fire extinguishers. Maintenance to monitor monthly or until compliance is met. Findings will be brought to the QAPI committee.
Failure to Ensure Proper Latching of Corridor Doors
Penalty
Summary
The facility failed to ensure that corridor doors were properly latched, which is a requirement for maintaining fire safety and smoke containment. During an observation on December 12, 2024, it was noted that the Housekeeping Closet door on the second floor was binding on the floor and failed to latch. Similarly, the Employee Storage Room door on the first floor also failed to latch. These deficiencies were confirmed during an exit interview with the Administrator and Maintenance Director. Additionally, further observations on the same day revealed that the Nourishment Room door on the second floor and the Storage Room door near resident room 106 on the first floor also failed to latch. These findings indicate a pattern of non-compliance with the requirement for corridor doors to have positive latching hardware, as mandated by the NFPA 101 and CMS regulations. The failure to ensure proper latching of these doors affects the facility's ability to resist the passage of smoke, which is critical for the safety of residents and staff.
Plan Of Correction
The latch & door were repaired for the second floor Housekeeping Closet across from resident room 252. The latch was repaired for the employee storage room door on the first floor. Maintenance staff to be educated on ensuring corridor doors are latched. Maintenance to monitor monthly or until compliance is met. Findings will be brought to the QAPI committee. The second-floor nourishment door latch was repaired. The first-floor storage room door near resident room 106 latch was repaired. Maintenance staff to be educated on ensuring corridor doors are latched. Maintenance to monitor monthly or until compliance is met. Findings will be brought to the QAPI committee.
Smoke Barrier Deficiency Due to Open Penetration
Penalty
Summary
The facility failed to maintain the smoke resistance of smoke barriers, which is a requirement for ensuring safety in the event of a fire. During an observation on December 12, 2024, at 9:08 a.m., it was noted that there was an open penetration by a data wire in the smoke barrier located on the third floor near resident room 304. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director later that morning at 10:30 a.m.
Plan Of Correction
Open penetration by data wire in the smoke barrier by resident room 304 was repaired using an UL approved stop gap penetration system. Maintenance staff to be educated on maintaining the smoke resistance of smoke barriers. Maintenance to monitor monthly or until compliance is met. Findings will be brought to the QAPI committee.
Smoke Barrier Door Deficiency on Third Floor
Penalty
Summary
The facility failed to maintain the smoke resistance of smoke barrier doors on the third floor, as observed during a survey. Specifically, there were holes found in the door frame, which compromised the smoke resistance of the doors. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director.
Plan Of Correction
Holes in the door frame on the third floor were repaired. Maintenance to be educated on maintaining the smoke resistance of smoke barrier doors. Maintenance to monitor monthly or until compliance is met. Findings will be brought to the QAPI committee.
Fire Resistance Deficiency in Linen and Trash Chutes
Penalty
Summary
The facility failed to maintain the fire resistance of soiled linen and trash chutes, affecting two of four levels in the component. During an observation on December 12, 2024, it was noted that the door to the soiled linen chute on the third floor would not close and latch. Additionally, the trash chute door on the second floor also failed to latch. These deficiencies were confirmed during an exit interview with the Administrator and Maintenance Director on the same day.
Plan Of Correction
Latch was repaired for the third-floor door to the Soiled Linen chute. Latch was repaired for the trash chute door. Maintenance to be educated on maintaining the fire resistance of Soiled Linen and trash chutes. Maintenance to monitor monthly or until compliance is met. Findings will be brought to the QAPI committee.
Failure to Implement Physician's Orders for Compression Stockings
Penalty
Summary
The facility failed to implement physician's orders for a resident diagnosed with dementia, hypertension, and chronic obstructive pulmonary disease. The resident, who was dependent on staff for dressing, was ordered by a physician on November 10, 2024, to have compression stockings (Tubigrips) applied to both legs for swelling. However, observations on December 10 and 11, 2024, revealed that the resident was seated in her wheelchair without the Tubigrips in place. A licensed practical nurse confirmed that the Tubigrips were supposed to be applied during morning care. The Director of Nursing also stated that the staff was to apply the Tubigrips daily as per the physician's order.
Plan Of Correction
1. Tubigrips were immediately placed on resident 2. 2. Current residents with Compression stockings were reviewed to assure residents had application per the physician orders. 3. Education will be completed for licensed nursing staff by staff educator/designee on Importance of ensuring residents have physician prescribed measures in place. 4. Audits will be completed by DON/designee to assure residents with Compression stockings have it in place per physician orders. Audits will be done weekly x4 & then monthly x2 or until compliance is met. Findings will be brought to the QAPI committee.
Deficiency in Call Bell System for Two Residents
Penalty
Summary
The facility failed to provide a working call bell system for two residents, leading to a deficiency in resident safety and communication. During a resident group meeting, one resident reported that activating the call bell from her bed did not trigger the light outside her door. Another resident stated that his call bell did not produce any sound or light, forcing him to yell for assistance. Observations confirmed these issues, as the call bell for the first resident did not activate the light, and the second resident's call bell produced neither sound nor light when tested.
Plan Of Correction
1) The call bell system was immediately repaired for residents 4 & 142. 2) Audit was completed to assure residents have a working call bell available. 3) Staff will be educated on the importance of ensuring residents have access to a working call bell. 4) Audits will be completed weekly x4 & then monthly x2 or until compliance is met by randomly auditing 10 resident rooms, to ensure residents have access to working call bells. Findings will be brought to the QAPI committee.
Building Construction Type Exceeds Allowable Height
Penalty
Summary
The facility failed to maintain the building construction requirements as per NFPA 101 standards. During a document review and interview conducted on December 12, 2024, it was found that the building is classified as a three-story, Type V(III), protected wood frame construction, which is fully sprinklered. However, this classification exceeds the maximum allowable story height for this type of construction by one story. This deficiency affects the entire component of the facility, as confirmed during the exit interview with the Administrator and Maintenance Director.
Plan Of Correction
I am requesting the Department of Health do the FSES in this case. Facility is consulting Lenhardt Rodgers Architecture to assist with this citation. Facility will also be requesting a TLW.
Failure to Notify Physician of Resident's Increased Pain Post-Fall
Penalty
Summary
The facility failed to notify a resident's physician of a change in clinical condition, specifically an increase in pain following a fall. The facility's policy, last reviewed on November 1, 2023, requires staff to notify the physician and resident representative of any change in clinical condition. A review of the clinical records for a resident with dementia, difficulty walking, and osteoporosis revealed that the resident experienced a fall on May 13, 2024, and was found on her left side. Initially, the resident's pain was rated as a 3, but by the following morning, it had increased to a 6, with specific pain noted in the left hip. Despite this significant change in the resident's condition, there was no documentation indicating that the resident's physician was notified of the increased pain level.
Failure to Evaluate Pain Medication Effectiveness
Penalty
Summary
The facility failed to evaluate the effectiveness of pain medication for a resident, which is inconsistent with professional standards. The resident, who had diagnoses including dementia, difficulty walking, and osteoporosis, had a physician's order for acetaminophen to be administered as needed for mild pain. After a fall, the resident was given acetaminophen for pain rated at a 3, but there was no documentation of an assessment to determine if the medication was effective. The following morning, the resident's pain worsened to a 6, and the nurse administered the same medication without notifying the physician for additional pain management orders. The Director of Nursing confirmed that the nursing staff should have documented the effectiveness of the pain medication.
Failure to Monitor Resident Weight Changes
Penalty
Summary
The facility failed to accurately monitor weight changes for two residents, CL1 and 3, as per the facility's weight monitoring policy and physician orders. Resident CL1, who was admitted with diagnoses including dementia, diabetes, and adult failure to thrive, had a care plan that required weekly weight monitoring for four weeks. However, there was no documented evidence that weights were obtained on March 19 or 26, 2024, as ordered by the physician. Similarly, Resident 3, admitted with dementia and dysphagia, had a care plan that included monitoring weights per facility policy. A nutrition assessment recommended weekly weights for four weeks, followed by monthly monitoring. Despite this, there was no documented evidence of a weight schedule being developed upon admission or that weekly weights were obtained as recommended. The Director of Nursing confirmed the lack of documentation for weights as per physician orders, dietitian recommendations, or facility policy.
Failure to Provide Palatable and Appetizing Food
Penalty
Summary
The facility failed to provide food that was palatable and at appetizing temperatures on three of five nursing units. A review of the facility policy revealed that food should be palatable, attractive, and served at a safe and appetizing temperature. However, interviews with residents indicated that the food was often cold and not palatable. A test tray audit showed that the temperatures of the chicken, stuffing, and Brussels sprouts were significantly below the required 130 degrees Fahrenheit. Further interviews with residents confirmed that the issue of cold food was consistent, affecting both room service and dining room meals.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Doylestown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harborview Rehabilitation Care Center At Doylestow | 0.2 mi | ★★★★★ | 8 | 1 |
| Wesley Enhanced Living - Doylestown | 0.5 mi | ★★★★★ | 13 | 0 |
| Heritage Pointe Rehabilitation And Healthcare Ctr | 0.9 mi | ★★★★★ | 5 | 0 |
| Pine Run Health Center | 2.5 mi | ★★★★★ | 11 | 0 |
| Neshaminy Manor Home | 3.4 mi | ★★★★★ | 8 | 0 |
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