Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sapphire Care And Rehab Center during CMS and state inspections, most recent first.
Failure to Implement Restorative Nursing Program: A resident with CVA, hemiplegia, hemiparesis, and severe cognitive impairment did not consistently receive the planned restorative nursing services needed to maintain mobility. PT discharged the resident to the RNP and directed daily ROM exercises, and a physician also ordered active-assisted to passive ROM, but review of the task report, documentation report, and MAR showed no documented evidence that the restorative ambulation program had been implemented. The DON confirmed the facility did not consistently carry out the planned restorative nursing program as recommended by PT.
Failure to Monitor and Respond to Significant Weight Loss: The facility did not follow its weight-monitoring and nutritional assessment policies for three residents with dysphagia, dementia, Parkinsonism, and severe protein malnutrition. One resident had an apparent large weight drop that was not promptly rechecked or reported, and two other residents had confirmed significant weight loss without documented notification of the MD, RD, or responsible party, interdisciplinary review, or timely evaluation of the cause of the decline.
Failure to provide recommended behavioral health follow-up for two residents. One resident with anxiety, bipolar disorder, and major depressive disorder, and another resident with anxiety and depression, both had care plans and psychiatric consults recommending therapy/LPC follow-up, but there was no documented evidence they received the ordered psychiatric or psychological services. The DON confirmed the missed follow-up services.
The facility failed to maintain a comprehensive infection prevention and control program with functional HAI surveillance and tracking. The IP and NHA could not provide documented evidence of infection tracking, trending, or data analysis, including for three residents who tested positive for SARS-CoV-2. The facility's records did not show routine collection, analysis, or review of infection data to identify trends or monitor spread.
Failure to provide and document wheelchair positioning devices: A resident with moderate cognitive impairment, total assist transfers, and short stature was repeatedly observed seated in a high-back wheelchair with both legs dangling unsupported. OT had evaluated the resident and provided bilateral leg rests and a foot/calf board for lower-extremity support, but the devices were missing during observations and were not documented in the care plan, physician orders, or Kardex, so staff did not consistently accommodate the resident’s assessed positioning needs.
A resident with anxiety, depression, and moderate cognitive impairment had a care plan and physician order for a Wander Guard on the left ankle, but surveyors observed no device on the resident and the LPN could not locate it. In a separate finding, a severely cognitively impaired resident with cerebral infarction and hemiplegia had zinc oxide and A and D ointment left at the bedside in a cup and spoon without an order for either cream; the DON confirmed staff should not leave medicated cream at the bedside.
A resident with respiratory failure and a tracheostomy had an order for supplemental O2 at 6 LPM, titrated to keep sats above 92% using a pulse oximeter. Surveyors observed that the oxygen setup used a fixed-flow device that was not designed for titration, and the device was intended for 8 LPM while the facility had it set at 6 LPM, which did not match the appliance chosen.
Failure to Monitor and Treat Severe Pain After Ankle Injury: A resident with acute respiratory failure and COPD sustained an ankle injury while transferring to a wheelchair and reported severe pain rated 8/10 to 10/10. Staff applied ice, elevated the foot, and gave PRN acetaminophen, but the MAR documented it as ineffective and the resident continued to report severe pain for hours. An X-ray later showed an acute fracture, and the resident was not transferred to the ED until late that night after the delayed imaging result was obtained.
Failure to Provide Timely Dental Services: A resident with dysphagia and HTN, who was cognitively intact and on Medicaid, had dental impressions taken for complete upper and lower dentures but then had no further documented follow-up with the dentist. The resident reported waiting a long time for dentures, had not received updates, and had not seen the dentist recently; the record showed no further communication after the initial dental consult and impressions.
Smoking Policy Not Consistently Enforced: A cognitively intact resident with COPD was allowed independent leave to smoke off-property, but staff did not consistently collect his cigarettes and lighter or prevent him from keeping smoking materials on his person inside the facility. The resident reported inconsistent enforcement of leave-of-absence hours, and an observation found cigarettes and a lighter stored on his walker.
A resident with Alzheimer’s disease and dementia, identified as high risk for elopement, had a PRN quetiapine order for agitation in addition to other psychotropic and dementia-related medications. The care plan included interventions such as reorientation, frequent monitoring, diversionary activities, and redirection, and documentation showed that redirection and contacting the resident’s husband were sometimes effective in calming exit-seeking and agitation. However, PRN quetiapine was administered multiple times without consistent documentation of the specific behaviors present, without evidence that non-pharmacological interventions were attempted and found ineffective before administration for half of the doses reviewed, and without clearly defined, measurable behavioral parameters to guide staff on when PRN antipsychotic use was clinically indicated, resulting in the use of a chemical restraint contrary to facility policy.
A resident with COPD and acute bronchitis experienced a significant change in condition, leading to new treatment orders including supplemental oxygen and medications. The facility did not document notification of the resident's designated representative or POA about these changes, despite policy requiring prompt notification within 24 hours.
A resident with diabetes and moderately impaired cognition did not receive insulin aspart as ordered on multiple occasions, with doses withheld despite the absence of physician-approved parameters for holding the medication. There was also no documentation that the physician was notified when insulin was not administered, contrary to facility policy.
The facility did not ensure proper inspection and maintenance of bed frames with extenders, resulting in gaps between mattresses and footboards in several rooms. Two residents were found with bed extenders creating entrapment zones, and staff reported using repositioning wedges to fill these gaps instead of appropriate equipment, leading to unaddressed safety hazards.
A deficiency was cited when a resident did not receive sufficient food and fluids to maintain their health, as required. The report indicates that the facility did not meet the necessary standards for nutrition and hydration, but does not provide further details about the circumstances or the resident's condition.
Surveyors found that several licensed resident rooms were missing required beds and mattresses, with no evidence that the missing beds were stored elsewhere in the facility. This resulted in the facility not maintaining the full complement of licensed and certified beds as required.
A resident with hemiplegia and contractures in both hands was unable to use the standard push-button call bell due to physical limitations. Despite facility policy requiring evaluation and accommodation of unique needs, the resident was not provided with a touch-sensitive call system until after surveyor inquiry. An LPN and the administrator confirmed the lack of appropriate accommodation prior to the survey.
Two residents did not have their clinical status accurately reflected in their MDS assessments, with one resident's significant weight loss not documented and another resident's ongoing dialysis treatments omitted, as confirmed by facility staff and clinical records.
A resident did not receive appropriate care for existing pressure ulcers, and preventive measures to avoid new ulcers were not consistently implemented. The facility did not follow established protocols for assessment, monitoring, and treatment of pressure ulcers.
A resident with hemiplegia and hemiparesis following a stroke did not receive restorative nursing services or a prescribed therapeutic device as ordered by the physician and recommended by therapy staff. The resident's care plan did not include the required interventions, and there was no documentation or evidence that staff provided the ordered exercises or consistently applied the palm guard.
Nursing staff did not consistently follow facility policy for documenting controlled medication counts, with multiple instances where required signatures from oncoming and off-going nurses were missing on narcotic count sheets for a medication cart. This failure was confirmed by staff interviews and review of records, indicating the facility did not consistently implement its procedures for controlled substance documentation.
Surveyors found that an LPN had left expired multi-dose insulin medications, including Humalog and Basaglar pens and vials, on a medication cart past their manufacturer-recommended 28-day discard dates. The medications remained available for resident use, contrary to facility policy and manufacturer instructions, a fact confirmed by both the LPN and the DON.
A resident with acute kidney failure and a history of inability to care for herself was discharged home without documented evidence that her needs for food and support services would be met. Social service notes lacked details on how the family would assist, and upon return home, the resident had no food available, indicating the facility did not ensure a safe and appropriate discharge.
A resident with moderate cognitive impairment tested positive for COVID-19 and, while both the resident and physician were informed, the facility did not promptly notify the resident's emergency contact as required by policy. The emergency contact only learned of the diagnosis through the resident, and staff confirmed there was no timely documentation of notification.
The facility did not meet the required nurse aide to resident ratios on five shifts. On specific dates, the evening and night shifts were understaffed, with no additional higher-level staff available to compensate. The Nursing Home Administrator confirmed these deficiencies.
The facility did not meet the required LPN to resident ratios on two night shifts, providing only 2.00 LPNs for 103 residents instead of the required 2.58. No additional higher-level staff were available to compensate for this deficiency, as confirmed by the Nursing Home Administrator.
The facility did not meet the required minimum of 3.2 hours of direct resident care per resident on two occasions, providing only 3.06 and 2.91 hours respectively. This was confirmed by the Nursing Home Administrator.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with chronic wounds or indwelling medical devices, as required by new CMS and CDC guidance. Observations revealed no EBP measures in place, confirmed by the DON, despite six residents meeting the criteria for EBP due to conditions like tube feeding and indwelling catheters.
The facility failed to comply with CMS regulation S483.80(b)(3) by not having a designated Infection Preventionist (IP) responsible for the Infection Prevention and Control Program. The previous IP left in April 2024, and as of the survey's end, no new IP had started. The DON confirmed the absence of credentialed infection preventionists.
The facility did not implement proper screening procedures for five employees, as required by their abuse prohibition policy. The policy lacked procedures for obtaining references from previous employers, and personnel files showed no evidence of such checks. This was confirmed by the NHA.
A resident's medications were left unattended on an overbed table, creating a potential accident hazard. The resident was scheduled to receive medications via a feeding tube, but there was no authorization for self-administration. An LPN confirmed the medications were left unattended, and the DON verified the resident was not to self-administer medications.
A facility failed to maintain sanitary conditions for a resident's catheter supplies, leading to potential urinary tract infection risks. The resident required an indwelling catheter due to urine retention, and a physician's order for Acetic Acid irrigation lacked clarity. Observations found unsanitary storage of irrigation supplies, with opened and undated bottles of Acetic Acid improperly stored, contrary to manufacturer instructions. An LPN and the DON confirmed the unsanitary conditions.
The facility did not follow physician orders for oxygen therapy and failed to maintain oxygen equipment properly for three residents. A resident with COPD had undated oxygen tubing and a dusty concentrator filter, while another resident received oxygen at a higher flow rate than prescribed. An LPN confirmed these issues, and the Nursing Home Administrator acknowledged the facility's non-compliance with policy.
The facility failed to implement procedures for accounting for controlled drugs on a medication cart. The narcotic logbook was not with the cart, and shift-to-shift sign-offs were incomplete on several occasions. The DON confirmed the failure to accurately account for controlled drugs at shift changes.
The facility failed to ensure that the attending physician acted upon the pharmacist's reports of irregularities in the drug regimens of four residents. For one resident, the pharmacist recommended identifying the duration of Lovenox therapy and considering therapy modification due to potential interactions with NSAIDs. However, there was no documentation of the physician's response. Similar issues were found for three other residents, where the facility could not provide evidence of the physician's acknowledgment or response to the pharmacist's recommendations.
The facility failed to document clinical rationale for the continued use of as-needed psychotropic medication for two residents. One resident with Bipolar Disorder received lorazepam without a documented rationale for its continued use. Another resident with anxiety and depression had lorazepam administered without an end date, despite pharmacy recommendations for a stop date. The DON confirmed the lack of documentation for the use of the medication beyond 14 days.
The facility failed to properly label and store insulin pens on two medication carts. Insulin pens were found opened without being dated or marked with expiration dates, and one pen was not labeled with resident identification. The DON confirmed these deficiencies.
The facility failed to offer routine annual dental services to a resident with Medicaid and did not promptly refer another resident with mouth pain for a dental consult, despite a physician's order. These deficiencies were confirmed through clinical record reviews and staff interviews, indicating non-compliance with nursing services regulations.
The facility did not implement an antibiotic stewardship program for six months, as required by their infection control policies. Despite the policy mandating antibiotic monitoring, there was no documentation of such monitoring from April to September 2024. The DON confirmed the absence of a surveillance system and could not provide tracking records for this period.
A resident with dementia was not assisted with her lunch meal for approximately 25 minutes after it was placed in front of her, despite requiring assistance with feeding. The NHA confirmed that the meal service did not promote the resident's dignity, as required by regulations.
A facility failed to ensure accurate MDS Assessments, as a resident's discharge was incorrectly recorded as to an acute care hospital instead of home. Clinical records and staff confirmed the resident was discharged home, highlighting a discrepancy in the MDS Assessment.
The facility failed to create comprehensive care plans for three residents, neglecting to include critical medical devices and behaviors in their plans. A resident with a pacemaker and another requiring a SmartVest for respiratory issues did not have these needs documented in their care plans. Additionally, a resident with dementia who hoarded food had no interventions for this behavior in their care plan. The DON confirmed these deficiencies.
A facility failed to update a resident's care plan to reflect current needs, despite the resident being assessed as a low wander risk and cognitively intact. The care plan, which included interventions for potential elopement, had not been revised since the previous year, even after a physician's order allowed the resident to go out on pass alone. The DON confirmed the oversight.
A resident with conditions including congestive heart failure and anxiety was prescribed Midodrine HCL with instructions to hold the medication if systolic blood pressure (SBP) exceeded 120 mm/Hg. However, the medication was administered multiple times despite the resident's SBP being above this threshold. The DON confirmed the nursing staff's failure to follow the physician's order, indicating a deficiency in nursing services and documentation.
A resident with dementia experienced significant weight loss, and the facility failed to adhere to its policy of reweighing after a 5-pound loss. The dietician's recommendations for nutritional support and weekly weights were not implemented, and the facility did not timely address the resident's weight loss, as confirmed by the DON.
A resident with end-stage renal disease and dependent on hemodialysis did not have necessary emergency supplies available in their room or on their wheelchair. The care plan included monitoring the dialysis catheter site but lacked interventions for emergency supplies. Observations and interviews confirmed the absence of supplies, and the deficiency was noted under nursing services regulations.
A resident with schizoaffective disorder exhibited ongoing behavioral issues such as agitation and restlessness, yet the facility failed to update the care plan or provide necessary psychological services. Despite recommendations for continued behavioral health services, the resident's care plan did not address these needs, and no interventions were observed during a survey.
Failure to Implement Restorative Nursing Program
Penalty
Summary
The facility failed to consistently provide restorative nursing services as planned to maintain mobility for one resident. Resident 115 was admitted with diagnoses including cerebral infarction, hemiplegia, and hemiparesis, and the Quarterly MDS dated April 9, 2026, showed the resident was severely cognitively impaired with a BIMS score of 02. The facility’s Restorative Nursing Programs Policy stated that maintenance and restorative services would be provided to maintain or improve residents’ abilities to the highest practical level, and that residents would receive maintenance nursing services as needed by CNAs. The clinical record showed that PT services were provided from March 22, 2025, through April 18, 2025, and the PT discharge summary recommended referral to the facility’s RNP to maintain the resident’s functional abilities. The discharge summary directed staff to provide ROM exercises through all planes of movement, 10 repetitions for two sets, for approximately 15 minutes daily, and a physician order dated September 29, 2025, directed active-assisted to passive ROM exercises through all planes of movement, 10 repetitions for two sets, for approximately 15 minutes daily. Review of the electronic task report, Documentation Survey Report v2, and MAR revealed no documented evidence that the restorative ambulation program had been implemented. The DON confirmed on June 30, 2026, that the facility failed to consistently implement the planned restorative nursing program for Resident 115 as recommended by PT to maintain the resident’s functional abilities and deter declines to the extent possible and to ensure the resident’s goals for ambulation were met.
Failure to Monitor and Respond to Significant Weight Loss
Penalty
Summary
The facility failed to ensure residents maintained acceptable parameters of nutritional status to the extent possible for Residents 13, 106, and 9. Facility policy required routine weight monitoring, reweights for any 5-pound or greater change, and notification of the physician, RD, and resident or responsible party when a significant weight change was confirmed. The facility also had a Nutritional Assessment policy requiring nutritional assessment and individualized care planning for residents at risk for impaired nutrition. Resident 13 had diagnoses including dysphagia and hypertension and was cognitively intact with a BIMS score of 15. The resident’s weight record showed 131 pounds, then 130 pounds, then 107.8 pounds within a short period. The RD documented that the resident may have lost 22.2 pounds in three days and recommended a reweight because the amount of loss was unlikely given the resident was eating more than 50 percent of meals and receiving Ensure twice daily. No documented evidence showed that the reweight was obtained when recommended, and there was no documented evidence that the physician or resident was notified of the possible weight loss. A later reweight showed 108 pounds, confirming the earlier low weight was not accurate. Resident 106 had diagnoses including Parkinsonism, dementia, and dysphagia and was severely cognitively impaired with a BIMS score of 7. The care plan identified the resident as at risk for altered nutritional status and included interventions such as monitoring dysphagia, providing a fortified mechanical soft chopped diet with nectar thickened liquids, oral nutrition supplementation, and obtaining weights as ordered. The resident lost 7.2 pounds in one month, confirmed by reweighing, but there was no documented evidence that the physician, RD, or responsible party were notified, and no documented evidence that the interdisciplinary team reviewed the loss or that additional nutritional interventions were evaluated. A later weight showed continued loss to 150.4 pounds, and there was no documented assessment of the cause of the ongoing decline or evidence that the facility recognized or acted on the weight loss identified earlier. Resident 9 had diagnoses including severe protein malnutrition and dementia and was severely impaired in decision-making. The resident was identified as at risk for altered nutritional status, with interventions including fortified meals and weekly weights. The weight record showed 98.0 pounds, then 94.2 pounds, and later 90.6 pounds after the resident was reweighed following surveyor inquiry, reflecting a 7.4-pound loss over 43 days. The RD was unable to provide documented evidence that weekly weights were obtained as required, and the resident had refused one weekly weight. A nutritional note documented significant weight loss and a BMI of 18.3, and physician orders for health shakes at meals were initiated only after surveyor inquiry. The facility did not demonstrate ongoing monitoring of the resident’s nutritional status and weight in accordance with its policies.
Failure to Provide Recommended Behavioral Health Follow-Up
Penalty
Summary
The facility failed to consistently provide necessary behavioral health services to meet the behavioral health needs of two residents. The facility’s Behavioral Health Services policy stated that residents should receive necessary behavioral health services to help them reach and maintain their highest level of mental and psychosocial functioning. Resident 8 was admitted with anxiety disorder, bipolar disorder, and major depressive disorder, and a June 2026 MDS showed the resident was cognitively intact with a BIMS score of 15. The care plan identified risk for mood changes related to major depressive disorder, anxiety, and adjustment disorder, with psychiatric consult and treatment as ordered. A psychiatric consultant recommended therapy services for anxiety and depression with follow-up in 45 to 60 days, and an LPC later documented a follow-up talk therapy session and recommended another follow-up, but there was no documented evidence that the resident received the recommended psychiatric or psychological follow-up services by the end of the survey. Resident 61 was admitted with anxiety disorder and depression, and a quarterly MDS showed moderately impaired cognition with a BIMS score of 9. The care plan identified risk for mood changes related to depression and episodes of anxiety, with psychological consultation and treatment and LPC consultation as needed. A psychiatric consultant recommended therapy services for anxiety, depression, insomnia, and dementia with follow-up in 14 to 21 days, and an LPC documented a follow-up talk therapy session and recommended another follow-up, but there was no documented evidence that the resident received the recommended psychiatric or psychological follow-up services by the end of the survey. During an interview, the DON confirmed that both residents did not receive the recommended follow-up psychiatric and psychological services.
Infection Control Tracking and Surveillance Deficiency
Penalty
Summary
The facility failed to maintain a comprehensive infection prevention and control program to monitor the development and spread of infections within the facility, including tracking infections for Residents 50, 122, and 140. Review of the Infection Prevention and Infection Control Plan showed the facility intended for the infection preventionist to provide ongoing, facility-wide outcome and process surveillance of healthcare-associated infections, including systematic collection, consolidation, analysis, and dissemination of infection data. However, review of the facility's infection control data during the survey ending June 30, 2026, found no documented evidence of a functional tracking system to monitor and investigate causes of infection or manner of spread, and no evidence that the facility could analyze clusters, changes in prevalent organisms, or increases in infection rates in a timely manner. Clinical record review showed Resident 140 tested positive for SARS-CoV-2 on December 19, 2025, Resident 50 tested positive on January 15, 2026, and Resident 122 tested positive on March 3, 2026. During interview, the infection preventionist was unable to provide documented evidence of facility tracking or analysis of healthcare-associated infections from November 1, 2025, through March 16, 2026, including tracking and monitoring of the three residents' SARS-CoV-2 infections. The infection preventionist and the nursing home administrator were also unable to provide documented evidence of healthcare-associated infection tracking, trending, or data analysis records for that period, and there was no documented evidence that the facility compiled or evaluated data to identify trends or implement specific interventions related to the infections.
Failure to Provide and Document Wheelchair Positioning Devices
Penalty
Summary
The facility failed to reasonably accommodate a resident’s assessed need for assistive positioning devices while seated in a wheelchair. Resident 12 was admitted with diagnoses including adult failure to thrive, bipolar disorder, and PTSD, and a quarterly MDS dated May 7, 2026 showed moderate cognitive impairment with a BIMS score of 9 and total staff assistance required for transfers. The resident was 55 inches tall. On June 28, 2026, the resident was observed seated in a high-back wheelchair with both legs and feet dangling 16-18 inches above the floor without support. Clinical records showed Occupational Therapy completed a wheelchair analysis on April 22, 2026 and documented that the resident was provided a new high-back wheelchair with bilateral leg rests and a foot/calf board to increase lower extremity support. However, the OT discharge summary did not identify the specific adaptive equipment and positioning devices needed to maintain the seated posture goal. A second observation on June 29, 2026 again showed the resident in the same wheelchair with both legs unsupported and dangling. The COTA confirmed the leg rests and foot/calf board were missing and not present in the room. The DOR stated OT had evaluated the resident’s seating and positioning needs and provided the wheelchair, leg rests, and foot/calf board because the resident’s feet could not reach the floor, but there was no documented evidence these devices were incorporated into the care plan, physician orders, or Kardex. The facility therefore failed to communicate and implement the resident’s assessed positioning needs across disciplines, and staff did not consistently provide the necessary equipment while the resident was out of bed.
Elopement Device Not Present and Medicated Cream Left at Bedside
Penalty
Summary
The facility failed to consistently implement planned elopement prevention interventions for a resident with anxiety disorder, depression, and moderately impaired cognition. The resident’s care plan identified the resident as an elopement and wander risk and included a Wander Guard bracelet on the left ankle, with a physician order requiring staff to verify placement and proper functioning every shift. Although the June 2026 TAR documented the device as being worn on the left ankle, direct observation on June 27, 2026 at 11:45 PM found no Wander Guard on the resident’s left ankle or any other extremity, and the LPN confirmed the device was absent and could not locate it in the room. The DON later reviewed the findings and confirmed the facility failed to consistently implement and monitor the planned elopement prevention intervention. The facility also failed to prevent unsecured medicated creams from being left at a resident’s bedside. A resident with cerebral infarction and hemiplegia/hemiparesis and severe cognitive impairment was observed with a clear plastic cup containing white paste and a disposable spoon on the nightstand next to the bed. A nurse aide stated the paste was a mixture of zinc oxide and A and D ointment kept at the bedside for use during incontinence care. The resident had no order for either cream, and the DON confirmed staff should not leave medicated cream at the bedside.
Oxygen Equipment Did Not Match Physician Order
Penalty
Summary
The facility failed to provide oxygen equipment in accordance with physician orders for a resident with respiratory failure and a tracheostomy. The resident’s quarterly MDS dated May 8, 2026, showed moderate cognitive impairment with a BIMS score of 12. Current physician orders required supplemental oxygen at 6 liters per minute, titrated to maintain oxygen saturations greater than 92% using a pulse oximeter. Observations on June 28, 2026, and June 29, 2026, showed the resident’s oxygen setup was not designed to allow titration because it required a fixed oxygen flow rate. Inspection of the device showed it was intended for an 8-liter-per-minute flow rate, but the facility had set it at 6 liters per minute, which did not match the appliance chosen. The physician was not contacted until after surveyor notification, and the Nursing Home Administrator stated the facility then contacted the physician and consulted with a respiratory therapist to modify the oxygen setup to correlate with the order and resident needs.
Failure to Monitor and Treat Severe Pain After Ankle Injury
Penalty
Summary
The facility failed to comprehensively monitor and implement appropriate interventions for a resident’s new onset and worsening pain in accordance with physician orders and facility policy. Resident 105 was admitted with acute respiratory failure and COPD, and her admission MDS showed she was cognitively intact with a BIMS score of 15. The facility’s pain policy stated that pain management should be provided consistent with professional standards, the care plan, and resident goals and preferences, and that pain should be reassessed at established intervals with revisions made if pain was not adequately controlled. On June 10, 2026, Resident 105 activated the call bell at about 4:30 AM and was observed halfway off the bed while trying to transfer to a wheelchair. She stated she struck her ankle on the wheelchair while attempting to go to the bathroom, could move the foot and ankle and wiggle her toes, and reported pain rated 10 out of 10. Staff applied ice, elevated the foot, and notified the nursing supervisor. At 5:40 AM, the resident reported continued pain radiating up the leg and requested acetaminophen. The MAR showed acetaminophen 650 mg was given for pain and documented as ineffective at 5:26 AM, and the pain level tab recorded pain ratings of 8 out of 10 at 4:30 AM, 10 out of 10 at 5:26 AM, and 10 out of 10 at 6:50 AM. A late-entry progress note at 9:00 AM documented left ankle pain with bruising, swelling, difficulty walking, and orders for an X-ray, therapy as needed, orthopedic follow-up as needed, acetaminophen, baclofen, and continued monitoring. The X-ray was performed at 4:51 PM and later reported an acute nondisplaced fracture of the left ankle/fibula. The resident remained in pain rated 8 out of 10 when transferred to the emergency department at 11:46 PM, and she stated during interview that she remained in severe pain until hospital transfer. The nursing supervisor stated she contacted the radiology provider around 11:00 PM to obtain the delayed X-ray results, then notified the on-call physician and initiated transfer after the fracture was confirmed. The NHA was unable to provide documented evidence of ongoing pain assessments or additional pain interventions between the injury and the transfer to the emergency department.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to ensure timely and necessary dental services for one Medicaid resident, Resident 13, out of 27 residents reviewed. The resident was admitted with diagnoses including dysphagia and hypertension, and a quarterly MDS dated April 5, 2026 showed the resident was cognitively intact with a BIMS score of 15. The facility’s Dental Services policy stated that it was the facility’s policy to assist residents in obtaining routine and emergency ancillary services as needed, including annual oral cavity inspection, diagnosis of dental disease, x-rays as needed, dental cleaning, and limited prosthodontic procedures such as impressions for dentures and fitting dentures. Resident 13 stated during interview that she had been waiting to receive dentures, had completed impressions a long time ago, had not received information about when the dentures would be available, and had not seen the dentist recently. The dental consult sheet showed the resident was seen on January 30, 2026 for a comprehensive exam, full mouth x-rays, and impressions and bite registration for complete upper and lower dentures. A later dental consult sheet dated March 30, 2026 indicated the resident was not seen because she was out of the facility in the hospital. The clinical record contained no further communication with the dentist regarding the dentures, and the resident had not been seen by the dentist since the impressions were obtained in January 2026.
Smoking Policy Not Consistently Enforced
Penalty
Summary
The facility failed to consistently implement and enforce its smoking policy for one resident who smoked. The policy stated that smoking was not allowed on the premises, that residents who were alert, oriented, and able to leave independently could smoke only off the property on an approved leave of absence, and that cigarettes, lighters, and other smoking materials were to be maintained by facility staff rather than kept by residents in their rooms or on their person. The resident involved had COPD, was cognitively intact with a BIMS score of 15, and had a physician order allowing independent leave of absence to smoke off the facility premises. The resident stated that after the physician order was issued and before he signed the leave-of-absence acknowledgment, he routinely kept cigarettes and a lighter on his person inside the facility and staff did not ask him to surrender them. He also stated he was able to leave to smoke without staff consistently enforcing the facility’s leave-of-absence hours. During observation, the resident showed a pack of cigarettes and a lighter stored beneath the seat of his walker, and stated that when he returned from a leave of absence the prior evening, no staff member was at the reception desk to receive his smoking materials, so he placed them on the desk with his name attached. The Nursing Home Administrator was unable to provide evidence that staff consistently collected smoking materials, prevented residents from retaining cigarettes or lighters inside the facility, or consistently enforced the leave-of-absence procedures.
Failure to Document and Use Non-Pharmacological Interventions Before PRN Antipsychotic Use
Penalty
Summary
The deficiency involves the facility’s failure to prevent the use of a chemical restraint and to ensure that non-pharmacological interventions were attempted and documented prior to administering a PRN psychotropic medication. Facility policy on psychotropic medication required that residents not receive such medications unless clinically indicated and necessary, with behavioral and other non-pharmacological approaches used first and documented as ineffective. The policy also required that psychotropic medications be used at the lowest possible dose and only after non-pharmacological interventions had been tried and found ineffective in relieving distressing or unsafe symptoms. The resident involved was admitted with Alzheimer’s disease and dementia and was assessed as moderately cognitively impaired, with a care plan identifying a high risk for elopement and interventions such as reorientation, frequent monitoring, structured and diversionary activities, and redirection away from exits. On admission, the resident had orders for divalproex, donepezil, and memantine, and shortly thereafter a PRN order for quetiapine every 12 hours for agitation was added. The clinical record showed multiple episodes of exit-seeking and agitation, including attempts to open the front door and a dining room window, searching for the resident’s husband, and attempts to pull a fire alarm. In some instances, documentation indicated that redirection or contacting the husband was effective in calming the resident. However, review of the MAR and progress notes showed that PRN quetiapine was administered on several occasions without adequate documentation of the behaviors requiring medication or of non-pharmacological interventions attempted beforehand. For one administration, there was no documentation of symptoms of agitation or any non-pharmacological measures prior to giving the medication. For two of four PRN administrations, the record lacked evidence that non-pharmacological interventions were attempted and found ineffective before quetiapine was given. The record also did not define the resident’s behavioral symptoms in observable, measurable terms to guide staff in determining when PRN quetiapine was clinically indicated, leaving staff without objective criteria for consistent and appropriate use of the antipsychotic. During interview, the DON was unable to provide documentation to show consistent use of non-pharmacological interventions or clearly defined behavioral parameters for PRN psychotropic use.
Failure to Notify Resident's Representative of Change in Condition and Treatment
Penalty
Summary
The facility failed to promptly notify a resident's designated representative and power of attorney of a significant change in the resident's condition and new treatment orders. According to the facility's policy, the resident, their attending physician, and representative must be notified within 24 hours of a significant change in the resident's medical or mental condition, unless otherwise instructed by the resident. A review of the clinical record for a resident with chronic obstructive pulmonary disease (COPD) and acute bronchitis showed that after the resident experienced increased coughing and hypoxia, new treatment orders were initiated, including supplemental oxygen, medication, and additional monitoring. Despite these changes, there was no documentation that the resident's responsible party or power of attorney was notified of the change in condition or the new treatment orders, as required by facility policy. Interviews confirmed that the resident wished for his daughter, who was his responsible party and POA, to be informed of changes to his care. The Nursing Home Administrator acknowledged that the facility could not provide evidence of such notification.
Failure to Administer Insulin per Physician Orders and Notify Physician When Withheld
Penalty
Summary
The facility failed to follow professional standards of practice for diabetes management for one resident. According to the clinical record, the resident had diagnoses including cerebral infarction and diabetes, and was assessed as having moderately impaired cognition. Physician orders specified that the resident was to receive insulin aspart 5 units subcutaneously four times daily. However, the Medication Administration Record (MAR) showed that multiple doses of insulin aspart were withheld on several occasions, with documented blood glucose levels ranging from 94 mg/dL to 118 mg/dL, and in one instance, no blood glucose was documented at all. There were no physician orders providing parameters for when insulin aspart could be held, and there was no documented evidence that the physician was notified when the insulin doses were withheld. Facility policy required that medications be administered according to physician orders and that the physician be contacted if there were concerns about the appropriateness of a medication or if it was withheld. The failure to administer insulin as ordered and to notify the physician of withheld doses constituted a deficiency in following professional standards and facility policy.
Failure to Maintain Bed Systems and Prevent Entrapment Hazards
Penalty
Summary
The facility failed to maintain an effective inspection and maintenance program for bed frames with bed extenders, resulting in unaddressed entrapment hazards in multiple resident rooms. Specifically, observations revealed that two residents were using bed frames with extenders that created significant gaps—ranging from approximately 4 to 6 inches—between the mattress and the footboard. In one instance, the gap was filled with wedges typically used for repositioning, rather than equipment designed to eliminate entrapment zones. Additional rooms were also found to have similar gaps when bed extenders were in use. Interviews with facility staff, including the physical therapy director, confirmed that the practice was to use repositioning wedges to fill these gaps when bed extenders were applied. This practice was acknowledged during the survey, and the information was reviewed with the Nursing Home Administrator. The deficiency was identified for two residents out of a sample of 29, as well as in three observed resident rooms, indicating a lack of consistent and appropriate maintenance procedures to minimize or eliminate entrapment hazards as required.
Failure to Provide Adequate Nutrition and Hydration
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide adequate food and fluids necessary to maintain a resident's health. The report notes that the required provision of nutrition and hydration was not met, which is essential for the well-being of residents. Specific details about the actions or inactions leading to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Missing Licensed Resident Beds on Two Care Units
Penalty
Summary
The facility failed to ensure the availability of a functioning bed for all current licensed and certified resident beds on two of three resident care units. During an environmental tour, surveyors observed that multiple resident rooms, which were licensed as double or triple occupancy, were missing beds for specific bed spaces (such as 104B, 106B, 113B, 116B, and 217B). These beds were not present in the rooms nor stored elsewhere in the facility, making them unavailable for immediate use. The facility is required to provide bedrooms that are appropriately furnished with a bed, mattress, and related equipment for each licensed bed in accordance with its license and certification. The absence of these beds demonstrated that the facility did not maintain the full complement of licensed and certified beds, as required. The findings were reviewed and confirmed with the Nursing Home Administrator.
Failure to Provide Call Bell Accommodation for Resident with Physical Limitations
Penalty
Summary
The facility failed to reasonably accommodate the needs of a resident with significant physical limitations by not providing an appropriate call bell system. The facility's policy requires that each resident be evaluated for unique needs and that any necessary special accommodations for the call system be identified and provided. In this case, a resident with hemiplegia, muscle wasting, and contractures in both hands was unable to use the standard push-button call bell due to these physical limitations. The resident expressed during an interview that he was unable to use the call bell and requested a touch-sensitive system. A Licensed Practical Nurse confirmed that the resident could not utilize the standard call light because of his hand contractures. It was only after the surveyor's inquiry that the facility provided a touch-sensitive call light device, which the resident was able to operate. The Nursing Home Administrator confirmed that the resident had not been provided with a compatible call system prior to the surveyor's involvement. This failure to provide a necessary accommodation was in direct violation of the facility's own policy and relevant regulatory requirements.
Inaccurate MDS Assessments for Weight Loss and Dialysis
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the clinical status of two residents. For one resident, the MDS assessment did not document a significant weight loss, despite clinical records showing a decrease from 123 pounds to 107 pounds within a month, which constitutes a 13% weight loss. The Registered Dietitian confirmed that this weight loss was not accurately recorded in Section K0300 of the MDS, resulting in an inaccurate assessment of the resident's nutritional status. For another resident with end-stage renal disease receiving maintenance hemodialysis, the MDS assessment failed to indicate that the resident was receiving dialysis treatments, even though clinical records showed dialysis was administered on multiple occasions. The Registered Nurse Assessment Coordinator confirmed that the omission in Section O0110 of the MDS was an error. These inaccuracies were identified through clinical record reviews and staff interviews, and they represent a failure to ensure that assessments accurately reflected the residents' conditions as required by regulatory standards.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through observations and record reviews that indicated lapses in the assessment, monitoring, and treatment of pressure ulcers for residents at risk. The report notes that necessary interventions to prevent skin breakdown were not consistently applied, and existing pressure ulcers were not managed according to established protocols.
Failure to Provide Ordered Restorative Nursing Services and Therapeutic Device
Penalty
Summary
The facility failed to provide restorative nursing services and a prescribed therapeutic device as ordered by the physician and recommended by rehabilitative therapy staff for one resident. The resident, who had a history of hemiplegia and hemiparesis following a stroke, was recommended to receive a restorative nursing program including bilateral lower extremity assisted active range of motion (AAROM) exercises and active range of motion (AROM) exercises for the left upper extremity. Additionally, the use of a left modified palm guard and specific positioning of the left upper extremity were ordered. These interventions were confirmed by physician orders and therapy discharge summaries. Despite these orders, the resident's plan of care did not incorporate the required restorative nursing needs. The resident reported not receiving restorative exercises since discharge from therapy and noted inconsistent application of the palm guard. Review of the clinical record revealed no documentation that the restorative nursing program or the application of the palm guard was provided as ordered. The Nursing Home Administrator was unable to provide evidence that these services were being delivered according to physician orders.
Failure to Document Controlled Medication Counts per Policy
Penalty
Summary
The facility failed to implement its procedures for accurate documentation of controlled medications on one of three medication carts reviewed. According to the facility's policy, nursing staff are required to count controlled medications at the end of each shift, with both the oncoming and off-going nurses completing the count together and signing the record to verify accuracy. The policy also requires that any discrepancies be reported to the Director of Nursing Services immediately. However, a review of controlled drug records for the first-floor, back medication cart revealed multiple instances where the required signatures were missing. Specifically, on several dates, either the oncoming or off-going nurses, or both, failed to sign the narcotic count sheets as required. These findings were confirmed through staff interviews and review with the Director of Nursing. The lapses in documentation were directly observed in the narcotic sheets, and staff acknowledged that the required signatures were not present on the specified dates. The facility did not consistently follow its established procedures to ensure accurate documentation of controlled substances, as required by its own policy and state regulations.
Expired Insulin Medications Found on Medication Cart
Penalty
Summary
Surveyors observed that the facility failed to follow its own policy and manufacturer guidelines regarding the storage and use-by dates for multi-dose insulin medications. During an inspection of a medication cart on the first floor, surveyors found a Humalog KwikPen, a Humalog Insulin vial, and a Basaglar KwikPen that had been opened beyond the manufacturer's recommended 28-day discard date. These medications were still available for resident use, despite being expired according to both facility policy and manufacturer instructions. A review of the facility's policy confirmed that discontinued, outdated, or deteriorated drugs should not be used and must be returned to the pharmacy or destroyed. Staff interviews, including with an LPN present during the observation, acknowledged that the insulin medications were past their use-by dates and should have been removed from the cart. The Director of Nursing also confirmed that the facility had not adhered to the required procedures for medication storage and use-by dates.
Failure to Ensure Safe and Appropriate Discharge Planning
Penalty
Summary
The facility failed to ensure that a resident's discharge was appropriate and necessary, as required by regulations. Clinical record review showed that a resident with acute kidney failure and unsteadiness, who had previously been hospitalized due to an inability to care for herself, was discharged home. The Minimum Data Set Assessment indicated the resident was cognitively intact, but there was documented evidence from the Area Agency on Aging that upon returning home, the resident had no food available except for ice cubes in the refrigerator/freezer. Social service notes indicated that discharge planning was discussed with the resident's family, but there was no documentation detailing how the family would assist the resident in obtaining food or other necessary services to support her transition home. Interviews with the Director of Social Services confirmed the lack of documented evidence that the resident would receive the required care and services to ensure a safe discharge. The facility did not demonstrate that the discharge was safe and appropriate, as required by state regulations.
Failure to Timely Notify Resident's Representative of Change in Condition
Penalty
Summary
The facility failed to promptly notify a resident's designated representative of a significant change in condition, specifically a positive COVID-19 test result. According to facility policy, the resident, their attending physician, and their representative must be notified of changes in the resident's medical or mental condition. The resident in question, who had Alzheimer's disease and hypertension and was assessed as having moderate cognitive impairment, reported feeling unwell and subsequently tested positive for COVID-19. Documentation confirmed that the resident and physician were informed of the positive result, but there was no evidence that the emergency contact was notified within the required timeframe. Further review of the clinical record and staff interviews revealed that the family was not updated about the resident's condition and positive COVID-19 test until two days after the diagnosis, and the emergency contact reported learning of the situation only through a conversation with the resident, not from facility staff. Both the President of Operations and the Infection Preventionist confirmed the lack of timely notification and documentation. This failure to notify the emergency contact as required by policy constituted a deficiency under the applicable nursing services regulations.
Failure to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide to resident ratios on five out of 21 reviewed shifts. Specifically, on December 17, 2024, the evening shift had 9.00 nurse aides instead of the required 9.36 for a census of 103, and the night shift had 6.00 nurse aides instead of the required 6.87. On December 21, 2024, the night shift had 5.00 nurse aides instead of the required 6.80 for a census of 102. On December 22, 2024, the day shift had 9.00 nurse aides instead of the required 10.20, and the night shift again had 5.00 nurse aides instead of the required 6.80. No additional higher-level staff were available to compensate for these deficiencies. The Nursing Home Administrator confirmed the facility's failure to meet the required staffing ratios during an interview on December 30, 2024.
Plan Of Correction
The facility cannot retroactively correct the deficiency. The Nursing Staffing Coordinator will be re-educated regarding the ratios for nurse aides. The facility will focus on retention of existing nurse aides and recruitment of new nurse aides through efforts of the facility Recruitment & Retention Committee. Calculation of the daily nurse aide ratios will be completed and reviewed for accuracy by the scheduler/designee. Daily ratios will be audited weekly x4 then monthly x2. The audits will be taken to QAPI for further action planning as needed. Facility will be in compliance 02/15/2025.
LPN Staffing Deficiency on Night Shifts
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratios on two specific night shifts. On December 19 and December 20, 2024, the facility provided only 2.00 LPNs for a census of 103 residents, whereas the regulation required 2.58 LPNs. This deficiency was identified through a review of the facility's weekly staffing records, which showed that the minimum staffing levels were not met. Additionally, there were no higher-level staff available to compensate for this shortfall. The Nursing Home Administrator confirmed the failure to meet the required LPN to resident ratios during an interview on December 30, 2024.
Plan Of Correction
The facility cannot retroactively correct the deficiency. The Nursing Staffing Coordinator will be re-educated regarding the ratios for LPNs. The facility will focus on retention of existing LPNs and recruitment of new LPNs through efforts of the facility Recruitment & Retention Committee. Calculation of the daily LPN ratios will be completed and reviewed for accuracy by the scheduler/designee. Daily ratios will be audited weekly x4 then monthly x2. The audits will be taken to QAPI for further action planning as needed. Facility will be in compliance 02/15/2025.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the state regulation requiring a minimum of 3.2 hours of direct resident care per resident in each 24-hour period. On December 21, 2024, the facility provided only 3.06 hours of direct care nursing per resident, and on December 22, 2024, the facility provided 2.91 hours per resident. This deficiency was confirmed during an interview with the Nursing Home Administrator on December 30, 2024, who acknowledged the facility's failure to consistently provide the required minimum general nursing care hours to each resident daily.
Plan Of Correction
The facility cannot retroactively correct the deficiency. The Nursing Staffing Coordinator will be re-educated regarding the new staffing hours of 3.2. The facility will focus on retention of existing staff and recruitment of new staff through efforts of the facility Recruitment & Retention Committee. Calculation of the daily staffing hours will be completed and reviewed for accuracy by the Nursing Staffing Coordinator/designee. Daily hours will be audited weekly x4 then monthly x2. The audits will be taken to QAPI for further action planning as needed. Facility will be in compliance by 02/15/2025.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain and implement a comprehensive infection prevention and control program, specifically regarding Enhanced Barrier Precautions (EBP) for residents with chronic wounds or indwelling medical devices. The deficiency was identified through a review of the facility's infection control tracking log, observations, and staff interviews. The facility did not adhere to the new guidance issued by CMS and the CDC, which requires the use of EBP during high-contact resident care activities to prevent the spread of multidrug-resistant organisms. Six residents were identified as requiring EBP due to their medical conditions, which included tube feeding, neurogenic bladder, stage 4 pressure ulcers, and indwelling urinary catheters. Despite these requirements, observations during the initial environmental tour revealed no evidence of EBP being implemented for these residents. The Director of Nursing confirmed that no EBP measures were in place for any resident at the time of the survey, despite the residents meeting the criteria for such precautions.
Lack of Designated Infection Preventionist
Penalty
Summary
The facility was found to be non-compliant with the Centers for Medicare and Medicaid Services regulation S483.80(b)(3), which requires the designation of one or more individuals as the Infection Preventionist (IP) responsible for the facility's Infection Prevention and Control Program. The regulation mandates that the IP must work at least part-time at the facility, be physically present onsite, and cannot be an off-site consultant or perform the IP work at a separate location. During interviews with the Nursing Home Administrator (NHA) and Director of Nursing (DON), it was revealed that the previous IP left the role in early April 2024, and as of the survey's conclusion on October 25, 2024, no new IP had started in the position. The DON confirmed that the facility currently had no staff credentialed as infection preventionists.
Failure to Implement Employee Screening Procedures
Penalty
Summary
The facility failed to fully develop and implement established abuse prohibition procedures for screening prospective employees, as required by regulatory standards. Specifically, the facility's Resident Abuse policy, last reviewed on January 24, 2024, did not include procedures for obtaining references from current or previous employers. This omission was identified during a review of the facility's abuse prohibition policy, employee personnel files, and staff interviews. The review revealed that five employees (a Nurse Aide, an LPN, an Activities staff member, another Nurse Aide, and an RN) were hired without the facility contacting their previous employers for references. The employees' applications indicated prior employment, yet there was no evidence in their personnel files that the facility had obtained information from former employers. This deficiency was confirmed during an interview with the Nursing Home Administrator, who verified the lack of evidence for contacting previous employers.
Medication Administration Hazard
Penalty
Summary
The facility failed to maintain an environment free of potential accident hazards during medication administration on the first floor nursing unit. An observation revealed that medications were left unattended on an overbed table in a resident's room. The medications included a clear plastic cup with crushed medications in a liquid, a second cup with a red liquid, and a large cup filled with a pink liquid. The resident, identified as Resident 83, confirmed that the nurse left the medications on the table and stated that she would eventually administer them herself. Further investigation revealed that Resident 83 was scheduled to receive multiple medications via a feeding tube at 8:30 AM. However, there was no evidence in the resident's physician orders that she was to self-administer her medications. An interview with an LPN confirmed that the medications were left unattended at the bedside, and the Director of Nursing verified that Resident 83 was not authorized to administer her own medications. This oversight created a potential accident hazard, as the medications could have been accidentally consumed by another resident.
Failure to Maintain Sanitary Catheter Supplies
Penalty
Summary
The facility failed to provide necessary care and services to prevent potential urinary tract infections for a resident with an indwelling urinary catheter. The resident, who was admitted with a diagnosis of urine retention, required the use of an indwelling catheter. A physician's order dated October 4, 2024, prescribed Acetic Acid irrigation solution to be used daily, but the order did not specify what was to be flushed or the amount to be administered. This lack of clarity in the physician's order contributed to improper catheter care. Observations on October 22, 2024, revealed unsanitary storage and handling of catheter irrigation supplies in the resident's room. Two opened irrigation kits with piston syringes and two opened, undated bottles of Acetic Acid were found behind the resident's television. The containers, which are single-dose, had significant amounts remaining, indicating improper use and storage. Manufacturer instructions specify that opened containers should be used promptly to prevent bacterial growth, and any unused portion should be discarded. An LPN confirmed the unsanitary condition of the supplies, and the DON, along with the NHA, acknowledged the facility's failure to maintain sanitary conditions for the resident's catheter supplies.
Failure to Follow Oxygen Therapy Orders and Equipment Maintenance
Penalty
Summary
The facility failed to adhere to physician orders for oxygen therapy and did not maintain oxygen equipment in a functional and sanitary manner for three residents. Resident 28, who has chronic obstructive pulmonary disease (COPD) and chronic respiratory failure, was observed with undated oxygen tubing and a dusty oxygen concentrator filter. Additionally, the resident's nebulizer equipment was improperly stored, uncovered, and undated. Resident 61, also diagnosed with COPD and chronic respiratory failure, was found with undated oxygen tubing and a dusty concentrator filter. An LPN confirmed these observations, indicating non-compliance with the facility's policy. Resident 52, dependent on supplemental oxygen, was receiving oxygen at a higher flow rate than prescribed, with undated tubing and a dusty concentrator filter. An LPN confirmed the discrepancy in oxygen administration and the condition of the equipment. The Nursing Home Administrator acknowledged the facility's failure to follow physician orders and maintain the oxygen delivery equipment according to policy, as required by state regulations.
Failure to Implement Controlled Drug Accounting Procedures
Penalty
Summary
The facility failed to implement pharmacy procedures for accounting for controlled drugs on one of its medication carts, specifically the First Floor Back cart. According to the facility's policy on Controlled Substances, nursing staff are required to count controlled medications at the end of each shift, with both the incoming and outgoing nurses conducting the count together. They must document and report any discrepancies to the Director of Nursing Services. However, a review of the Change of Shift Controlled Substances Count Sheet revealed that the required signatures of the nurses arriving and departing were missing on several occasions, indicating that the controlled drugs were not properly counted and reconciled. Observations on October 24, 2024, showed that the narcotic logbook was not with the medication cart as required, but instead was found on the desk at the nurse's station while the assigned nurse was passing morning medications. Further investigation revealed that on specific dates, the shift-to-shift sign-off was not completed, including on October 9, 17, and 23, 2024. The Director of Nursing confirmed these findings and acknowledged that the facility failed to implement procedures for accurately accounting for controlled drugs at the beginning and end of each shift.
Failure to Act on Pharmacist's Recommendations
Penalty
Summary
The facility failed to ensure that the attending physician acted upon the pharmacist's reports of irregularities in the drug regimens of four residents. For Resident 28, the consultant pharmacist recommended that the physician identify the duration of Lovenox therapy and consider therapy modification due to potential interactions with NSAIDs. However, there was no documentation of the physician's response to these recommendations, nor acknowledgment of the pharmacy report. Similarly, for Resident 10, the facility documentation indicated that a medication regimen review was conducted, but the facility was unable to provide the Clinical Pharmacy Report or documentation of the physician's response to the pharmacist's recommendations. This lack of documentation was also observed for Residents 73 and 36, where the facility failed to provide evidence of the physician's acknowledgment or response to the pharmacist's recommendations following medication regimen reviews. An interview with the Director of Nursing confirmed the facility's inability to provide documented evidence that the attending physician acted upon the pharmacy recommendations. This deficiency was identified under the regulations 28 Pa. Code 211.2 (d)(3)(9) Medical director, 28 Pa Code 211.5 (f)(vii) Medical records, and 28 Pa. Code 211.9 (k) Pharmacy services.
Failure to Document Clinical Rationale for PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary psychoactive drugs by not providing clinical rationale for the continued use of as-needed psychotropic medication for two residents. Resident 44, diagnosed with Bipolar Disorder, had a physician's order for lorazepam to be administered as needed for anxiety, starting in September 2023, with no specified end date. The medication was administered four times in October 2024, but the physician did not document the clinical rationale for its continued use or the need for an extended duration without re-evaluation. Similarly, Resident 20, with diagnoses of anxiety and depression, had a physician's order for lorazepam as needed, also without an end date. The medication was last administered in December 2023, and despite pharmacy recommendations in January 2024 for a stop date or gradual dose reduction, the physician did not document the clinical rationale for its continued use. The Director of Nursing confirmed the lack of physician documentation for the use of the prn medication beyond 14 days.
Improper Labeling and Storage of Insulin Pens
Penalty
Summary
The facility failed to adhere to proper labeling and storage protocols for multi-dose medications, specifically insulin pens, on two of the six medication carts observed. During an inspection of the first-floor medication cart, it was found that several insulin pens, including Basaglar, Lispro, and Humulin 70/30, were opened and available for use without being dated when opened or marked with an expiration/beyond use date. Additionally, a Fiasp insulin pen was observed to be labeled as opened on September 19, 2024, but had not been discarded after the recommended 28 days as per manufacturer instructions. Employee 9, an LPN, confirmed these deficiencies during the observation. On the second-floor medication cart, two Lispro insulin pens were also found to be opened and available for use without being dated when opened or marked with an expiration/beyond use date. Furthermore, one of these pens was not properly labeled with resident identification. The Director of Nursing confirmed that the facility failed to correctly label and date multi-dose medications when opened, which is necessary to ensure acceptable storage times and adherence to expiration dates.
Failure to Provide Dental Services to Residents with Medicaid
Penalty
Summary
The facility failed to provide necessary dental services to two residents with Medicaid as their payor source. Resident 52, who was admitted to the facility, was not offered routine annual dental services within the past year, as confirmed by the Director of Nursing. Additionally, Resident 86, who was experiencing mouth pain, had a physician's order dated August 1, 2024, for a dental consult. However, the facility did not provide timely assistance to obtain the required dental services for this resident, as there was no documented evidence of a dental consult being conducted by the time of the survey ending October 25, 2024. These deficiencies were identified through a review of clinical records, payor source data, and staff interviews, highlighting the facility's failure to comply with the necessary nursing services regulations as per 28 Pa. Code 211.12 (c)(d)(3)(5).
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for six months, from April 2024 to September 2024, as required by their infection control policies. The facility's policy, last reviewed in January 2024, mandates that antibiotics be prescribed and administered under the guidance of an antibiotic stewardship program to monitor their use among residents. However, a review of the facility's infection control surveillance records from September 2023 to September 2024 revealed a lack of documentation indicating that antibiotic monitoring was conducted during the specified six-month period. During an interview on October 25, 2024, the Director of Nursing confirmed the absence of a system for surveillance to monitor antibiotic use and laboratory correlation for infections during this time. The Director was unable to provide tracking records for the months in question, further confirming the facility's failure to adhere to its antibiotic stewardship program.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for Resident 42, who was admitted with a diagnosis of unspecified dementia. On October 22, 2024, at approximately 12:20 p.m., Resident 42 was observed in the dining room on the third floor nursing unit. Her lunch tray was placed in front of her at approximately 12:22 p.m., but she was not assisted with her meal until approximately 12:47 p.m., a delay of about 25 minutes. Resident 42 required assistance with feeding and was unable to feed herself, which was not provided in a timely manner. An interview with the Nursing Home Administrator confirmed that Resident 42 should have been served and assisted with her lunch meal within the same time frame as other residents on the third floor unit. The administrator acknowledged that the facility failed to conduct the lunch meal service in a manner that promotes each resident's dignity, as required by resident rights regulations.
Inaccurate MDS Assessment for Resident Discharge
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) Assessments accurately reflected the status of a resident. Specifically, for one resident, the MDS Assessment incorrectly indicated that the resident was discharged to an acute care hospital, while the clinical records and staff interviews confirmed that the resident was discharged home. The resident's clinical record included a physician's order for discharge to home, and a nurse's note documented the resident's discharge home via facility transport, noting the resident's ability to walk independently and that all discharge procedures were completed. The Nursing Home Administrator confirmed the discrepancy in the MDS Assessment regarding the discharge location.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement person-centered comprehensive care plans for three residents, leading to deficiencies in meeting their medical and treatment needs. Resident 86, who had a pacemaker implanted, did not have this critical medical device included in their care plan, despite having a remote monitoring device in their room and a physician's order for a cardiologist check. Similarly, Resident 28, who required the use of a SmartVest for cough assistance due to chronic respiratory conditions, did not have the use and care of this device reflected in their care plan, even though there was a physician's order for its application. Resident 13, diagnosed with dementia and known to hoard food, had a room with a strong odor and visible food items hidden, yet their care plan only addressed hoarding of personal belongings and did not include interventions for food hoarding. The Director of Nursing confirmed the facility's failure to ensure comprehensive care plans were developed to meet the residents' needs, as required by regulations.
Failure to Update Resident Care Plan for Elopement Risk
Penalty
Summary
The facility failed to ensure that a resident's comprehensive care plan was reviewed and revised to accurately reflect the resident's current needs and services. Resident 22, who was admitted with diagnoses including congestive heart failure, stroke, and anxiety, was assessed as a low wander risk with a score of 1 on the Elopement/Wander Risk Evaluation. Despite being cognitively intact with a BIMS score of 15 and having no presence of wandering during the 7-day lookback period, the resident's care plan still included interventions for potential elopement and associated injury related to exit-seeking behavior, which had not been updated since November 1, 2023. The care plan for Resident 22 included interventions such as door alarms, encouraging group activities, and notifying social services for persistent exit-seeking behavior. However, there was no documented evidence that the care plan had been reviewed or revised to reflect the resident's current status, particularly after a physician's order allowed the resident to go out on pass by himself via the bus. The Director of Nursing confirmed that the facility did not update the care plan to reflect the resident's current needs, leading to the deficiency noted in the report.
Failure to Administer Medication as Prescribed
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of quality by not administering medications as prescribed to a resident. The resident, who was admitted with diagnoses including congestive heart failure, stroke, and anxiety, had a physician's order for Midodrine HCL 10mg to be administered three times a day for essential hypotension, with instructions to hold the medication if the systolic blood pressure (SBP) exceeded 120 mm/Hg. However, a review of the resident's Medication Administration Record for September 2024 revealed multiple instances where the medication was administered despite the resident's SBP being greater than 120 mm/Hg. The Director of Nursing confirmed that the nursing staff failed to adhere to the physician's order by not holding the medication when the resident's SBP was above the specified threshold. This oversight was identified through a review of clinical records and staff interviews, highlighting a deficiency in the facility's nursing services and documentation practices as per the Pennsylvania Code and the American Nurses Association Principles for Nursing Documentation.
Failure to Monitor and Address Resident's Nutritional Needs
Penalty
Summary
The facility failed to adequately monitor and address the nutritional needs of a resident who experienced significant weight loss. The facility's policy required that any weight change of 5 pounds or more be retaken for confirmation, and if verified, the physician and dietician should be notified. However, the facility did not adhere to this policy for a resident diagnosed with dementia, who showed a weight loss from 125.0 lbs on July 1, 2024, to 114.0 lbs by September 10, 2024, indicating a 6.6% weight loss in 30 days. The dietician requested a reweight after a 5-pound loss was noted between August 2 and September 4, 2024, but the facility delayed the reweighing by six days. Additionally, the dietician recommended adding nutritious shakes twice a day and requested weekly weights to prevent further weight loss. Despite these recommendations, the facility failed to complete the weekly weights as requested. There was no evidence that the facility had timely acted upon the resident's weight loss or developed and implemented nutritional support measures to maintain acceptable nutritional parameters and deter further weight loss. The Director of Nursing confirmed the facility's failure to timely identify, address, and implement weight loss interventions.
Failure to Provide Emergency Supplies for Dialysis Resident
Penalty
Summary
The facility failed to ensure the ready availability of necessary emergency supplies for a resident receiving hemodialysis. Resident 85, who was admitted with end-stage renal disease and dependent on renal hemodialysis, did not have emergency care supplies available in their room or on their wheelchair. The resident's care plan, last revised in August 2024, included monitoring the dialysis catheter site for signs of infection, swelling, bleeding, and pain but did not include planned interventions for emergency supplies related to the dialysis access site. Observations conducted in October 2024 confirmed the absence of emergency supplies in the resident's room and on their wheelchair. Interviews with the resident, an LPN, and the Director of Nursing corroborated the lack of emergency supplies at the bedside, as well as the omission of necessary interventions in the care plan for the dialysis access site in case of an emergency. This deficiency was noted under the 28 Pa. Code 211.12 (d)(3)(5) Nursing Services.
Failure to Provide Behavioral Health Care
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident diagnosed with schizoaffective disorder. The resident, admitted with symptoms such as agitation, restlessness, crying, and yelling, was observed to be restless and agitated without any behavioral interventions being implemented. Despite these ongoing behaviors, the resident's care plan, initiated in January 2024, did not address these specific behavioral problems or symptoms, as noted in the nursing documentation. The last psychological evaluation for the resident was conducted in August 2024, which recommended continued behavioral health services due to intermittent behaviors that were not easily redirectable. However, nursing progress notes from August to October 2024 indicated continued and increased behaviors, yet the facility did not update the care plan to address the resident's mental health needs. Furthermore, the facility failed to provide evidence of continued psychological services to maintain the resident's highest practicable mental and psychosocial well-being, as confirmed by the Nursing Home Administrator during an interview.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near East Stroudsburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Whitestone Care Center | 3.7 mi | ★★★★★ | 11 | 0 |
| Clover Rest Home | 6.2 mi | ★★★★★ | 0 | 0 |
| Stroudsburg Post Acute Nursing & Rehabilitationllc | 6.6 mi | ★★★★★ | 22 | 0 |
| Slate Belt Health & Rehabilitation Center | 8.3 mi | ★★★★★ | 6 | 0 |
| Forest Manor Hcc | 13.7 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.