Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 Maple Winds Healthcare And Rehabilitation, Llc during CMS and state inspections, most recent first.
A resident with cognitive impairment and anxiety received PRN lorazepam on numerous occasions for anxiety, but the MAR and clinical record contained no documented evidence that non-pharmacological interventions were tried before the medication was administered. The DON confirmed that no such interventions had been attempted for the listed doses and that they should have been.
A facility failed to clarify provider orders for two residents before meds were administered. One resident with severe cognitive impairment and a documented Keflex allergy received Cefepime IV despite a possible same-family allergy noted in the chart, and there was no documented clarification with the MD before administration. Another resident with cognitive impairment and insulin-dependent DM had conflicting bedtime insulin glargine orders in the record, and the MAR showed varying doses that were not consistent with the physician orders; the DON confirmed the orders should have been clarified.
Failure to Follow Ordered Medications and Treatments: Multiple residents had physician orders that were not carried out as written. Staff gave insulin and cardiac meds without checking required blood sugars or BPs, failed to notify the MD for elevated glucose, did not complete an ordered biopsy-site dressing regimen, gave the wrong magnesium oxide dose without follow-up lab monitoring, discontinued a resident’s Dupixent despite the pulmonologist’s order to continue it, missed ordered weekly weights, and transcribed a pain med from routine to PRN instead of following the original order.
Failure to Follow Wound Consultant Orders for Pressure Ulcers: Two residents with stage III and stage IV pressure ulcers did not receive wound care as recommended by the wound consultant. One resident’s TARs showed continued use of collagen particles and calcium alginate instead of the ordered Silver fiber, and another resident was observed in bed without the recommended air mattress; the DON confirmed the wound recommendations were not followed.
A resident received IV Cefepime multiple times through a long-term IV catheter, but the MAR lacked documentation that the catheter was flushed before and after administration as required by facility policy. The DON confirmed the nurse should have flushed the IV catheter pre- and post-medication administration.
Controlled medication accountability was not maintained for several residents. A resident with pain and arthritis had PRN oxycodone doses signed out without documentation that they were administered, and another resident had unused oxycodone concentrate that was not documented as destroyed after discontinuation. Additional residents with chronic pain, MS, fibromyalgia, anxiety, and a fracture had PRN controlled meds such as tramadol, alprazolam, and hydrocodone-acetaminophen signed out on the drug record without matching MAR documentation, and the DON confirmed the missing documentation.
The facility failed to document that three cognitively intact residents were offered the COVID-19 vaccine or that education was provided to the resident and/or representative about the benefits and potential risks, and there was no evidence that staff were offered the vaccine or educated. The DON/IP stated there was no documentation of vaccine offers or education for the residents, no COVID policy in place, and that staff were not offered the vaccine.
Facility failed to provide required QAPI training for five of five Nurse Aides reviewed. The facility assessment stated all personnel were to receive QAPI education, but the education records for the Nurse Aides showed no documented QAPI training, and the NHA confirmed there was no evidence of annual QAPI education.
The facility failed to document that two cognitively intact residents and/or their representatives were informed in advance of the risks, benefits, and treatment alternatives before buspirone was started for anxiety. One resident was newly started on buspirone for anxiety, and another resident with adjustment disorder and anxiety/depression was also started on buspirone, but the clinical record contained no evidence of the required advance notification. The DON confirmed the missing documentation.
Incorrect MDS Medication Coding: Three residents had MDS assessments that failed to code medications documented on the MAR/TAR during the look-back period. One resident received lorazepam for anxiety, one received bacitracin to a nephrostomy tube exit wound, and one received metformin and linagliptin for diabetes, but the corresponding antianxiety, antibiotic, and hypoglycemic sections were left uncoded; the DON confirmed the coding errors.
Failure to develop individualized care plans for two residents. One resident was cognitively intact and received buspirone for depression, but there was no documented care plan addressing the antidepressant use. Another resident was cognitively intact, had malnutrition, and had upper and lower dentures that she wore daily, but no care plan addressed her denture needs. The DON confirmed both omissions.
Care plans were not updated to reflect current resident needs for four residents. One resident’s care plan still showed anticoagulant therapy even though apixaban was not being administered, another resident’s plan still listed anticoagulant therapy despite no anticoagulant on the MAR, a third resident’s plan still directed use of resting hand splints after the order had been discontinued, and a fourth resident’s plan still listed anticoagulant therapy even though no anticoagulant was being given. The DON confirmed the mismatches between the care plans and current treatment records.
Dentures Not in Place for Breakfast: A resident with cognitive intactness, assistance needs, malnutrition, and upper/lower dentures was served breakfast without her dentures in place after her diet had been upgraded from pureed to mechanical soft with nectar-thick liquids. The dentures were found in a cup at the sink rather than in the resident’s mouth or within reach, and the nurse aide confirmed they had not been placed before the meal. The DON later confirmed the dentures should have been in before the breakfast tray was provided.
Missing Safety Assessments for Air Mattress Use: The facility failed to complete documented safety assessments before placing air mattresses on the beds of three residents. The residents had conditions including pressure ulcers, limited ROM, heart failure, stroke, and MS, and the DON confirmed the assessments for potential safety hazards were not completed before the air mattresses were used.
Failure to monitor nephrostomy output and keep urology follow-up: A resident with bilateral nephrostomy tubes had orders to have output recorded every shift, but documentation showed missed shift recordings on multiple occasions. Another resident with an indwelling urinary catheter had discharge orders for a voiding trial and urology follow-up, but there was no documented evidence that the trial occurred or that the urology appointment was kept; RN and DON interviews confirmed the missed follow-up.
Feeding Tube Orders Not Followed: A resident with a feeding tube and cognitive impairment received tube feeding without documented placement verification. An LPN observed administering Jevity by gravity without checking placement, and both the LPN and DON confirmed there was no order or documentation for flushing the tube before and after feedings and meds.
A resident with cognitive impairment, CAD, and an order for continuous oxygen was found in the dining room with an empty portable O2 tank set at 2 LPM. Staff confirmed the tank was empty, and an LPN stated the resident usually needs O2 mostly at night and that her pulse ox typically runs in the low 90s. The resident was later placed on a concentrator, and nursing documentation noted fluctuating pulse ox readings and that the RN and MD were notified.
Clinical records were incomplete for a resident who was cognitively intact, had fibromyalgia, and received PRN Tramadol for pain. The MAR showed multiple Tramadol administrations, but there was no controlled medication record in the chart to verify the doses, and the DON confirmed the missing documentation.
QAPI Committee Failed to Address Repeated Deficiencies: The facility’s QAPI committee did not successfully implement prior plans of correction tied to repeated survey deficiencies. Current findings showed ongoing problems with MDS accuracy, care plan creation and revision, quality care, safety hazards, incontinence and catheter care, IV catheter maintenance, narcotic accountability, and infection control, despite prior audit-based plans being reported to the QAPI committee.
An LPN administered tube feeding to a resident with cognitive impairment, pneumonia, MDRO, gastrostomy status, and a Stage III coccyx pressure ulcer without EBP supplies or signage in the room. The LPN and DON both confirmed the resident should have had EBP during feeding and that the sign was not posted.
Failure to Offer and Document Flu and Pneumococcal Vaccinations: The facility did not ensure that a resident was offered the flu shot during flu season and did not ensure that five residents were offered the pneumococcal vaccine. MDS assessments showed the residents were not offered the vaccines, and the immunization records had no documentation that the vaccines were offered, received, or refused. The DON/IP confirmed the omissions.
Failure to document required annual nurse aide education. The facility reviewed employee education records and found no evidence that three of five nurse aides completed the required 12 hours of annual training. The facility assessment stated that personnel would receive annual education credits, but the records for the three nurse aides did not show completion of the required training, and the NHA confirmed the missing documentation.
Surveyors found that the facility did not complete the required Annual Fuel Quality Test for the emergency generator, as documentation showed the test was failed due to fuel contamination and the issue was not corrected at the time of inspection. This deficiency was confirmed by both the Facility Administrator and Maintenance Director.
A missing ceiling tile was observed in the Physical Therapist's office within the Patient Therapy room, creating an opening that could impact the function of the automatic sprinkler system. This deficiency was confirmed by the Facility Administrator and Maintenance Director and affected one of five smoke compartments.
Surveyors found that corridor doors to two resident rooms did not close and latch properly, as confirmed by the facility's Administrator and Maintenance Director. This deficiency affected one of five smoke compartments and did not meet regulatory requirements for smoke resistance and positive latching.
Surveyors found that the facility did not have a written Emergency Preparedness Plan that included an annually updated facility-based and community-based risk assessment using an all-hazards approach. This deficiency was confirmed through document review and interviews with facility leadership.
Surveyors found that the facility's Emergency Preparedness Plan did not include required procedures outlining the facility's role under a waiver declared by the Secretary of the Department of Health, specifically regarding care provision at an alternate care site as identified by emergency management officials. This omission was confirmed by facility leadership during interviews.
Surveyors found that the facility failed to maintain documentation of initial and annual emergency preparedness training for all new and existing staff. Interviews with the Administrator and Maintenance Director confirmed that required training records were not kept, resulting in a deficiency related to emergency preparedness training documentation.
Maple Winds Healthcare and Rehabilitation LLC did not maintain documentation for the two annual exercises required to test its Emergency Preparedness Plan, as confirmed by interviews and documentation review during a survey.
Surveyors observed that several opened food items, including pasta, cheese, flour, and rice, were not labeled with open dates in the kitchen and dry storage areas. Facility staff confirmed that all opened food items should be dated according to policy, but this was not followed.
The facility did not complete comprehensive admission MDS assessments within the required 14-day timeframe for several residents, with delays ranging from one to eight days. This deficiency was confirmed through clinical record review and staff interviews, as mandated assessment deadlines were not met.
A resident with a history of obstructive uropathy had their indwelling urinary catheter discontinued and subsequently experienced frequent bladder incontinence. The care plan was not updated to reflect this significant change in condition, as confirmed by the DON and review of clinical records.
Surveyors found that the facility did not consistently document urine output for a resident with an indwelling catheter, as required by policy, and failed to ensure proper incontinent care and documentation, including the application of barrier cream, for another resident needing assistance with toileting. These deficiencies were confirmed through record review and staff interviews.
The facility did not ensure that two residents with IV access had their catheters flushed with Normal Saline before and after medication administration, as required by policy and physician orders. Additionally, staff failed to obtain physician orders for the care and maintenance of a midline catheter for one resident. The DON confirmed the lack of documentation for both the required flushes and the necessary physician orders.
A resident with a history of acute respiratory failure and multiple chronic illnesses experienced a significant change in condition, including difficulty to arouse, abnormal vital signs, and a distended bladder. Nursing staff intervened but did not notify the physician or the resident's responsible party as required by facility policy. In a similar later event, proper notifications were made, highlighting the earlier failure.
A facility failed to document and log grievances reported by a resident's family regarding the resident being found soiled and the presence of pills in the resident's room. Although grievance forms were completed and staff were notified, the incidents were not entered into the official grievance log as required by facility policy and federal regulations.
The facility did not provide written transfer notifications, bed-hold notices, or ombudsman notifications for three residents transferred to the hospital, and failed to complete a discharge summary for another resident discharged to a personal care home. These residents had significant medical conditions at the time of transfer, and the required documentation and notifications were not completed as confirmed by the DON.
Two residents received medications, including a diuretic and an anticonvulsant, as documented in physician orders and the MAR, but their MDS assessments were inaccurately coded to indicate these medications were not administered during the required look-back period. This was confirmed by record review and staff interviews, including with the DON.
A resident who was cognitively intact and required extensive assistance with daily care tasks was prescribed an anticoagulant, antiplatelet, and diuretic, but the facility did not develop a care plan to address the specific needs related to these medications. The DON confirmed that such a care plan was not created, despite facility policy requiring individualized, person-centered care planning.
A resident did not receive all ordered doses of IV Meropenem for a UTI, with only 19 out of 21 doses administered as documented in the MAR. The DON confirmed the missed doses, indicating a failure to follow physician orders for antibiotic therapy.
A resident who was at risk for falls and required extensive assistance was found on the floor after fall prevention interventions, including bilateral fall mats, were not in place as specified in the care plan. Observation later confirmed that the required fall mats were still not present, and the DON acknowledged this omission.
A resident who was cognitively impaired and received routine opioid pain management did not have proper documentation for the destruction of Fentanyl patches, as required by facility policy. On multiple occasions, two staff signatures were missing from the controlled drug record after patch removal, and this was confirmed by the DON.
A resident with cancer and cognitive impairment did not have updated hospice nurse aide or RN charting in their clinical record, as required. The last documented charting was nearly a month old, and the DON confirmed the documentation was missing and should have been present.
The QAPI committee failed to effectively address recurring deficiencies, resulting in repeated citations for issues such as care plan revisions, quality of care, accident hazards, intravenous catheter maintenance, and controlled medication accountability. Despite implementing audits and reviews, the committee was ineffective in ensuring sustained compliance with regulations.
The facility did not ensure that the Medical Director attended any of the required quarterly QAA Committee meetings, as confirmed by attendance records and the DON, resulting in noncompliance with regulations for committee composition and participation.
An LPN failed to follow hand hygiene protocols during medication administration for three residents, neglecting to sanitize hands before preparing or handling medications and after removing gloves, as required by facility policy. This was confirmed through direct observation and staff interviews, indicating noncompliance with infection prevention procedures.
A resident's PICC line dressing was not changed weekly as ordered, with the last change documented on December 13, 2024. The resident, who was cognitively impaired, used a sock cuff to secure the dressing, which was not adhering properly. Staff interviews revealed the dressing was on back order, and there was confusion about sourcing alternatives.
Two residents in an LTC facility were found without adequate window coverings, compromising their privacy. Both residents, who are cognitively impaired and require assistance, had beds near windows facing the parking lot without blinds or curtains. Despite requests and orders for blinds, they had not been installed, failing to uphold the residents' rights to dignity and privacy.
A resident's privacy was compromised due to the absence of window coverings in their room, which faced the facility's main parking lot. The resident, who was cognitively impaired and required assistance for daily care, expressed feeling exposed while using the urinal and dressing. The facility had ordered blinds, but they had not yet arrived, and the Director of Housekeeping was unsure of how long the room had been without them.
A resident with severe cognitive impairment and a history of Alzheimer's and Parkinson's diseases was readmitted to the facility with bruising on her hands and arms. The facility failed to conduct a thorough investigation into the cause of her injury, as required by their policy, by not interviewing all staff who had potential contact with her. The Director of Nursing confirmed the lack of documentation for a comprehensive investigation.
Failure to Document Non-Pharmacological Interventions Before PRN Lorazepam
Penalty
Summary
The facility failed to ensure that non-pharmacological interventions were attempted before administering a psychotropic medication for one resident. Resident 5 had a quarterly MDS dated April 8, 2026 showing cognitive impairment, a diagnosis of anxiety, and use of an anti-anxiety medication. Physician orders dated February 19, March 1, March 24, March 27, and April 14, 2026 included lorazepam 1 mg every six hours as needed for anxiety. Review of the MAR for March and April 2026 showed the resident received lorazepam on multiple occasions, including several administrations on March 4, March 7, March 9, March 12, March 30, and on numerous other dates in March and April. There was no documented evidence that non-pharmacological interventions were attempted before these doses were given, and the DON confirmed on May 17, 2026 that no such interventions had been attempted for the listed dates and that they should have been.
Unclarified medication orders for antibiotic and insulin
Penalty
Summary
The facility failed to clarify provider orders for two residents before medications were administered. Resident 8 had an admission MDS dated April 10, 2026 showing severe cognitive impairment, dependence on staff for daily care needs, and diagnoses including a urinary tract infection and neurocognitive disorder with Lewy bodies. Physician orders dated April 24, 2026 included Cefepime HCl IV every 12 hours for 7 days, even though the resident’s record showed an allergy to Keflex, which is in the same drug family as Cefepime HCl. A medication order note dated April 30, 2026 identified the possible drug allergy to Cefepime HCl, but there was no documented evidence that the allergy was clarified with the physician before the medication was given, and the MAR showed the resident received Cefepime as ordered. Resident 48’s annual MDS dated February 28, 2026 showed cognitive impairment, dependence on staff for daily care needs, and insulin-dependent diabetes. The record contained conflicting insulin glargine orders: physician orders dated March 23, 2026 and April 7, 2026 listed bedtime insulin glargine at 52 units/ml, while physician progress notes dated March 31, April 9, April 28, and May 12, 2026 each documented an order to increase bedtime insulin to 20 units/ml. The MAR showed the resident received varying bedtime doses, including 36 units, 44 units, 52 units/ml, 16 units, 20 units, and 16 units/ml across the reviewed period. The DON confirmed that the bedtime insulin glargine orders were not consistent with the physician’s orders and should have been clarified with the physician to confirm the correct dose.
Failure to Follow Medication, Treatment, and Monitoring Orders
Penalty
Summary
The facility failed to follow physician orders for medications and treatments for multiple residents. Review of records and staff interviews showed that ordered vital signs were not obtained before some medications were given, ordered hold parameters were not followed, ordered laboratory monitoring was not completed, and some ordered treatments were not carried out as written. For one resident with insulin-dependent diabetes who was cognitively intact and dependent on staff for daily care, the physician ordered bedtime insulin glargine with instructions to hold it if blood sugar was below 70 or above 400. The MAR showed the insulin was administered at bedtime during February through May 2026, but staff were not checking blood sugar before giving it to determine whether it should have been held. For another resident with heart failure and a stroke, metoprolol tartrate was ordered to be held for low blood pressure, but it was administered on several dates when systolic blood pressure was below 100. The same resident also had an order to notify the medical director if blood sugar was greater than 401 mg/dl, but blood sugars of 419, 405, and 409 were documented without evidence of notification. In addition, the ordered biopsy-site treatment was not followed as written; instead of cleansing with peroxide, applying Vaseline, and covering with a dry dressing, the TAR reflected a different wound cleanser and xeroform dressing. A resident with coronary heart disease and hypertension had orders for amlodipine and carvedilol to be held if blood pressure was below specified parameters, but the MAR showed no documented blood pressure readings before repeated administrations over multiple days and shifts. Another resident with heart failure and hypertension had an order for magnesium oxide 600 mg twice daily and a repeat magnesium level in one week, but the MAR showed the resident was receiving 400 mg three times daily and there was no documented evidence that the order was changed or that the follow-up magnesium level was obtained. A resident with chronic respiratory failure and COPD had Dupixent ordered every 14 days, but the medication was discontinued by an LPN on the MAR, and the resident missed two doses even though the pulmonologist’s note indicated the medication was to continue. A resident readmitted after hospitalization had an order for weekly weights, but the TAR showed the weights were not obtained. Another resident’s Lyrica order for pain was transcribed on readmission as PRN instead of routine every 12 hours, contrary to the physician’s order.
Failure to Follow Wound Consultant Recommendations for Pressure Ulcers
Penalty
Summary
The facility failed to provide pressure ulcer care in accordance with professional standards of practice for two residents with pressure ulcers. One resident was cognitively intact, required assistance with daily care needs, had limited range of motion to the lower extremity, and had a stage IV sacral pressure ulcer with undermining. A wound consult note recommended cleansing the wound and applying collagen particles and calcium alginate twice daily, and a physician order was entered for that treatment. Later wound consult notes continued to document the stage IV sacral ulcer and recommended cleansing with wound cleanser and applying collagen particles and Silver fiber daily, but the treatment administration records showed the resident continued to receive collagen particles and calcium alginate from May 5 through May 17, 2026, with no documented evidence that Silver fiber was provided. A second resident was cognitively impaired, required assistance with daily care needs, and had diagnoses including pneumonia, multi-drug-resistant organism, and gastrostomy status. A wound consultant documented a stage III coccyx pressure ulcer and recommended cleansing with wound cleanser, applying calcium alginate and zinc oxide paste to the peri-wound area, securing with boarded foam, and using an air mattress while in bed. When the resident was observed lying in bed, no air mattress was in place, and the DON confirmed that the wound recommendations were not followed.
Failure to Flush IV Catheter During Antibiotic Administration
Penalty
Summary
Professional standards of practice were not followed for the care of a resident's long-term IV catheter. Resident 8 had physician orders for IV Cefepime HCl, including 2 grams every 12 hours for seven days and a one-time 2 gram dose, and the facility's IV catheter policy required flushing the catheter with 5 ml of normal saline before and after infusion. Review of the MARs for April and May 2026 showed that staff administered IV Cefepime 14 times, but there was no documented evidence that the IV catheter was flushed before or after medication administration. The DON confirmed in interview that the nurse should have flushed the IV catheter pre- and post-medication administration.
Controlled Medication Accountability Not Maintained
Penalty
Summary
The facility failed to maintain accountability for controlled medications for five residents. The report cited a policy requiring discontinued controlled or narcotic medications to be destroyed in the presence of two licensed nurses, with both nurses counting the remaining medication and signing the control drug record to document the destruction. Surveyors found that this process was not consistently followed, and controlled medication records did not match the clinical documentation for several residents. For one resident with arthritis, spinal stenosis, and frequent pain who had an order for PRN oxycodone, the controlled drug accountability record showed multiple doses signed out on different dates and times, but there was no documented evidence that those doses were administered. The DON confirmed there was no documentation showing the oxycodone had been given. For another resident with cognitive impairment and pain medication use, the facility received 66 doses of oxycodone concentrate and administered 16 doses, but there was no documented evidence that the remaining 50 doses were destroyed. Staff stated the medication should have been destroyed when discontinued, and the DON confirmed there was no documentation of destruction. Additional discrepancies were identified for three more residents. One resident with fibromyalgia and PRN tramadol had several doses signed out on the controlled drug log without documentation that they were administered. Another resident with multiple sclerosis and PRN tramadol had multiple signed-out doses that were not documented as administered in the clinical record. A fifth resident with a fractured tibia and anxiety disorder had PRN alprazolam and hydrocodone-acetaminophen signed out on the controlled drug record, but the MAR did not show those doses as administered. In each of these cases, the DON confirmed there was no documented evidence that the signed-out controlled medications were given.
Failure to Document COVID-19 Vaccine Offers and Education
Penalty
Summary
The facility failed to ensure that residents were offered the COVID-19 vaccine and that education was provided to the resident and/or representative regarding the benefits and potential risks of the COVID-19 vaccination for three reviewed residents. Resident 1 had a quarterly MDS dated April 22, 2026 showing the resident was cognitively intact and not up to date with the COVID vaccination, but the immunization record contained no documented evidence that the vaccine was offered, received, or refused, and no documentation that education was provided. Resident 36 had a quarterly MDS dated May 6, 2026 showing the resident was cognitively intact and not up to date with the COVID vaccination, and Resident 52 had an admission MDS dated April 17, 2026 showing the resident was cognitively intact and not up to date with the COVID vaccination; neither resident had documented evidence that the vaccine was offered, received, or refused, or that education was provided. The facility also failed to ensure that staff were offered the COVID-19 vaccine and that education was provided to staff regarding the benefits and potential risks of the vaccination. During an interview on May 18, 2026, the Infection Preventionist/DON stated there was no documented evidence that Residents 1, 36, and 52 were offered, received, or refused the COVID vaccine and that education was provided to the resident and/or representative. She stated that she documented a list of residents offered the COVID vaccine, but there was no documentation that education was provided to residents or representatives. She also stated that there was no COVID policy in place and that the facility follows CDC guidelines, and that staff were not offered the COVID vaccine.
Failure to Provide Required QAPI Training
Penalty
Summary
The facility failed to provide mandatory training on its Quality Assurance and Performance Improvement (QAPI) Program for five of five Nurse Aides reviewed, identified as Nurse Aides 4, 5, 6, 7, and 8. The facility assessment dated January 2026 stated that all personnel, including managers, staff, and volunteers, were to receive education related to QAPI, but review of each of the five Nurse Aides' 2024-2025 education records showed no documented QAPI training. During an interview on May 18, 2026, at 2:26 p.m., the Nursing Home Administrator confirmed there was no documented evidence that these Nurse Aides received the facility's annual education regarding QAPI.
Failure to Inform Residents Before Starting Buspirone
Penalty
Summary
The facility failed to inform two residents and/or their resident representatives in advance of the risks, benefits, and treatment alternatives before initiating buspirone, a psychotropic medication. Facility policy dated August 26, 2025 stated that prior to starting or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed in advance of the benefits, risks, alternatives, and any black box warnings for antipsychotic medications, and that the resident has the right to accept or decline the medication. The policy also required documentation that this information was provided in advance. Resident 24 had a quarterly MDS dated January 30, 2026 showing the resident was cognitively intact and not receiving psychotropic medications. A psychiatry note on March 2, 2026 recommended buspirone 5 mg twice daily for anxiety, and physician orders that same day included buspirone 5 mg every morning and bedtime. There was no documented evidence that the resident or representative was informed in advance of the risks, benefits, and treatment alternatives. Resident 36 had an admission MDS dated May 6, 2026 showing the resident was cognitively intact, was receiving psychotropic medications including antianxiety and antidepressant medications, and had adjustment disorder with mixed anxiety and depressed mood. Psychiatry and physician orders on May 11, 2026 initiated buspirone 2.5 mg twice daily, with a later order on May 13, 2026 listing buspirone 2.5 mg every day and evening shift for anxiety. There was no documented evidence that the resident or representative was informed in advance, and the DON confirmed this lack of documentation during interview.
Incorrect MDS Medication Coding
Penalty
Summary
Accurate MDS assessments were not completed for three residents when medication items were not coded despite documented administration during the seven-day look-back period. The RAI User's Manual stated that Section N0415B1 was to be coded for antianxiety medications taken during the look-back period, Section N0415F1 for antibiotic medications taken during the look-back period, and Section N0415J1 for hypoglycemic medications taken during the look-back period. Resident 2 had physician orders for lorazepam 0.5 mg every morning and at bedtime for anxiety/restlessness, and the MAR showed the medication was given daily during the seven-day look-back period, but the quarterly MDS dated March 17, 2026 did not code Section N0145B for antianxiety medication. Resident 4 had an order for bacitracin ointment to be applied weekly to the nephrostomy tube exit wound, and the TAR showed it was given on April 3 and 10, 2026, but the annual MDS dated April 11, 2026 did not code Section N0401F1 for antibiotic medication. Resident 7 had orders for metformin 500 mg twice daily and linagliptin 5 mg every morning for diabetes, but the quarterly MDS dated February 24, 2026 did not code Section N0415J for hypoglycemic medication. The DON confirmed that the MDS assessments for Residents 2, 4, and 7 were coded incorrectly.
Failure to Develop Individualized Care Plans for Depression and Denture Needs
Penalty
Summary
The facility failed to develop and implement individualized care plans for two residents. For one resident, a quarterly MDS assessment dated May 7, 2026, showed the resident was cognitively intact and receiving an antidepressant medication. Physician orders dated April 30 and May 11, 2026, included buspirone 5 mg every morning and bedtime for depression, then buspirone 2.5 mg every morning and night for depression. MARs for May 2026 showed the resident received buspirone from May 1 through May 18, 2026, but there was no documented evidence of a care plan addressing the resident’s depression and use of buspirone. The DON confirmed on May 18, 2026, that no care plan had been developed for the resident’s depression and antidepressant use. For another resident, an admission MDS assessment dated May 6, 2026, showed the resident was cognitively intact, required assistance with daily care needs, and had a diagnosis of malnutrition. An admission assessment dated May 1, 2026, documented that the resident had upper and lower dentures. The resident stated on May 16, 2026, that she wore her dentures daily but did not have them in at the time of the interview, and observation showed the dentures in a denture cup at the sink in the resident’s room. There was no documented evidence that a care plan was developed to address the resident’s dentures and daily use of them. The DON confirmed on May 16, 2026, that no care plan had been developed for the resident’s denture needs.
Care Plans Not Revised to Match Current Resident Status
Penalty
Summary
The facility failed to ensure that the comprehensive care plan was reviewed and revised to reflect residents’ current care needs for four residents. A facility policy dated August 26, 2025 stated that the comprehensive care plan would be reviewed and revised as necessary when a resident experienced a status change. For Resident 13, a quarterly MDS dated February 15, 2026 indicated the resident was cognitively intact, did not receive an anticoagulant, and had diagnoses including high blood pressure and dementia; however, the current physician’s order included apixaban 5 mg twice daily for atrial fibrillation, and the May 2026 MAR showed the resident was not receiving apixaban. The current care plan still indicated anticoagulant therapy. The DON confirmed on May 18, 2026 that the resident was not receiving anticoagulant medications and the care plan should have been revised. For Resident 16, a quarterly MDS dated April 29, 2026 indicated the resident was cognitively intact, required assistance with daily care needs, and had diagnoses including heart failure and high blood pressure, but the current care plan dated March 6, 2025 still indicated anticoagulant therapy even though the May 2026 MAR showed no anticoagulant medication was being given. For Resident 24, a quarterly MDS dated May 7, 2026 indicated the resident was cognitively intact, had limited range of motion to the upper and lower extremities, required assistance with daily care needs, and had multiple sclerosis; the physician’s order for bilateral resting hand splints had been discontinued on April 8, 2026, yet the care plan still directed use of the splints. For Resident 52, an admission MDS dated April 17, 2026 indicated cognitive impairment, need for assistance with daily care needs, and diagnoses including pneumonia, multi-drug-resistant organism, and gastrostomy status, but the care plan still indicated anticoagulant therapy even though the May 2026 MAR showed no anticoagulant medication. The DON confirmed that the care plans for Residents 16, 24, and 52 should have been revised to reflect the current status, but were not.
Dentures Not in Place for Breakfast
Penalty
Summary
The facility failed to ensure that a resident had dentures in place for breakfast. Resident 36 was cognitively intact, required assistance with daily care needs, and had a diagnosis of malnutrition. The resident had upper and lower dentures and was ordered a regular diet with mechanical soft texture and nectar consistency liquids. The facility policy stated that nursing staff would provide denture care and clean dentures during routine oral care if a resident was unable to care for them independently. During interview, the resident stated that she had dentures but did not have them in for breakfast. Observation later that morning showed her dentures in a denture cup at the sink in her room, not in her mouth or within her reach. A nurse aide confirmed the resident did not have her dentures in and stated she probably did not need them as much when she had been on a pureed diet, but her diet had been upgraded the previous day to mechanical texture. The nurse aide then cleaned the dentures and gave them to the resident. The DON confirmed the resident should have had her dentures in before receiving her breakfast tray, and the Therapy Manager stated that with the upgraded mechanical diet, she would expect the resident to have her teeth in to assist with chewing.
Missing Safety Assessments for Air Mattress Use
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards by not completing safety assessments before placing air mattresses on the beds of three residents. The facility policy dated August 26, 2025 stated that air mattresses were to be used according to evidence-based practice and manufacturer recommendations, with consideration of factors such as medical condition, mobility, pressure injury risk, pain, and contraindications, and that inspection and replacement schedules would be established accordingly. Resident 4 had an annual MDS assessment showing cognitive intactness, limited lower-extremity range of motion, need for staff assistance with daily care, and a pressure ulcer; the care plan noted a pressure sore and use of an air mattress, but there was no documented evidence of a safety assessment before the mattress was placed on the bed. Resident 6 had a quarterly MDS assessment showing cognitive intactness, need for staff assistance with daily care, and diagnoses including heart failure and stroke; physician orders included an air mattress for the bed, but no documented safety assessment was found before placement. Resident 24 had a quarterly MDS assessment showing cognitive intactness, limited upper- and lower-extremity range of motion, staff assistance needs, pressure ulcers, and diagnoses including multiple sclerosis; the care plan noted a pressure sore and use of an air mattress, but there was no documented evidence of a safety assessment before the mattress was placed on the bed. The DON confirmed that these three residents did not have assessments completed regarding potential safety hazards prior to the air mattresses being placed.
Failure to Monitor Nephrostomy Output and Keep Urology Follow-Up
Penalty
Summary
The facility failed to ensure that nephrostomy output was monitored for a resident who was cognitively intact, had limited range of motion of the lower extremities, required staff assistance with daily care needs, and had bilateral nephrostomy tubes for renal disease and obstructive uropathy. Physician orders required staff to empty both nephrostomy tubes and record the output every shift, and the resident’s care plan also directed that the tubes be emptied every shift. Review of the Treatment Administration Records showed that the nephrostomy output was not obtained every shift on multiple dates across February, March, April, and May 2026. The facility also failed to ensure that a follow-up appointment was kept for another resident who was cognitively impaired and had an indwelling urinary catheter. Hospital discharge orders included a voiding trial by January 13, 2026, followed by a urology appointment on January 21, 2026 at 8:00 a.m. There was no documented evidence that the resident had a voiding trial or attended the scheduled urology follow-up, and staff interviews confirmed that the voiding trial did not occur and the appointment was missed.
Feeding Tube Orders Not Followed
Penalty
Summary
The facility failed to follow physician's orders for a resident with a feeding tube. Resident 52 had an admission MDS dated April 17, 2026 that identified the resident as cognitively impaired, needing staff assistance with daily care tasks, and having a feeding tube. Physician's orders dated April 14, 2026 directed the resident to receive Jevity 1.5, 237 milliliters, five times daily. During an observation on May 18, 2026, at 9:18 a.m., an LPN gathered supplies, washed hands, applied gloves, listened for bowel sounds, and then attached a feeding syringe and began pouring Jevity 1.5 into the syringe by gravity. The LPN confirmed during interview that she did not check tube placement before administering the feeding and that there was no physician order for flushing the feeding tube before or after feedings. The DON also confirmed there was no documentation that staff verified the feeding tube placement with residual and no documentation that the tube was flushed before and after feedings and medications.
Empty oxygen tank left in use during meal
Penalty
Summary
The facility failed to administer continuous oxygen as ordered for one resident who had cognitive impairment, required supervision with daily care needs, received oxygen therapy, and had a diagnosis of coronary artery disease. The physician's order directed that the resident receive continuous oxygen at 1-5 LPM via nasal cannula every shift and as needed. During an observation in the dining room, the resident was eating lunch with an oxygen tank on the back of her wheelchair, and the tank was set at 2 LPM but was empty. A nurse aide confirmed the tank was empty, and an LPN also confirmed it was empty and stated the resident mostly needed oxygen at night and that her pulse oximetry usually ran in the low 90s. The resident's empty portable tank was replaced with a full tank, and she was taken back to her room and placed on an oxygen concentrator. A nursing note documented that the resident's portable tank was empty while she was in the dining hall and that pulse oximetry readings ranged from 80-94% and were not holding continuously. The note further stated that after nail polish was removed, the resident's pulse oximetry ranged from 99% down to 80%, oxygen was on at 2 LPM via nasal cannula, and the RN and doctor were notified. The resident's oxygen was then increased to 3 LPM via nasal cannula, and her pulse oximetry was 94% at two different times. The DON confirmed that the oxygen tank was empty and should have been checked and replaced.
Incomplete controlled medication documentation for PRN Tramadol
Penalty
Summary
Clinical records were not maintained in a complete and accurately documented manner for one resident who was cognitively intact, required assistance with daily care needs, had occasional pain, received PRN pain medication, was taking an opioid medication, and had a diagnosis of fibromyalgia. The resident had a physician’s order for Tramadol 50 mg every four hours as needed for moderate to severe pain. Review of the MAR for April 2026 showed multiple administrations of Tramadol on numerous dates and times, but there was no documented controlled medication record in the resident’s clinical record from April 8 through April 28 to verify those administrations. The DON confirmed during interview that there was no documented evidence of a controlled medication record for that period to verify the Tramadol doses given.
QAPI Committee Failed to Address Repeated Deficiencies
Penalty
Summary
The facility’s QAPI committee failed to correct repeated quality deficiencies and did not ensure that plans to improve the delivery of care and services effectively addressed recurring problems identified in prior and current surveys. The report states that the facility’s plans of correction for the annual survey ending July 2, 2025, included quality assurance systems and audits to maintain compliance, but the current survey ending May 18, 2026, found repeated deficiencies involving accurate MDS assessments, care plan creation and revision, quality care, safety and accident hazards, bowel/bladder incontinence and indwelling urinary catheters, IV catheter maintenance, narcotic accountability, and infection control. The report specifically notes that for each of these previously cited areas, the facility had stated in its prior plans of correction that audits would be completed and results reported to the QAPI committee for review. Despite those stated plans, the current survey found that the QAPI committee failed to successfully implement the plans to ensure MDS assessments were completed accurately, care plans were created and revised timely, quality care was provided, safety hazards were prevented, incontinence and catheter care were treated appropriately, IV catheters were maintained appropriately, narcotics were accounted for appropriately, and infection control was properly maintained.
Failure to Use Enhanced Barrier Precautions During Tube Feeding
Penalty
Summary
The facility failed to follow infection control guidelines from CMS and CDC to reduce the spread of infections and prevent cross-contamination for one resident. CDC guidance cited in the report states that Enhanced Barrier Precautions (EBP) are used during high-contact resident care activities for residents with chronic wounds or indwelling medical devices, and CMS guidance effective April 1, 2024, includes EBP for residents with chronic wounds or indwelling medical devices regardless of MDRO status. The facility policy also stated that an order for EBP would be obtained for residents with wounds or indwelling medical devices, including chronic wounds such as pressure ulcers and devices such as feeding tubes. Resident 52’s admission MDS showed cognitive impairment, need for assistance with daily care, pneumonia, MDRO, and gastrostomy status. A wound consultant note documented a Stage III coccyx pressure ulcer with daily wound treatment. During observation of tube feeding administration, an LPN gathered supplies, washed hands, applied gloves, listened for bowel sounds, and administered Jevity 1.5 by gravity through the feeding syringe. The LPN later confirmed that the resident should have had EBP during feeding and did not have supplies or signage in the room. The DON also confirmed that the resident should have had an EBP sign on the door and while receiving gastrostomy tube feeding.
Failure to Offer and Document Flu and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that residents were offered and/or received influenza and pneumococcal immunizations as required by its policies. The influenza vaccine policy stated that between October 1 and March 31 each year, the vaccine shall be offered unless medically contraindicated or already received, and that refusals must be documented. For one resident who was cognitively intact, the quarterly MDS indicated the resident was not offered the influenza vaccine, and the immunization record contained no documentation that the vaccine was offered, received, or refused during the current flu season. The pneumococcal vaccine policy stated that residents are to be assessed prior to or upon admission for eligibility and offered the vaccine series unless medically contraindicated or already vaccinated, with refusals documented in the medical record. Review of MDS assessments and immunization records showed five residents were not offered the pneumococcal vaccine and had no documentation that they received or refused it. These residents included two who were cognitively intact, one who was cognitively impaired, and one admission assessment that noted the resident was not up to date with COVID vaccination. The Infection Preventionist/DON confirmed that the resident was not offered the influenza vaccine and that the five residents were not offered pneumococcal vaccination and should have been.
Failure to Document Required Annual Nurse Aide Education
Penalty
Summary
The facility failed to ensure that nurse aides completed the required annual education for three of five nurse aides reviewed, identified as Nurse Aides 4, 6, and 7. The facility assessment dated January 2026 stated that all personnel, including manager, staff, contract staff, and volunteers, would receive their necessary education credits annually. However, review of the employee education files showed no documented evidence that Nurse Aide 4 completed the required 12 hours of education between 2024 and 2025, no documented evidence that Nurse Aide 6 completed the required 12 hours of education between 2024 and 2025, and no documented evidence that Nurse Aide 7 completed the required 12 hours of education between 2024 and 2025. During an interview, the Nursing Home Administrator confirmed that there was no documented evidence that Nurse Aides 4, 6, and 7 completed the 12 hours of annual training as required.
Failure to Complete Annual Emergency Generator Fuel Quality Test
Penalty
Summary
The facility failed to perform required emergency generator maintenance testing, specifically the Annual Fuel Quality Test for the emergency generator. Documentation reviewed during the survey revealed that the facility did not pass the Annual Fuel Quality Test due to contaminants found in the fuel. At the time of inspection, the fuel had not been repaired or replaced, and this failure was confirmed in interviews with both the Facility Administrator and the Maintenance Director. This deficiency affected the entire facility, as the emergency generator is a critical component for maintaining essential electrical systems. The lack of compliance with the required maintenance and testing protocols, as outlined by NFPA 101 and related standards, was directly observed and documented by surveyors during the recertification survey.
Plan Of Correction
Emergency generator maintenance testing is now current for the facility. The Maintenance Director/designee has replaced the emergency generator fuel and completed the Annual Fuel Quality Test for the emergency generator maintenance testing and documented passing results. The Facility Administrator will ensure compliance by confirming results of Emergency Generator Fuel Quality test annually. Findings will be reviewed at monthly Quality Assurance Meetings.
Failure to Maintain Sprinkler System Due to Missing Ceiling Tile
Penalty
Summary
The facility failed to maintain the automatic sprinkler system as required, as evidenced by an observation of a missing ceiling tile in the Physical Therapist's office, located in the Patient Therapy room. This opening in the ceiling could allow the passage of heat and smoke, which may affect the operation of the automatic sprinkler system. The deficiency was confirmed during an interview with the Facility Administrator and the Maintenance Director. The issue was identified in one of five smoke compartments within the facility. No information regarding specific patients, their medical history, or their condition at the time of the deficiency is provided in the report.
Plan Of Correction
The automatic sprinkler system is now maintained in the facility in all five smoke compartments. The Maintenance Director replaced the missing ceiling tiles in the Physical Therapist's office and in the Patient Therapy room, ensuring there are no current openings in the ceiling, preventing the passage of heat and smoke, and ensuring correct operation of the automatic sprinkler system. The Maintenance Director/designee will complete a check for missing ceiling tiles monthly for three months, ensuring compliance and no automatic sprinkler system deficiency. Findings will be reviewed at monthly Quality Assurance Meetings.
Failure to Maintain Corridor Doors for Smoke Resistance and Latching
Penalty
Summary
Surveyors observed that the facility failed to maintain corridor doors in accordance with NFPA 101 requirements in two separate instances. During inspections, it was found that the door to resident room 140 and the door to resident room 109 would not close and latch properly in their frames when tested. These deficiencies were identified during routine observations on July 7, 2025, at different times in the morning. Interviews conducted with the Facility Administrator and the Maintenance Director confirmed the issues with the corridor doors. The deficiencies affected one of five smoke compartments in the facility, as the doors did not meet the required standards for resisting the passage of smoke and ensuring positive latching, as specified by regulatory guidelines.
Plan Of Correction
Resident room 140 door now closes and latches in its frame when tested, maintaining corridor doors and all five smoke compartments within the facility. The Maintenance Director/designee will ensure corridor doors close and latch into their frames monthly times three months. Findings will be reviewed at monthly Quality Assurance Meetings. Resident room 109 door now closes and latches in its frame when tested, maintaining corridor doors and all five smoke compartments within the facility. The Maintenance Director/designee will ensure corridor doors close and latch into their frames monthly times three months. Findings will be reviewed at monthly Quality Assurance Meetings.
Failure to Maintain Emergency Preparedness Plan with Required Risk Assessment
Penalty
Summary
The facility failed to provide a written Emergency Preparedness (EP) Plan that included a facility-based and community-based risk assessment, as required by regulations. During a document review and interview conducted on July 7, 2025, it was found that the EP plan did not contain an annually updated risk assessment utilizing an all-hazards approach. This assessment is necessary to identify and address potential emergency events, including missing residents, as part of the facility's preparedness planning. Interviews with the Facility Administrator and Maintenance Director confirmed the absence of the required documentation in the EP plan. The deficiency was identified through both the review of the facility's emergency preparedness documentation and direct confirmation from facility leadership.
Plan Of Correction
A written Emergency Preparedness Plan that includes a facility-based and community-based risk assessment is now present in the facility. The Maintenance Director/designee will complete a check of the written Emergency Preparedness Plan to ensure it includes an annually updated facility-based and community-based risk assessment, utilizing an all-hazards approach. To ensure compliance, this check will be performed monthly for three months. Findings will be reviewed at monthly Quality Assurance Meetings.
Missing Emergency Preparedness Procedures for 1135 Waiver
Penalty
Summary
The facility failed to include procedures in its Emergency Preparedness (EP) Plan that address the role of the facility under a waiver declared by the Secretary of the Department of Health, as required by Section 1135 of the Act. During a review of the EP Plan and interviews conducted, it was found that the plan did not contain written procedures for the provision of care at an alternative care site identified by emergency management officials during such a waiver. This deficiency was confirmed through both documentation review and interviews with the Facility Administrator and Maintenance Director, who acknowledged that the EP plan lacked the necessary written plan outlining the facility's responsibilities and actions during a waiver situation. No information about specific residents or their medical conditions was included in the findings.
Plan Of Correction
A plan for the role of the facility under a waiver declared by the Secretary of the Department is now present in the facility. The Maintenance Director/designee will ensure procedures to address the role of the facility under a waiver declared by the Secretary, in accordance with Section 1135 of the Act, in the provision of care at an alternative care site identified by emergency management officials is included in the Emergency Preparedness Plan. The Facility Administrator will ensure compliance by confirming the Emergency Preparedness Plan contains a written plan of the facility's role during a waiver declared by the Secretary of the Department of Health monthly times three months. Findings will be reviewed at monthly Quality Assurance Meetings.
Failure to Maintain Documentation of Emergency Preparedness Training
Penalty
Summary
Surveyors identified a deficiency related to the facility's Emergency Preparedness (EP) training program. During a review of the facility's EP Plan and associated documentation, it was found that the facility did not maintain records of initial and annual emergency preparedness training for all new and existing staff. This lack of documentation was discovered during an interview and documentation review conducted on July 7, 2025, at 9:00 a.m. Further interviews with the Facility Administrator and the Maintenance Director confirmed that the required training documentation was not maintained. The absence of these records means there was no evidence to demonstrate that staff, individuals providing services under arrangement, and volunteers received the necessary initial and annual EP training as required by federal regulations. No specific residents or patient cases were mentioned in the report, and there were no details provided regarding the medical history or condition of any individuals at the time of the deficiency. The deficiency centers solely on the facility's failure to document and maintain records of emergency preparedness training for its personnel.
Plan Of Correction
Documentation of staff Emergency Preparedness Training and Testing is now present in the facility. The Maintenance Director/designee has completed and will continue to complete initial and annual Emergency Preparedness Training and Testing for all new and existing staff. The Facility Administrator will ensure compliance by confirming the Emergency Preparedness Training and Testing documentation of initial and annual training for all new and existing staff is maintained by checking monthly times three months. Findings will be reviewed at monthly Quality Assurance Meetings.
Failure to Document Required Emergency Preparedness Exercises
Penalty
Summary
Maple Winds Healthcare and Rehabilitation LLC failed to maintain documentation for the two required annual exercises to test its Emergency Preparedness (EP) Plan. During a Medicare/Medicaid Recertification Survey, surveyors reviewed the facility's EP Plan and found that documentation for these exercises was not available for review. An interview and documentation review conducted on July 7, 2025, at 9:05 a.m. confirmed the absence of records for the two annual exercises. The surveyors specifically noted that the facility could not provide evidence that the required emergency plan testing had been conducted as mandated by federal regulations. Further confirmation was obtained during an interview with the Facility Administrator and Maintenance Director later that day. Both individuals acknowledged that the documentation for the two required exercises was not available at the time of the survey. No information regarding specific residents or their medical conditions was included in the findings.
Plan Of Correction
Documentation for the two required annual exercises to test the Emergency Preparedness Plan is now present in the facility. The Maintenance Director/designee will ensure the facility maintains documentation for the two exercises required annually to test the Emergency Preparedness Plan. The Facility Administrator will ensure compliance by confirming documentation for the two exercises are present and available every six months times two. Findings will be reviewed at monthly Quality Assurance Meetings. E 0039
Failure to Date Opened Food Items in Kitchen and Storage
Penalty
Summary
The facility failed to ensure that food items stored in the kitchen and dry storage room were properly dated once opened, as required by facility policy. During observations, surveyors found an opened 10-pound bag of pasta in the dry storage room that was not labeled with an open date. In the kitchen refrigerator, two opened 5-pound bags of cheese, one containing parmesan and the other a mixture of cheddar and mozzarella, were also found without open dates. Additionally, approximately ten pounds of flour and twenty-five pounds of rice in the kitchen were observed to be opened and not labeled with an open date. Interviews with the Dietary Manager and the DON confirmed that all open food items in the kitchen should be labeled with a date once they are opened, in accordance with the facility's policy. The lack of proper labeling and dating of opened food items was directly observed by surveyors and acknowledged by facility staff.
Plan Of Correction
Opened, unlabeled food items in the dry storage room, the kitchen refrigerator, and the kitchen were immediately discarded. Any resident admitted to the facility who receives a meal has the ability to be affected by this alleged deficient practice. A baseline audit of food stored in the dry storage room and in the kitchen has been completed to ensure any opened food item has been labeled with an open date. The Dietary Manager re-educated dietary staff that food items stored in the dry storage area, in the kitchen, and in the kitchen refrigerator are to be labeled with an open date upon opening of the food item. The Dietary Manager/designee will audit the dry storage area, the kitchen, and the kitchen refrigerator to ensure open food items are labeled with an open date weekly times six weeks and then monthly times four months and then reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement, and/or continuation of audits. Results of these audits will be reviewed in Quality Assurance and Performance Improvement times six months or until substantial compliance is noted.
Failure to Complete Admission MDS Assessments Within Required Timeframe
Penalty
Summary
The facility failed to complete comprehensive admission Minimum Data Set (MDS) assessments within the required timeframe for 10 out of 35 residents reviewed. According to federal regulations and the Resident Assessment Instrument (RAI) User's Manual, an admission MDS assessment must be completed no later than 13 calendar days after a resident's admission. The review of clinical records revealed that for multiple residents, the MDS assessments were completed between one and eight days past the required deadline. Specific examples include residents whose admission dates and corresponding MDS completion dates showed delays ranging from one to eight days. For instance, one resident admitted on May 5 had their MDS completed on May 19, which was one day late, while another admitted on May 12 had their MDS completed on June 12, which was eight days late. These findings were corroborated by documentation in section Z0500B of the MDS and confirmed during an interview with the LPN Assessment Coordinator, who acknowledged that the assessments were not completed within the mandated timeframes. The deficiency was identified through a combination of clinical record review, reference to the RAI User's Manual, and staff interviews. The report does not provide additional details about the residents' medical histories or conditions at the time of the deficiency, focusing solely on the failure to meet the required assessment completion deadlines as specified by federal and state regulations.
Plan Of Correction
Resident 14 no longer resides in the facility. Resident 26 no longer resides in the facility. Resident 34 was assessed with no noted concerns related to her May 26th Admission Minimum Data Set Assessment being completed on June 2, 2025, which was one day late. Resident 43 was assessed with no noted concerns related to her May 7th Admission Minimum Data Set Assessment being completed on May 19, 2025, which was six days late. Resident 44 no longer resides in the facility. Resident 139 no longer resides in the facility. Resident 140 no longer resides in the facility. Resident 141 no longer resides in the facility. Resident 142 no longer resides in the facility. Resident 143 no longer resides in the facility. Any resident admitted to the facility has the ability to be affected by this alleged deficient practice. A whole house audit of recent resident admissions was completed to ensure the Admission Minimum Data Set Assessments were completed on time. Nursing Home Administrator completed re-education with the Registered Nurse Assessment Coordinator and Licensed Practical Nurse Assessment Coordinator of the need to have Admission Minimum Data Set Assessments completed timely, no later than the resident's admission date plus thirteen calendar days as per the Long-Term Care Facility Resident Assessment Instrument User's Manual. Resident 142 no longer resides in the facility. Resident 143 no longer resides in the facility. Any resident admitted to the facility has the ability to be affected by this alleged deficient practice. A whole house audit of recent resident admissions was completed to ensure the Admission Minimum Data Set Assessments were completed on time. Nursing Home Administrator/designee will audit Admission Minimum Data Set Assessments weekly times four weeks, monthly times three months. Results of these audits will be reviewed in Quality Assurance and Performance Improvement for results, areas of improvement and/or continuation of audits times four months or until substantial compliance is noted.
Failure to Update Care Plan After Change in Continence Status
Penalty
Summary
A deficiency was identified when the facility failed to update a resident's care plan to reflect a significant change in their care needs. The resident, who had a history of obstructive uropathy and previously required an indwelling urinary catheter, had the catheter discontinued per physician's orders. Following the removal of the catheter, documentation showed that the resident was frequently incontinent of bladder. Despite this change, there was no evidence in the clinical record that the resident's care plan was revised to address the new incontinence status. The facility's policy required care plans to be reviewed and revised with significant changes in condition, but as of the date of review, the care plan had not been updated to reflect the resident's bladder incontinence. This was confirmed by the Director of Nursing during an interview.
Plan Of Correction
Resident 13's care plan was revised/updated to reflect her bladder incontinence since removal of her indwelling urinary catheter on April 15, 2025. Any resident who has their indwelling urinary catheter removed has the ability to be affected by this alleged deficient practice. A whole house audit of residents recently having their indwelling urinary catheter removed was completed to ensure his/her care plan has been revised to reflect their current bladder continence/incontinence status. Licensed nursing staff, including agency licensed nursing staff, re-educated on the importance of updating/revising resident care plans to reflect resident-specific care needs, including residents who have their indwelling urinary catheter removed to include his/her bladder continence/incontinence status in the care plan. Licensed Practical Nurse Assessment Coordinator will routinely review order summary reports to ensure resident care plans are updated/revised with changes, new orders, and/or discontinued orders that reflect a change to the resident's current plan of care. Interdisciplinary Care Plan Team will continue to review care plans upon resident admissions, at regularly scheduled care plan conferences, and as needed to ensure individualized, person-centered care needs are included and up to date in resident care plans. The Director of Nursing/designee will audit care plans for residents who have had their indwelling urinary catheter removed weekly times twelve weeks and then monthly times four months, and then reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement, and/or continuation of audits. Results of these audits will be reviewed in Quality Assurance and Performance Improvement times seven months or until substantial compliance is noted. Licensed Practical Nurse Assessment Coordinator/designee will conduct random audits of resident care plans to ensure that all person-centered care needs are included/updated to reflect the resident's current care needs weekly times fifteen weeks, then monthly times four months, and then reviewed by the Quality Assurance and Performance Improvement Committee for results, areas of improvement, and/or continuation of audits. Results of these audits will be reviewed in Quality Assurance and Performance Improvement times eight months or until substantial compliance is noted.
Failure to Document Urinary Output and Incontinent Care
Penalty
Summary
The facility failed to ensure proper monitoring and documentation of urinary output for a resident with an indwelling urinary catheter. According to the facility's policy, urine output was to be documented in the resident's chart or electronic medical record. However, review of the clinical records for a resident with neurogenic bladder and a physician's order for a Foley catheter revealed multiple instances across several dates and shifts where urine output was not recorded as required. This lack of documentation was confirmed by the Director of Nursing. Additionally, the facility did not ensure that proper incontinent care was completed for another resident who required assistance with toileting due to limited mobility. The care plan specified that staff should document the resident's bladder continence or incontinence every two hours, but there were numerous occasions where this documentation was missing. Furthermore, staff were required to document the application of barrier cream to the resident's buttocks, but there was no evidence that this was done on several shifts across multiple days. These deficiencies were identified through review of facility policies, clinical records, and staff interviews. The Director of Nursing confirmed the absence of required documentation for both urinary output and incontinent care, including the application of barrier cream, on the specified dates and times.
Plan Of Correction
Resident 1 was assessed with no ill effects and/or noted concerns related to her not having her urine output documented on the first shift (0600 to 1430) on May 13, 2025; June 11, 2025; June 14, 2025; June 16, 2025; and June 20, 2025. The documentation was also missing on the second shift (1400 to 2230) on May 21, 2025; June 9, 2025; and June 20, 2025, and on the third shift (2200 to 0630) on June 6, 2025, and June 30, 2025. Resident 1's physician was notified of the resident not having her urine output documented on the first shift (0600 to 1430) on May 13, 2025; June 11, 2025; June 14, 2025; June 16, 2025; and June 20, 2025. The physician was also notified of missing documentation on the second shift (1400 to 2230) on May 21, 2025; June 9, 2025; and June 20, 2025, and on the third shift (2200 to 0630) on June 6, 2025, and June 30, 2025. Resident 13 was assessed with no ill effects and/or noted concerns related to her not having her bladder continence/incontinence documented on May 14, 2025, at 0800, 1000, and 1200; May 15, 2025, at 0800, 1000, and 1200; May 17, 2025, at 0800, 1000, and 1200; May 24, 2025, at 0800, 1000, and 1200; May 25, 2025, at 0000, 0200, and 0400; June 4, 2025, at 0000, 0200, and 0400; June 5, 2025, at 0000, 0200, and 0400; June 6, 2025, at 0800, 1000, and 1200; June 10, 2025, at 0800, 1000, and 1200; June 11, 2025, at 0800, 1000, and 1200; June 13, 2025, at 0000, 0200, and 0400; June 15, 2025, at 0800, 1000, 1200, 1400, 1600, 1800, and 2000; and June 25, 2025, at 0800, 1000, and 1200. The physician was notified of the missing documentation of bladder continence/incontinence for Resident 13 on the same dates and times as above. Resident 13 was also assessed with no ill effects and/or noted concerns related to her not having any documented evidence of her barrier cream being applied to her buttocks during the day shift on May 1, 2025; May 15, 2025; May 17, 2025; May 24, 2025; and May 26, 2025. The documentation was missing during the evening shift on May 1, 2025; May 2, 2025; June 3, 2025; and June 15, 2025, and during the night shift on May 24, 2025; May 31, 2025; June 2, 2025; June 3, 2025; June 4, 2025; and June 12, 2025. The physician was notified of the missing documentation of barrier cream application to Resident 13’s buttocks during these shifts and dates. Any resident who has an indwelling urinary catheter has the potential to be affected by this alleged deficient practice. A whole house audit of residents with indwelling urinary catheters was completed to ensure their urinary output has been monitored and documented in the resident's medical record/electronic medical record every shift. Similarly, any resident who has a nurse aide task to document bladder continence/incontinence every two hours has the potential to be affected. A whole house audit of residents with this scheduled task was completed to ensure documentation of bladder continence/incontinence has been monitored and recorded in the medical record/electronic medical record every two hours. Any resident with a nurse aide task to document application of barrier cream also could be affected. A whole house audit of residents with this task was completed to ensure documentation of barrier cream application was present in the Point Click Care - Point of Care electronic record. Direct care staff, including agency staff, were re-educated on the facility's Urinary Output Policy, emphasizing the importance of monitoring and documenting urinary output every shift for residents with indwelling urinary catheters. Staff were also re-educated on the importance of frequently monitoring residents' bladder continence/incontinence throughout the shift and documenting in Point Click Care as scheduled, including every two hours. Additionally, staff were re-educated on the importance of applying barrier cream to residents and documenting the application in the electronic medical record/Point Click Care as per scheduled tasks. The Director of Nursing/designee will audit the documentation of urinary output for residents with indwelling urinary catheters weekly for fifteen weeks, then monthly for six months, and review the results with the Quality Assurance Performance Improvement Committee for areas of improvement and/or continuation of audits. Results of these audits will be reviewed in the Quality Assurance and Performance Improvement meetings for ten months or until substantial compliance is noted. Similarly, the Director of Nursing/designee will conduct random audits of Point Click Care - Point of Care task documentation for bladder continence/incontinence weekly for fifteen weeks, then monthly for six months, with results reviewed by the committee. The same process applies for audits of resident barrier cream applications, with results reviewed in the same manner.
Failure to Document IV Flushes and Obtain Orders for Catheter Care
Penalty
Summary
The facility failed to ensure that intravenous (IV) catheters were flushed according to facility policy and did not obtain physician's orders for the care and maintenance of IV catheters for two residents. Facility policy required that midline dressings be changed weekly or as needed, and that IV lines be flushed according to physician orders. The policy for peripheral IV access specified a regimen of Normal Saline flush before and after medication administration, and a Heparin flush if ordered. For one resident, clinical records showed that the resident was cognitively intact, had a multi-drug resistant organism, was receiving IV antibiotics, and had IV access. Physician's orders included administration of Meropenem and routine saline flushes every shift. However, review of the Medication Administration Records (MARs) revealed no documented evidence that staff flushed the resident's IV with Normal Saline before and after medication administration, as required by policy and physician orders. The Director of Nursing confirmed the lack of documentation for these flushes. For another resident, a midline was placed and later removed without complications, and the resident received IV antibiotics as ordered. However, there was no documented evidence that the physician was contacted for orders regarding the care and maintenance of the midline during the time it was in place. Additionally, MARs did not show documentation that the midline was flushed with Normal Saline before and after medication administration. The Director of Nursing confirmed both the lack of physician orders for midline care and the absence of documentation for required flushes.
Plan Of Correction
Resident 9 assessed with no noted concerns related to having no documented evidence that her peripheral intravenous catheter was flushed with normal saline solution before and after the administration of her physician-ordered meropenem doses on April 10, 2025 through April 16, 2025. Resident 9's physician was notified regarding the facility having no documented evidence that her peripheral intravenous catheter was flushed with normal saline solution before and after her meropenem doses administered on April 10, 2025 through April 16, 2025. Resident 12 assessed with no noted concerns related to having no physician orders regarding care and maintenance of her midline May 22, 2025 through May 29, 2025, and related to having no documented evidence that her midline was flushed with normal saline solution before and after the administration of her physician-ordered meropenem doses May 22, 2025 through May 29, 2025. Resident 12's physician was notified regarding the facility having no physician orders regarding care and maintenance of her midline May 22, 2025 through May 29, 2025, and related to having no documented evidence that her midline was flushed with normal saline solution before and after the administration of her physician-ordered meropenem doses May 22, 2025 through May 29, 2025. Any resident receiving intravenous medications via a peripheral intravenous catheter has the ability to be affected by this alleged deficient practice. A whole house audit was completed for residents with intravenous catheters to ensure physician orders and documentation are present for flushing the intravenous catheter with saline routinely, including before and after the administration of intravenous medication as per his/her physician order. Any resident having a midline has the ability to be affected by this alleged deficient practice. A whole house audit was completed for residents with midlines to ensure physician orders were obtained for the care and maintenance of the resident's midline. Any resident receiving intravenous medications via a midline has the ability to be affected by this alleged deficient practice. A whole house audit was completed for residents with a midline to ensure physician orders and documentation are present for flushing the midline before and after the administration of intravenous medication as per his/her physician order. Licensed nursing staff, including agency licensed nursing staff, were re-educated on the facility Peripheral medication as per his/her physician order. Any resident having a midline has the ability to be affected by this alleged deficient practice. A whole house audit was completed for residents with midlines to ensure physician orders were obtained for the care and maintenance of the resident's midline. Any resident receiving intravenous medications via a midline has the ability to be affected by this alleged deficient practice. A whole house audit was completed for residents with a midline to ensure physician orders and documentation are present for flushing the midline before and after the administration of intravenous medication as per his/her physician order. Licensed nursing staff, including agency licensed nursing staff, were re-educated on the facility Peripheral Intravenous Access Flushing Policy and the facility Peripheral Intravenous Access Medication Administration Policy, including the importance of obtaining a physician order for routine saline flushing and saline flushing prior to and following the administration of intravenous medications. They were also re-educated on the Peripherally Inserted Central Catheter Line and Midline Maintenance and Care Policy and the Peripherally Inserted Central Catheter Line and Midline Access Medication Administration Policy, including the importance of obtaining a physician order for routine saline flushing and saline flushing prior to and following the administration of intravenous medications. Registered Nurse Charge Nurse/Designee will audit residents receiving intravenous medications via a peripheral intravenous catheter to ensure physician orders are present for routine saline flushes as well as saline flushes before and after intravenous medication administrations three times per week for eight weeks, then monthly until resolved. Findings from audits will be reviewed by the Quality Assurance Performance Improvement Committee for recommendations and/or resolution at its regularly scheduled meetings, focusing on results, areas of improvement, and/or continuation of audits. Registered Nurse Charge Nurse/Designee will also audit residents receiving intravenous medications via a peripheral intravenous catheter to ensure documentation is present on the resident's administration record for routine saline flushes as well as saline flushes before and after intravenous medication administrations three times per week for eight weeks, then monthly until resolved. Findings from audits will be reviewed by the Quality Assurance Performance Improvement Committee for recommendations and/or resolution. Similarly, registered nurses will audit residents receiving intravenous medications via a midline catheter to ensure physician orders are present for routine saline flushes as well as saline flushes before and after intravenous medication administrations three times per week for eight weeks, then monthly until resolved. Findings from these audits will also be reviewed by the Quality Assurance Performance Improvement Committee for recommendations and/or resolution. Finally, registered nurses will audit residents with a midline to ensure documentation is present on the resident's administration record for routine saline flushes as well as saline flushes before and after intravenous medication administrations three times per week for eight weeks, then monthly until resolved. The results and any recommendations will be discussed and reviewed during the committee meetings to determine further actions or continuation of audits.
Failure to Notify Physician and Responsible Party of Change in Condition
Penalty
Summary
A deficiency was identified when the facility failed to notify a physician and the resident's responsible party regarding a significant change in condition for one resident. The facility's policy required immediate notification of physicians and responsible parties in the event of any change in a resident's condition. However, documentation revealed that this protocol was not followed for a resident with a history of acute respiratory failure and multiple chronic conditions, including diabetes, congestive heart failure, and chronic obstructive pulmonary disease. On one occasion, the resident was found difficult to arouse, with abnormal vital signs including elevated blood pressure, low temperature, and a distended bladder with no urine output. Nursing staff intervened by providing warmth, administering BiPAP, and performing straight catheterization, but there was no documented evidence that the physician or the resident's son was notified of this change in condition. This lack of notification was confirmed through review of the clinical record and staff interviews. A subsequent similar event occurred several days later, during which the resident became pale, unresponsive, and had low oxygen saturation. On this occasion, the physician was notified and the resident was sent to the hospital, and a voicemail was left for the resident's son. The Director of Nursing confirmed that, in contrast to the later event, the required notifications were not made during the initial incident, which was not in accordance with facility policy.
Plan Of Correction
Resident 2's physician was notified of her change in condition on November 13, 2024. Resident 2's responsible party was not notified of the change in condition on November 13, 2024, as per her wishes. Immediate re-education was provided to the Registered Nurse by the Director of Nursing regarding the importance of ensuring a resident's physician and responsible family member or legal representative are notified as soon as possible of any changes in the resident's condition. Any resident who has a change in condition has the ability to be affected by this alleged deficient practice. A whole house audit of residents who recently had a change in condition was completed to ensure his/her physician and his/her responsible family member or legal representative were notified as soon as possible of the change in the resident's condition. Licensed nursing staff, including agency licensed nursing staff, were re-educated on the facility Notification of Changes Policy, including the importance of ensuring a resident's physician, responsible family member, or legal representative are notified as soon as possible of any changes in the resident's condition. The Director of Nursing/designee will randomly audit notifications of physicians and responsible family members/legal representatives of residents with changes in condition weekly times eight weeks and then monthly times four months, and then reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement, and/or continuation of audits. Results of these audits will be reviewed in the Quality Assurance and Performance Improvement meetings times six months or until substantial compliance is noted.
Failure to Log and Document Resident Grievances
Penalty
Summary
The facility failed to follow its own grievance policy regarding the documentation and logging of grievances for one resident. According to the facility's policy, when a concern or grievance is brought forward by staff, family, responsible party, or resident, a concern form should be completed and submitted to the Social Services Director or Administrator, who is then responsible for logging the concern into a grievance log. The policy also requires that the results of grievances be maintained for a minimum of three years. In the case of one resident, the quarterly Minimum Data Set (MDS) assessment indicated that the resident was able to understand and be understood by others. Two separate grievances were documented: one involving the resident's daughter finding the resident soiled with a bowel movement and without a brief, and another involving the discovery of pills in a medication cup, in the resident's bed, and on the floor. Both incidents were reported to staff and the Director of Nursing, and immediate actions were taken to address the resident's condition and to notify staff. Despite the completion of grievance forms for both incidents, a review of the facility's grievance/complaint logs revealed that neither of these concerns was entered into the official log as required by policy. This was confirmed by the Director of Nursing, who acknowledged that there was no documented evidence of these grievances being logged. The failure to document and log these grievances constitutes noncompliance with both facility policy and federal regulations regarding the handling of resident grievances.
Plan Of Correction
Facility's new Social Services Director immediately completed facility grievance/complaint concern forms for the June 14th and June 15th grievances regarding Resident 13 and placed both concerns onto the June 2025 Grievance/Concern and Complaint Log. Any resident admitted to the facility has the ability to be affected by this alleged deficient practice. A whole house audit was completed to ensure recent grievances/complaints and/or concerns were placed onto the monthly Grievance/Concern and Complaint Log, and a grievance/complaint concern form was completed for the grievance. Nursing Home Administrator educated the new Social Services Director on the facility Concern/Grievance Policy and the facility grievance/complaint concern form. Nursing Home Administrator/designee will randomly audit the monthly Grievance/Concern and Complaint Log weekly times four weeks and then monthly times three months, and then reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement, and/or continuation of audits. Results of these audits will be reviewed in Quality Assurance and Performance Improvement times four months or until substantial compliance is noted.
Failure to Provide Required Transfer Notifications and Discharge Documentation
Penalty
Summary
The facility failed to provide required written notifications and documentation during resident transfers to the hospital for three residents. Specifically, there was no evidence that written notification of transfer was given to the residents or their representatives, nor was a bed-hold notice provided to the responsible parties. Additionally, the facility did not notify the ombudsman of these hospital transfers as mandated by regulation. These deficiencies were confirmed through review of clinical records and staff interviews. The residents involved had significant medical conditions at the time of transfer. One resident was cognitively intact with chronic obstructive pulmonary disease and was transferred to the hospital for acute respiratory failure. Another resident, who was severely cognitively impaired with Alzheimer's, Parkinson's disease, and a history of respiratory failure, was transferred after being found lethargic and difficult to arouse. The third resident, also cognitively intact but with paraplegia, respiratory failure, and pneumonia, was transferred due to difficulty breathing and was later diagnosed with sepsis in the hospital. In all three cases, the required notifications and documentation were not completed. Additionally, the facility failed to complete a post-discharge summary for another resident who was discharged back to a personal care home. The physician did not provide a discharge summary that included the diagnosis, course of treatment, and pertinent test results as required. The Director of Nursing confirmed these documentation and notification failures during an interview.
Plan Of Correction
Written notification of Resident 2's transfer to the hospital on November 18, 2024, was immediately provided by the new Social Services Director to Resident 2 and the resident's representative. Facility's new Social Service Director immediately provided Bed-hold notice to Resident 2's responsible party for her transfer to the hospital on November 18, 2024. Ombudsman was immediately notified by the facility's new Social Services Director, as required, of Resident 2's transfer to the hospital on November 18, 2024. Written notification of Resident 19's transfer to the hospital on November 5, 2024, was immediately provided by the new Social Services Director to Resident 19's representative. Facility's new Social Service Director immediately provided Bed-hold notice to Resident 19's responsible party for her transfer to the hospital on November 5, 2024. Ombudsman was immediately notified by the facility's new Social Services Director, as required, of Resident 19's transfer to the hospital on November 5, 2024. Resident 38 no longer resides in the facility. Physician Discharge Summary Form completed for Resident 37. Any resident transferred from the facility to the hospital has the ability to be affected by this alleged deficient practice. A whole house audit was completed on recent resident transfers to the hospital to ensure written notification was provided to resident and resident's responsible party regarding the reason for transfer to the hospital. A whole house audit was completed on recent resident transfers to the hospital to ensure a bed-hold notice was provided to resident's responsible party. A whole house audit was completed on recent resident transfers to the hospital to ensure the Ombudsman was notified of the transfer to the hospital. Any resident discharged from the facility has the ability to be affected by this alleged deficient practice. A whole house audit was completed on recent resident discharges to ensure the Physician Discharge Summary Form has been completed. Facility's new Social Services Director and Marketing Liaison/Admissions Director were educated by the Nursing Home Administrator on contacting the resident/resident's representative following a facility-initiated transfer to an acute care facility or hospital, including the need to provide written notification of hospital transfer to resident/resident's representative, the need to provide bed-hold notice to responsible party, and the need to notify the Ombudsman as required. Registered Nurses, including agency Registered Nurses, were re-educated on the facility Physician Discharge Summary Policy. Resident transfers to the hospital will be audited by the Nursing Home Administrator/designee to ensure written notification was provided to resident and resident's responsible party regarding the reason for transfer weekly times three weeks then monthly times three months. Results of these audits will be reviewed in Quality Assurance and Performance Improvement times four months or until substantial compliance is noted. Facility transfers to acute care facilities/hospitals will be audited weekly times three weeks then monthly times three months by the Nursing Home Administrator/designee to ensure resident's electronic medical record contains written documentation that the resident/resident's representative was notified via phone call or in person and received a written copy of facility bed-hold policy. Results of these audits will be reviewed in Quality Assurance and Performance Improvement times four months or until substantial compliance is noted. Nursing Home Administrator/designee will audit resident transfers to the hospital to ensure the Ombudsman was notified of the transfer weekly times three weeks then monthly times three months. Results of these audits will be reviewed in Quality Assurance and Performance Improvement times four months or until substantial compliance is noted. Director of Nursing/designee will audit resident discharges to ensure a Physician Discharge Summary Form is completed weekly times six weeks then monthly times six months. Results of these audits will be reviewed in Quality Assurance and Performance Improvement times eight months or until substantial compliance is noted.
Inaccurate MDS Medication Coding for Two Residents
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments for two residents, as required by federal regulations. For one resident, physician's orders indicated the administration of Lisinopril-hydrochlorothiazide, a combination antihypertensive and diuretic medication, every morning during the assessment period. However, the corresponding MDS assessment did not reflect that a diuretic was administered during the seven-day look-back period. For another resident, physician's orders and the Medication Administration Record (MAR) showed that Dilantin, an anticonvulsant, was given every morning and at bedtime throughout the assessment period, but the MDS assessment failed to indicate that an anticonvulsant was received during the same timeframe. These discrepancies were confirmed through a review of clinical records, the RAI User's Manual, and staff interviews, including confirmation by the Director of Nursing. The inaccurate coding in the MDS assessments did not accurately reflect the residents' medication administration as documented in the MAR and physician's orders, resulting in noncompliance with regulatory requirements for assessment accuracy.
Plan Of Correction
A Modification Request to correct the erroneous coding for Section N0415G1 for Resident 1 for the Annual Minimum Data Set Assessment dated May 24, 2025 was completed and submitted on July 15, 2025. A Modification Request to correct the erroneous coding for Section N0415K1 for Resident 25 for the Significant Change Minimum Data Set Assessment dated April 22, 2025 was completed and submitted on July 2, 2025. Residents who receive diuretic medications have the ability to be affected by this alleged deficient practice. A whole house audit of recently completed Minimum Data Set Assessments was completed by the Director of Nursing/designee to ensure residents receiving diuretic medications were coded correctly on completed assessments. Residents who receive anticonvulsant medications have the ability to be affected by this alleged deficient practice. A whole house audit of recently completed Minimum Data Set Assessments was completed by the Director of Nursing/designee to ensure residents receiving anticonvulsant medications were coded correctly on completed assessments. The Director of Nursing reviewed the coding instructions for Section N0415G1 in the Resident Assessment Instrument Manual with the Registered Nurse Assessment Coordinator and the Licensed Practical Nurse Assessment Coordinator. The Director of Nursing reviewed the coding instructions for Section N0415K1 in the Resident Assessment Instrument Manual with the Registered Nurse Assessment Coordinator and the Licensed Practical Nurse Assessment Coordinator. Audits will be performed by the Director of Nursing/designee weekly times four weeks then monthly times two months to ensure any resident receiving diuretic medications is coded correctly. Results of these audits will be reviewed in Quality Assurance and Performance Improvement times three months or until substantial compliance is noted. Audits will be performed by the Director of Nursing/designee weekly times four weeks then monthly times two months to ensure any resident receiving anticonvulsant medications is coded correctly. Results of these audits will be reviewed in Quality Assurance and Performance Improvement times three months or until substantial compliance is noted.
Failure to Develop Individualized Care Plan for High-Risk Medications
Penalty
Summary
The facility failed to develop a comprehensive, individualized care plan for a resident who was cognitively intact and required extensive assistance with daily care tasks. Despite the resident receiving multiple high-risk medications, including an anticoagulant (Apixaban), an antiplatelet (Aspirin), and a diuretic (Lasix), there was no documented evidence that a care plan was created to address the specific care and treatment needs associated with these medications. The facility's policy indicated that residents and their representatives should participate in the development and implementation of person-centered care plans, but this was not followed in this case. A review of the resident's clinical records and physician's orders confirmed the ongoing use of these medications. During an interview, the Director of Nursing acknowledged that a care plan addressing the resident's needs related to anticoagulant, antiplatelet, and diuretic use was not developed and confirmed that it should have been. This omission was identified during a review of 35 residents, with this specific deficiency noted for one resident.
Plan Of Correction
Resident 9's comprehensive care plans were updated to reflect her care needs related to her use of anticoagulant, antiplatelet, and diuretic medications. Any resident who uses anticoagulant medications has the ability to be affected by this alleged deficient practice. A whole house audit on residents who use anticoagulant medications was completed to ensure that an individualized written plan of care was developed and in place for these residents addressing their care needs related to their anticoagulant use. Any resident who uses antiplatelet medications has the ability to be affected by this alleged deficient practice. A whole house audit on residents who use antiplatelet medications was completed to ensure that an individualized written plan of care was developed and in place for these residents addressing their care needs related to their antiplatelet use. Any resident who uses diuretic medications has the ability to be affected by this alleged deficient practice. A whole house audit on residents who use diuretic medications was completed to ensure that an individualized written plan of care was developed and in place for these residents addressing their care needs related to their diuretic use. Licensed Nursing Staff, including Agency Licensed Staff, re-educated on the importance of creating an individualized, person-centered plan of care for residents including care needs for residents who use anticoagulant medications, who use antiplatelet medications, and who use diuretic medications. Interdisciplinary Care Plan Team will continue to review care plans upon resident admissions, at regularly scheduled care plan conferences, and as needed to ensure individualized, person-centered care needs are included and up to date. The Director of Nursing/designee will audit care plans for residents who use anticoagulant medications, who use antiplatelet medications, and who use diuretic medications to be sure these medications are addressed in their care plans weekly times ten weeks and then monthly times four months. These will then be reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement, and/or continuation of audits. Results of these audits will be reviewed in Quality Assurance and Performance Improvement times seven months or until substantial compliance is noted.
Failure to Administer All Prescribed IV Antibiotic Doses
Penalty
Summary
A deficiency was identified when a resident, who was assessed as able to understand and communicate, did not receive all prescribed doses of intravenous Meropenem as ordered by the physician for treatment of a urinary tract infection. The physician's order specified that the resident was to receive one gram of Meropenem intravenously every eight hours for seven days, totaling 21 doses. However, review of the Medication Administration Records (MARs) showed that only 19 doses were administered over the prescribed period. This discrepancy was confirmed during an interview with the Director of Nursing, who acknowledged that the resident did not receive the full course of antibiotic therapy as ordered. The report notes that any resident with a physician order for intravenous antibiotics could potentially be affected by this practice, indicating a failure to ensure that care and treatment were provided in accordance with professional standards and physician orders.
Plan Of Correction
Resident 12 assessed with no noted concerns related to her receiving only 19 of the 21 doses of meropenem intravenously over seven days as ordered by the physician on May 20, 2025. Resident 12's physician notified of meropenem being administered intravenously for only 19 out of 21 doses from May 22, 2025 through May 28, 2025. Any resident with a physician order for intravenous antibiotics has the ability to be affected by this alleged deficient practice. A whole house audit on residents with physician orders for intravenous antibiotics was completed to ensure the correct number of doses was administered to the resident as per the physician orders. Licensed nursing staff, including agency licensed nursing staff, re-educated to administer intravenous antibiotics to residents as per physician orders for the correct number of specified doses. The Director of Nursing/designee will audit medication administration records of residents who are to receive/receiving/received intravenous antibiotics to ensure the resident is administered/receives the correct number of doses as per the physician orders weekly times eight weeks and then monthly times three months and then reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement and/or continuation of audits. Results of these audits will be reviewed in Quality Assurance and Performance Improvement times five months or until substantial compliance is noted.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
A deficiency was identified when a resident, who was cognitively intact but required extensive assistance with daily care and had limited lower extremity range of motion, was not provided with required fall prevention interventions. The resident's care plan indicated a risk for falls and specified that fall mats should be placed at the bedside. Despite this, a nursing note documented that the resident was found lying on the floor on the left side of her bed, after which new interventions were ordered, including placing the bed in the lowest position and using bilateral fall mats. Subsequent observation revealed that the resident was in bed without fall mats on either side, contrary to the care plan and the interventions ordered after the fall. An interview with the Director of Nursing confirmed that the resident should have had bilateral fall mats in place while in bed. This failure to implement and maintain fall prevention interventions resulted in the environment not being as free of accident hazards as possible for the resident.
Plan Of Correction
Resident 9's bilateral fall mats were immediately placed on each side of her bed while she was in bed. Resident 9 was assessed with no noted concerns related to her not having her bilateral fall mats on each side of her bed while she was in bed. Any resident with the fall/injury prevention intervention of fall mat/mats has the ability to be affected by this alleged deficient practice. A whole house audit on residents with the fall/injury prevention intervention of fall mat/mats was completed to ensure the fall mat/mats were correctly in place. Direct care staff, including agency direct care staff, were re-educated on the importance of ensuring fall/injury prevention interventions are in place, including fall mat/mats, as care planned. The Director of Nursing/designee will conduct audits of residents care planned to have a fall mat/fall mats for fall/injury prevention weekly times eight weeks and then monthly times four months and then reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement and/or continuation of audits. Results of these audits will be reviewed in Quality Assurance and Performance Improvement times six months or until substantial compliance is noted.
Failure to Document Destruction of Controlled Medications
Penalty
Summary
The facility failed to maintain proper accountability for controlled medications for one resident. According to the facility's policy, the destruction of controlled or narcotic medications, such as Fentanyl patches, must be witnessed and signed by two licensed nurses, with the amount destroyed logged on the Control Drug Record. Review of the clinical records and controlled drug count logs for a cognitively impaired resident who routinely received opioid pain medication revealed that, although Fentanyl patches were administered and logged as given, there was no documented evidence that two staff members signed for the destruction of the old patches after removal on multiple occasions. Further review of the Medication Administration Record and controlled drug count record confirmed that the required dual signatures for the destruction of Fentanyl patches were missing for several dates. An interview with the Director of Nursing corroborated that the two witness signatures were not present for the destruction of the patches as required by policy. This failure to document the destruction of controlled substances in accordance with facility policy and regulatory requirements resulted in a deficiency related to pharmacy services and recordkeeping.
Plan Of Correction
Resident 25 assessed with no noted concerns with his pain and/or his pain medications. Any resident having a physician order to receive a narcotic pain patch has the ability to be affected by this alleged deficient practice. A whole house facility audit was completed to ensure the Controlled Drug Count Records of residents who recently received narcotic pain patches have recorded documentation of two licensed nurse witness signatures for the destruction of the narcotic pain patches when removed from these residents. Licensed nursing staff, including agency licensed nursing staff, were re-educated on the facility Narcotic and Controlled Substance Policy and Procedure regarding maintaining accountability for controlled medications, including the importance of witnessing and recording the destruction of any narcotic by two licensed nurses on the resident's Controlled Drug Record, including the removal of narcotic pain patches. The Director of Nursing/Designee will complete random audits of residents receiving narcotic pain patches, including Fentanyl, to ensure accurate documentation of the witnessing and recording of the witnessed destruction of the narcotic pain patch by two licensed nurses on the resident's Controlled Drug Record when the patch was removed. These audits will be conducted weekly for twelve weeks, then monthly for six months until substantial compliance is noted. The Director of Nursing will conduct a thorough investigation of audit findings of any noted discrepancies and/or missing witness documentation of narcotic/controlled medication destruction to rule out any resident misappropriation and to ensure narcotic/controlled drug medication accountability. Findings from audits will be reviewed by the Quality Assurance Performance Improvement Committee for recommendations and/or resolution at its regularly scheduled meetings, times nine months, for results, areas of improvement, and/or continuation of audits.
Failure to Obtain and Document Required Hospice Charting
Penalty
Summary
The facility failed to ensure that the designated interdisciplinary team member obtained the required information from the contracted hospice provider for a resident receiving hospice services. Specifically, for a resident with a diagnosis of cancer and cognitive impairment, there was no documented evidence that updated hospice nurse aide or registered nurse charting was obtained and included in the resident's clinical record or the hospice provider's clinical record. The last available hospice nurse aide charting was dated nearly a month prior, and the last registered nurse charting was also outdated. A significant change Minimum Data Set (MDS) assessment indicated that the resident was cognitively impaired and receiving hospice services for basal cell carcinoma of the left upper limb. The care plan and physician's orders confirmed the resident was to be treated by hospice for end-of-life services. Despite these orders, the required documentation from hospice staff was not present in the records as of the review date. An interview with the Director of Nursing confirmed that the hospice nurse aide and registered nurse charting was missing from both the resident's clinical record and the hospice provider's clinical record, and acknowledged that this documentation should have been present. This lack of documentation demonstrates the facility's failure to meet regulatory requirements for coordination and documentation of hospice care services.
Plan Of Correction
F 0849 Resident 25's updated hospice nurse aide and updated hospice Registered Nurse charting was immediately placed into the hospice provider's clinical record. Any resident receiving hospice services has the ability to be affected by this alleged deficient practice. A baseline audit of residents receiving hospice services has been completed to ensure updated hospice personnel charting is present and available in the hospice provider's clinical record. The Director of Nursing re-educated hospice providers regarding the importance of and the need for updated charting documentation to be timely placed into the resident's hospice provider's clinical chart consistently. The Director of Nursing/designee will audit residents receiving hospice services for the presence of timely documentation of hospice providers' charting in the resident's hospice provider's clinical chart weekly times three weeks and then monthly times two months and then reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement and/or continuation of audits. Results of these audits will be reviewed in Quality Assurance and Performance Improvement times three months or until substantial compliance is noted.
Repeated QAPI Failures Lead to Ongoing Regulatory Deficiencies
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations by not effectively addressing recurring deficiencies identified in multiple state surveys. Despite developing plans of correction that included quality assurance systems such as audits and QAPI committee reviews, the facility continued to have repeated deficiencies in several key areas. These areas included care plan revisions, provision of quality care, ensuring a safe environment free from accident hazards, maintenance of intravenous catheters, and accountability for controlled medications. Specifically, the facility's plans of correction for deficiencies related to care plan timing and revision, quality of care, accident hazards, intravenous catheter maintenance, and controlled medication accountability all involved conducting audits and reporting results to the QAPI committee. However, subsequent surveys found that these measures were not successfully implemented or sustained, as evidenced by repeated citations under F657, F684, F689, F694, and F755. The QAPI committee was found to be ineffective in ensuring ongoing compliance with regulations in these areas. The report does not provide specific details about individual residents or their medical histories, but it does document that the deficiencies persisted across multiple survey cycles. The QAPI committee's failure to implement and sustain corrective actions resulted in ongoing noncompliance with federal and state regulations, as observed in the repeated survey findings.
Plan Of Correction
New Nursing Home Administrator met with the Interdisciplinary Team Facility Directors to review the current outstanding deficiencies and the facility plan to correct these deficiencies to maintain compliance with nursing home regulations. Current facility residents have the ability to be affected by this alleged deficient practice. Quality Assurance Performance Improvement Committee Meetings will continue to be held monthly to ensure quality care is being delivered to the residents residing at the facility and cited deficiencies including recurring deficiencies are being effectively addressed and corrected. New Nursing Home Administrator re-educated Quality Assurance Performance Improvement Committee members on the importance of facility and interdisciplinary team collaboration to correct cited facility deficiencies and ensure plans of correction improve the delivery of care and services to residents and effectively address recurring deficiencies, including care plan timing and revisions, providing quality care, ensuring resident environments are free from accident hazards, maintaining intravenous catheters and preventing issues with the accountability of controlled medications. The New Nursing Home Administrator will hold a weekly Department Head Meeting with the Interdisciplinary Team Facility Directors to review the progress and compliance of the current plan of correction audit process. Concerns and suggestions will be provided and reviewed as needed upon review of outstanding deficiency audits to ensure that improvements are being made and the facility is moving forward and progressing in its quality care being delivered to the residents residing at the facility. Weekly Department Head Meetings will continue until facility compliance is established. Results from audits will be reviewed by the Quality Assurance Performance Improvement Committee for recommendations and/or resolution at monthly meetings times nine months for results, areas of improvement and/or continuation of audits.
Failure to Ensure Required QAA Committee Attendance
Penalty
Summary
The facility failed to ensure that all required members of the Quality Assessment and Assurance (QAA) Committee attended the quarterly meetings, as mandated by federal regulations. Specifically, review of the QAA Committee attendance records for the first quarter of 2025 revealed that the Medical Director did not attend any of the meetings. This was confirmed through an interview with the Director of Nursing, who acknowledged the Medical Director's absence from all QAA Committee meetings during this period. The facility's policy, dated March 12, 2025, states that the QAA Committee meetings are to be held at least quarterly and must include the Nursing Home Administrator, Director of Nursing, all department heads, a community member, and the Medical Director. Despite this policy, the required participation of the Medical Director was not met, resulting in noncompliance with both federal and state regulations regarding the composition and functioning of the QAA Committee.
Plan Of Correction
Director of Nursing reviewed the Quality Assessment and Assurance Committee Meeting minutes from the first quarter of 2025 with the facility's new Medical Director. Current facility residents have the ability to be affected by this alleged deficient practice. Nursing Home Administrator educated the new facility Medical Director of the requirement to attend the Quality Assessment and Assurance Committee Meetings on at least a quarterly basis and provided the date of the next upcoming scheduled Quality Assurance Committee Meeting. Nursing Home Administrator will audit attendance of members of the Quality Assessment and Assurance Committee Meetings to ensure the Medical Director attends at least on a quarterly basis monthly times six months until resolved. Results from audits will be reviewed by the Quality Assurance Performance Improvement Committee for recommendations and/or resolution at its regularly scheduled meetings times six for results, areas of improvement and/or continuation of audits.
Failure to Follow Hand Hygiene Protocols During Medication Administration
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) failed to follow proper hand hygiene protocols during medication administration for three residents. The facility's hand hygiene policy required staff to sanitize their hands before preparing or handling medications and after removing gloves. However, during a medication pass, the LPN prepared and administered medications to one resident, then donned gloves and took another resident's blood pressure without sanitizing her hands. After removing her gloves, she again failed to sanitize her hands before preparing and administering medications to the next resident. This pattern continued as the LPN checked a third resident's blood sugar, removed gloves, and prepared medications without hand sanitizing, only using hand sanitizer at the medication cart after completing the rounds. Interviews with the LPN and the Director of Nursing confirmed that the LPN did not adhere to the required hand hygiene procedures during the medication pass and after glove removal. The observations and staff interviews demonstrated a failure to implement the facility's infection prevention and control policies, specifically regarding hand hygiene during direct resident care activities.
Plan Of Correction
Resident 45 was assessed with no ill effects and/or noted concerns related to License Practical Nurse 1 failing to use proper hand washing techniques during her medication administration. Resident 29 was assessed with no ill effects and/or noted concerns related to License Practical Nurse 1 failing to use proper hand washing techniques during her medication administration. Resident 2 was assessed with no ill effects and/or noted concerns related to License Practical Nurse 1 failing to use proper hand washing techniques during her medication administration. The Director of Nursing immediately spoke to Licensed Practical Nurse 1 regarding proper hand sanitization during medication administration, including after glove removal, with Licensed Practical Nurse 1 verbalizing understanding and willingness to comply. Current facility residents receiving medications have the ability to be affected by this alleged deficient practice. A baseline audit was completed on residents currently receiving medications to ensure licensed nurses completed hand washing/hand hygiene during medication administration, including after glove removal. Hand washing/hand hygiene competencies were completed with current facility licensed staff and current agency licensed staff. Direct care staff, including agency direct care staff, were re-educated on the facility's Hand Hygiene Policy, including the importance of proper hand sanitization during medication administration and after glove removal. Facility direct care staff, including agency direct care staff, received training regarding appropriate practices for wearing gloves, changing gloves, hand washing, and hand hygiene, including when to wear and change gloves, perform hand washing and/or hand hygiene during resident care and treatment. Facility licensed staff, including agency licensed staff, were re-educated on preventing the spread of infection, including hand washing/hand hygiene. The Director of Nursing/designee will audit licensed nurses administering medications to residents weekly times four weeks then monthly times three months to ensure proper hand washing/hand hygiene utilized throughout medication administration. Results from audits will be reviewed by the Quality Assurance Performance Improvement Committee for recommendations and/or resolution at its regularly scheduled meetings times four months for results, areas of improvement, and/or continuation of audits.
Failure to Change PICC Line Dressing as Ordered
Penalty
Summary
The facility failed to ensure that peripherally-inserted central catheters (PICC lines) site dressings were changed according to physician's orders for one resident. The facility's policy required that PICC line dressings be changed weekly. However, for one resident, the dressing had not been changed since December 13, 2024, despite physician's orders to change it weekly. This was confirmed through clinical record reviews, observations, and interviews with the resident and staff. The resident, who was cognitively impaired and required assistance for daily care needs, expressed concern that the dressing was not sticking and might fall off, potentially leading to the PICC line being pulled out. The resident had improvised by using a sock cuff to hold the dressing in place. Interviews with a registered nurse and the Director of Nursing revealed that the dressing was on back order from the pharmacy, and there was uncertainty about why it was not sourced from elsewhere. The deficiency was noted as a failure to adhere to physician's orders and facility policy.
Plan Of Correction
1. Resident 2's peripherally inserted central catheter line dressing changed on December 26, 2024. Resident 2 noted to not have any complications from the incident. Resident 2 assessed with no noted/additional concerns as well. 2. All residents having peripherally inserted central catheter line dressings have the ability to be affected by this alleged deficient practice. A whole house audit completed for residents with peripherally inserted central catheter line dressings to ensure licensed nurses changed dressing weekly. 3. Licensed nursing staff, including agency licensed nursing staff, were re-educated on the facility Peripherally Inserted Central Catheter Line Maintenance and Care Policy, including the importance of changing the dressings weekly and proper documentation of dressing changes on the medication/treatment administration records. 4. Registered Nurse Charge Nurse/Designee will audit residents with peripherally inserted central catheter line dressings to ensure proper weekly dressing changes are completed by licensed nurses three times per week times four weeks then monthly until resolved. Findings from audits will be reviewed by the Quality Assurance Performance Improvement Committee for recommendations and/or resolution at its regularly scheduled meetings times three for results, areas of improvement and/or continuation of audits.
Failure to Provide Privacy for Residents
Penalty
Summary
The facility failed to maintain resident dignity for two residents by not providing adequate window coverings, which compromised their privacy. Resident 2, who is cognitively impaired and requires assistance for daily care needs, was observed without a curtain or blind covering the window next to his bed, which faced the facility's main parking lot. He expressed discomfort and a sense of exposure when using the urinal, bedside commode, and while dressing, as he could not pull the privacy curtain around his bed due to its location and his physical limitations. Despite his request for a curtain or blind, none had been installed. Similarly, Resident 6, also cognitively impaired and requiring assistance, was observed in a similar situation with her bed near a window without blinds or curtains, facing the parking lot. The Director of Housekeeping confirmed that blinds had been ordered for both residents' windows but had not yet arrived, and she was unsure of how long the rooms had been without these coverings. This lack of window coverings failed to uphold the residents' rights to dignity and privacy as outlined in the facility's policy and federal regulations.
Plan Of Correction
1. A blind covering the window to the outside has been installed in Resident 2's room. Resident 2 interviewed with no further verbalized concerns. Window blind covering has been installed in Resident 6's room. 2. Any resident who resides in the facility has the ability to be affected by this alleged deficient practice. A whole house random audit was completed with interviewable residents to verify maintenance of his/her resident dignity. 3. Facility staff, including agency staff, were re-educated on the facility Resident Rights Policy, including the importance of maintaining resident dignity and protecting/promoting the rights of each resident, particularly those rights that pertain to a dignified existence. 4. Director of Nursing/designee will randomly audit residents to ensure protection/promotion of resident dignity is maintained weekly times four weeks and then monthly times three months and then reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement and/or continuation of audits. Results of these audits will be reviewed in Quality Assurance and Performance Improvement times three months or until substantial compliance is noted.
Failure to Ensure Resident Privacy Due to Lack of Window Coverings
Penalty
Summary
The facility failed to ensure personal privacy for a resident, identified as Resident 2, as required by federal regulations. The resident's room lacked a curtain or blind covering the window, which faced the facility's main parking lot. This deficiency was observed during a survey on December 26, 2024. The resident, who was cognitively impaired and required assistance for daily care needs, expressed concerns about feeling exposed while using the urinal, bedside commode, and dressing himself. He was unable to pull the privacy curtain around his bed due to its location and his physical limitations, and he preferred not to have the curtain closed at all times as he enjoyed watching TV and looking outside. An interview with the Director of Housekeeping revealed that blinds had been ordered for the windows of Resident 2 and another resident, but they had not yet arrived. The Director was unsure of how long the rooms had been without curtains or blinds. The facility's policy on Resident Rights, dated May 6, 2024, stated that the facility would protect and promote the rights of each resident, including the right to a dignified existence, which was not upheld in this instance.
Plan Of Correction
1. Window blind covering has been installed in Resident 2's room. Resident 2 interviewed and verbalized he no longer feels exposed to the parking lot and had no further concerns. 2. Any resident who resides in the facility has the ability to be affected by this alleged deficient practice. A whole house audit was completed to ensure each resident's room contained window blind coverings to ensure resident personal privacy. 3. Facility staff, including agency staff, were re-educated on the importance of ensuring residents are provided personal privacy. 4. Nursing Home Administrator/designee will randomly audit resident rooms to ensure presence of window blind coverings for personal privacy weekly times three weeks and then monthly times two months and then reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement and/or continuation of audits. Results of these audits will be reviewed in Quality Assurance and Performance Improvement times three months or until substantial compliance is noted.
Inadequate Investigation of Resident's Injury
Penalty
Summary
The facility failed to conduct a thorough investigation into an injury of unknown origin for a resident, identified as Resident 5, to rule out abuse or neglect. The facility's policy requires the Director of Nursing or designee to conduct investigations, review accident/incident reports, obtain written statements from staff, and interview witnesses. However, there was no documented evidence that the investigation was expanded to include interviews with all staff who had potential contact with the resident around the time she complained of pain and swelling in her right wrist. The Director of Nursing confirmed the lack of documentation for a comprehensive investigation. Resident 5, who has severe cognitive impairment due to Alzheimer's and Parkinson's diseases, was readmitted to the facility after a hospital stay. Upon readmission, she had scattered bruising on her hands and arms. A subsequent skin assessment noted multiple small bruises on her hands. A nursing note indicated increased pain and swelling in her right wrist, which was not thoroughly investigated. Witness statements from staff revealed that some aides did not have contact with the resident, but there was no evidence of further interviews with other staff members who might have interacted with her.
Plan Of Correction
1. Physical assessment completed by a Registered Nurse on Resident 5. Incident report and investigation of Resident 5's injury of unknown cause on November 19, 2024 that included wrist swelling and pain to her right hand/wrist with movement was completed to rule out abuse. Immediate re-education provided to Licensed Nursing Staff, including licensed agency staff, on facility policy regarding reporting incidents and accidents and completing incident reports/investigations thoroughly with staff interviews to rule out abuse. 2. All residents with injuries of unknown cause have the ability to be affected by this alleged deficient practice. A whole house audit of current incident and accident reports has been completed to ensure each incident report with an injury of unknown cause has a thorough investigation, including staff interviews, to rule out abuse. 3. Facility Staff, including Agency Staff, were re-educated on facility policies regarding abuse prevention and reporting and abuse, neglect and mistreatment of residents including importance of reporting, investigating and obtaining/providing witness statements. The Charge Nurse will be notified of incidents and/or accidents including injuries of unknown origin, so medical attention may be provided and a physical assessment and thorough investigation, including staff interviews, can be completed to rule out abuse. Incident reports are reviewed daily for completion, including review of staff interview statements. 4. Director of Nursing/designee will audit injuries of unknown origin to ensure that their completed incident reports include a thorough investigation with staff interview statements to rule out abuse weekly times six weeks, monthly times two months and then reviewed by the Quality Assurance Performance Improvement Committee for results, areas of improvement and/or continuation of audits. Results of these audits will be reviewed in Quality Assurance and Performance Improvement times three months or until substantial compliance is noted.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 217 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Portage
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Maple Heights Health & Rehab Center, Llc | 8.9 mi | ★★★★★ | 30 | 1 |
| Richland Nursing And Rehab | 10.8 mi | ★★★★★ | 12 | 0 |
| Concordia At Arbutus Park | 12.6 mi | ★★★★★ | 14 | 0 |
| Windber Woods Senior Living & Rehabilitation Ctr | 12.8 mi | ★★★★★ | 16 | 0 |
| Conemaugh Memorial Medical Center Tcu | 13.7 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.