Below average — CMS composite of the measures below.
The next survey window likely opens around March 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 Sayre Health Care Center during CMS and state inspections, most recent first.
Side rail entrapment assessments were incomplete for four residents. The facility’s policy addressed gaps between the mattress and side rails, but did not identify the space between the rail ends and the headboard/footboard as a potential entrapment area. For residents with bilateral side rails or a grab bar and a headboard, the assessments marked zone 6 as N/A even though the bed systems had measurable gaps between the rail ends and the headboard.
Medication Error Rate Exceeded Allowed Threshold: Surveyors found a 7.41% medication error rate, with two errors in 27 medication opportunities. An LPN administered sucralfate and bethanechol to two residents while they were eating breakfast, even though both medications were labeled to be given on an empty stomach, and the LPN stated she was not aware of the special instructions.
Food Storage and Kitchen Sanitation Deficiencies: The main kitchen had multiple sanitation issues, including dust on clean dish shelving, brown stains on the oven, food debris under the oven and stove, and black buildup in floor grout. Clean dishes were stored on an open wire rack with the lowest shelf 10 inches from the floor and no solid barrier below it. The dishwasher area, walk-in freezer and refrigerator, and ice machine area also had wet floors, brown and white buildup, food debris, and items stored underneath equipment.
Inaccurate MDS assessments failed to reflect the clinical status of three residents. One resident was coded as receiving an antibiotic when the record and RN interview showed he was not. Another resident, a bilateral amputee with gait and mobility issues, was not accurately coded for ROM impairment despite needing substantial to maximal help with toileting, standing, and transfers. A third resident was coded with a wound infection, but the chart showed skin impairments without evidence of a wound infection.
Failure to Follow Ordered Fluid Restriction: A resident with acute kidney failure and chronic combined systolic and diastolic HF had a physician-ordered 1200 cc fluid restriction, but EHR fluid intake records showed repeated daily totals above the limit. There was no documentation that the resident refused the restriction or that the physician was notified when the ordered fluid limit was exceeded.
Failure to Implement Fall Prevention Interventions: A resident assessed as high fall risk fell after being found on the floor in front of a wheelchair without an alarm. The resident required staff assistance for transfers and ambulation, and the record showed the resident was in a different wheelchair than assigned at the time of the fall, despite existing fall-prevention interventions such as a chair alarm and use of assistive devices.
Respiratory Care Not Consistently Documented or Provided for a Resident Using BiPAP/CPAP: A resident with obstructive sleep apnea and a history of oxygen therapy had a care plan referencing BiPAP use at bedtime, but the chart contained no current order for BiPAP, CPAP, or related equipment. Surveyors observed the BiPAP/CPAP device on the dresser and not in use, while the resident could not confirm use in the facility. An LPN said the device was used overnight, but the DON later stated the resident did not use it and it remained on the care plan.
Failure to develop a trauma-informed care plan for a resident with PTSD. The resident reported severe past trauma involving male perpetrators and stated she could not accept personal care from male caregivers, but the care plan did not reflect those events or preferences. The plan also lacked outside psych resources, male-caregiver restrictions for personal care, and documented non-medicinal PTSD interventions, while psych notes referenced Sertraline and Clonazepam without documenting triggers or trauma history.
The facility failed to ensure accurate acquiring and administration of a resident’s ordered potassium chloride ER 20 MEQ for low potassium. The MAR showed repeated missed doses because the medication was awaiting pharmacy, not available in Cubex, or not in the pack, and provider notification forms documented missed doses while waiting for pharmacy supply. An RN stated staff had pulled the available potassium chloride from Cubex and pharmacy was notified.
A consultant pharmacist’s MRR identified duplicate PRN Tylenol orders for a resident, but the report did not clearly show that the irregularity was sent to the physician, and the physician did not respond in a timely manner. Additional MRRs also lacked clear physician reporting, including a note to separate two eye drops by several minutes and a recommendation to formally assess psychotropic orders, with no separate report to the MD documented.
A resident with heart failure, anemia, vitamin D deficiency, and GI hemorrhage was identified as nutritionally at risk, and the care plan called for weights per MD order. Dietary notes and a provider response indicated weekly weights were needed, but the EHR did not show weekly weights completed, and a separate weekly weights sheet for multiple residents was not part of the clinical record and had not been transcribed into the resident’s chart.
The facility failed to provide complete transfer/discharge notices for three residents who were sent to the hospital. One resident’s notice omitted required appeal-rights details and listed the wrong Ombudsman contact, while two other residents’ records did not show that the resident and/or RP received the written transfer notice and bed-hold information as required. Both of those notices also lacked the required appeal-rights statement and correct State LTC Ombudsman information.
The facility failed to maintain posted daily nurse staffing data for the required 18-month period. Review of the staffing binder showed multiple missing postings across several months, including missing day and shift entries, and the NHA and DON confirmed the facility could not produce documentation showing the postings were maintained for 18 months.
A resident with dementia was transferred to another facility due to behavioral issues and unmet needs, but the required physician documentation detailing the necessity of the transfer, unmet needs, attempts to address those needs, and services at the receiving facility was not present in the clinical record.
A resident with a history of elopement attempts, falls, and behavioral issues was transferred to another SNF after the facility determined it could not meet their needs. The facility did not provide the required written notice of transfer to the responsible party prior to discharge, omitting information on the reason for discharge, effective date, discharge location, appeal rights, and Ombudsman contact details.
The facility was found non-compliant with NFPA 101 standards as a door in the Dietary Dry storage area was held open by a rubber wedge, affecting one of eight smoke compartments. This was confirmed during an exit interview with the Facility Administrator and Maintenance.
The facility did not comply with NFPA 101 standards as the Dietary Dry storage door was held open, blocking the manual pull station for the ansul system. This issue was confirmed during an interview with the Facility Administrator and Maintenance.
The facility failed to maintain automatic sprinkler systems, with dust-loaded sprinkler heads found in three locations affecting three of eight smoke compartments. Observations revealed dust on sprinkler heads near resident rooms in the 200, 300, and 400 Hall corridors. This was confirmed during an exit interview with the Facility Administrator and Facility Maintenance.
The facility failed to maintain smoke barrier doors between 300 Hall and 500 Hall, affecting two smoke compartments. The doors required adjustment to latch properly into the frame, as observed and confirmed by facility staff.
The facility did not maintain monthly inspections for a fire extinguisher in the Mechanical Room on 300 Hall, as required by NFPA 10. The last inspection was conducted during the annual maintenance in November 2024. This was confirmed during an exit interview with the Facility Administrator and Facility Maintenance.
The facility failed to properly cool beef rounds according to HACCP guidelines, leading to potential foodborne illness risks. The beef rounds were not cooled to a safe temperature before being served to residents. Additionally, the Unit 1 Nursing pantry had unsanitary conditions and expired food supplements available for use.
A facility failed to honor a resident's advance directive choices by not updating the resident's code status from full code to DNR in a timely manner. Despite the responsible party completing and the physician signing the necessary forms on February 27, 2025, the change was not documented until March 6, 2025.
A facility failed to provide a CMS-10055 form to a resident after Medicare payment ended, leaving the resident uninformed about potential liability for non-covered care. The resident remained in the facility without receiving the necessary notification, as confirmed by a review of records and an interview with the Nursing Home Administrator.
The facility failed to maintain a clean and homelike environment in Nursing Unit 2, with issues such as stained walls in a resident's room, cigarette butts in a non-smoking area, marred drywall, and peeling furniture. These deficiencies were observed and confirmed with the NHA.
The facility failed to conduct an FBI background check for a newly hired cook who had not lived in the state for more than two years, as required by their abuse prohibition policy. Despite this oversight, the employee had been providing services and had access to residents. Interviews with HR and the Nursing Home Administrator confirmed the lapse in completing the background check within the required timeframe.
The facility failed to implement comprehensive care plans for two residents, leading to inadequate care. One resident experienced agitation during a shower due to staff not following care plan interventions, while another resident lacked a care plan for their pacemaker and anticoagulation therapy. These deficiencies were identified through clinical record reviews and staff interviews.
A resident discharged to home with home health services had an incomplete discharge summary that failed to document a Stage 3 Pressure Ulcer and related treatment. The summary inaccurately noted no wound care, despite previous records indicating otherwise. This deficiency was identified through a closed clinical record review and staff interview.
The facility failed to implement restorative nursing programs for two residents following their discharge from skilled therapy services. One resident did not start the recommended exercises until over a month after discharge, while another had no evidence of an active program until questioned by a surveyor. This resulted in a lack of necessary care to maintain or improve their abilities in activities of daily living.
The facility failed to follow physician orders for two residents. One resident was not given prescribed artificial tears for dry eye syndrome, and another resident's daily weights were not consistently documented as ordered. These deficiencies were confirmed by the Nursing Home Administrator.
A facility failed to timely implement wound care recommendations for a resident with a sacral pressure ulcer. Despite wound care service recommendations, the care plan and physician orders were initiated after the resident's discharge, and there was no evidence of treatment completion. The facility lacked documentation of staff awareness or implementation of the recommendations.
The facility failed to provide appropriate respiratory care for two residents. One resident's oxygen concentrator was set incorrectly, and their nebulizer equipment was not bagged or changed as required. Another resident's nebulizer equipment was also not bagged or changed, despite available supplies. These deficiencies were confirmed through observations and resident interviews.
A facility failed to provide appropriate behavioral health interventions for a resident with known behavioral symptoms, leading to a deficiency. The resident, who exhibited behaviors such as false accusations, was not provided with a care plan that included necessary interventions like having two staff present during care. During a shower incident, the resident became agitated and falsely accused staff of harm, highlighting the facility's failure to implement existing care plan instructions to manage agitation.
The facility failed to securely store medications and ensure proper labeling, leading to deficiencies. An LPN crushed a Rosuvastatin tablet for a resident, despite resources indicating it should be swallowed whole, due to a lack of precautionary instructions on the label. Additionally, a pill was found on the floor in a common area, indicating a lapse in medication storage protocols.
A resident with dental concerns did not receive timely dental services, despite experiencing dental pain and infection. The facility delayed obtaining consent for dental services and failed to provide professional dental care for nearly a year, leading to a deficiency.
A facility failed to implement enhanced barrier precautions for a resident with a tunneled dialysis catheter, as required by their infection prevention and control program. Despite having a medical device that necessitates such precautions, there was no evidence of EBP being used, such as signs, PPE, or instructions for staff. The Nursing Home Administrator confirmed the oversight, which was contrary to the facility's policy and previously cited in an earlier survey.
The facility did not follow its procedures for rotating emergency water supplies, resulting in expired water being stored in essential areas. Observations revealed that multiple boxes of water on Nursing Unit 1 and in the main kitchen were past their best by dates, with no evidence of regular rotation as per policy. Staff interviews indicated a lack of clarity on managing expired supplies.
The facility did not meet the required minimum staffing levels for nurse aides across multiple shifts, failing to ensure the mandated nurse aide-to-resident ratios. Specific instances of insufficient staffing were noted during various periods, indicating a consistent failure to comply with regulations.
The facility failed to meet the required LPN staffing levels across multiple shifts, as evidenced by a review of nursing staffing hours. The facility did not ensure a minimum of one LPN per 25 residents on eight of 21 day shifts, one LPN per 30 residents on eight of 21 evening shifts, and one LPN per 40 residents on three of 21 overnight shifts. This deficiency was identified during specific periods, including October 2024, December 2024, and February 2025.
The facility did not meet the required 3.2 hours of direct nursing care per resident per day for eight days, with hours ranging from 2.74 to 3.19. This deficiency was confirmed through a review of staffing hours and an interview with the Nursing Home Administrator.
The facility failed to provide timely Notice of Medicare Non-Coverage (NOMNC) to two residents, as required by Medicare regulations. The notices were not delivered at least two calendar days before the end of Medicare-covered services, impacting the residents' ability to appeal the termination of services.
The facility failed to maintain a safe environment in the beauty shop, leaving it unattended with hazardous items and high water temperature. The beautician was unaware of the need to secure the area when not present.
The facility failed to maintain food service equipment in a sanitary manner and proper working order. Observations revealed thick dust buildup on the hood system and a dishwasher running at insufficient temperatures without a sanitizing agent. The issue persisted despite being logged and reported.
The facility failed to implement enhanced barrier precautions for three residents with indwelling devices and did not ensure hygienically clean laundry processing. Staff were unaware of the need for these precautions, and the facility lacked mechanisms to monitor laundry water temperatures and chemical sanitization.
The facility failed to provide adequate care for a resident with a PICC line, including the absence of a comprehensive care plan, emergency procedures, and documentation of required treatments and medications. Interviews and observations confirmed these deficiencies.
The facility failed to identify and care plan triggers for a resident with Chronic PTSD. The resident disclosed that loud noises and bright lights were triggers due to his combat experience, but these were not documented in the care plan. This deficiency was confirmed by the Nursing Home Administrator and DON.
The facility failed to develop and implement an individualized person-centered care plan for a resident diagnosed with dementia. Despite the admission MDS indicating the need for such a plan, a review of the resident's current care plan showed no indication that it had been created or implemented. This deficiency was confirmed during an interview with the Administrator and DON.
The facility failed to ensure that the consultant pharmacist reviewed the drug regimen of each resident and reported any irregularities to the attending physician monthly. For one resident, there was a delay and lack of evidence in reporting medication irregularities, and for another resident, there was no monthly review completed for a specific month. These findings were confirmed by the Nursing Home Administrator and the Director of Nursing.
The facility's medication error rate was 7.69 percent due to an LPN not following proper procedures for insulin administration for two residents. The LPN did not verify the correct attachment of the safety pen needle or ensure the presence of liquid before administering insulin.
The facility failed to ensure a resident received a COVID-19 vaccine despite signed consents and conflicting documentation about vaccine refusal. Staff interviews confirmed the absence of proper documentation and adherence to the facility's vaccination policy.
A facility failed to accurately assess the entrapment risk for a resident with dementia using a specialized mattress and side rails. The mattress was observed to shift, creating a gap, but the assessment inaccurately indicated it fit securely. The occupational therapist confirmed the mattress was not secured and the assessment was based on typical equipment without physical measurement.
Side rail entrapment assessments failed to address zone 6 gaps
Penalty
Summary
The facility failed to assess potential entrapment risks from the use of side rails for four residents reviewed for accident hazards. The report states that the facility policy on side rails, last reviewed without changes on June 3, 2025, required assessment of the space between the mattress and side rails to reduce entrapment risk, but it did not identify the space between the side rails and a headboard or footboard as a potential entrapment area. The FDA Hospital Bed System Dimensional and Assessment Guidance was cited as identifying seven zones of potential entrapment, including zone 6, the space between the end of the rail and the side edge of the headboard or footboard. For Resident 5, observation showed a bed with bilateral side rails at the head of the bed, a headboard, and a footboard. The resident’s Side Rail Entrapment Assessment dated January 2, 2026, documented zone 6 as N/A. The assessment asked whether an angle at the end of the rail and side of the headboard was greater than 60 degrees, but it did not question whether the gap between the end of the rail and the side edge of the headboard or footboard presented an entrapment risk. During follow-up observation with the surveyor, Employee 1 measured the gap between the end of the side rail and the headboard at approximately two inches. For Resident 42, observation showed bilateral side rails at the head of the bed with a headboard and footboard, and the Side Rail Entrapment Assessment completed by Employee 1 on February 2, 2026, also assessed zone 6 as not applicable. For Resident 6, the bed had bilateral side rails at the head of the bed and a headboard, and the assessment completed on March 13, 2026, marked zone 6 as not applicable. For Resident 70, the bed had a grab bar on the resident’s left side while in bed and a headboard, and the assessment completed on March 12, 2026, marked zone 6 as not applicable. The surveyor reviewed these findings with the DON and NHA, who were informed that the bed systems created a gap between the end of each rail and the headboard, and that zone 6 should have been assessed as having no entrapment risks rather than being marked not applicable.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to ensure a medication error rate of less than five percent. Based on clinical record review, observation, and resident and staff interview, surveyors determined the medication error rate was 7.41 percent, with two medication errors identified out of 27 medication opportunities involving Residents 10 and 59. During observation of a medication administration pass, an LPN administered Sucralfate 1 gm to Resident 59 while the resident had a breakfast tray in front of them and had already eaten half of a pancake, even though the medication packaging instructed that it be given on an empty stomach. Later in the same observation, the LPN administered Bethanechol 25 mg to Resident 10 while the resident had a breakfast tray in front of them and had already eaten all of their breakfast, despite the packaging instruction to administer it on an empty stomach. The LPN stated during interview that she was not aware of the special instruction packaging instructions for the medications for Residents 59 and 10.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to store food and maintain food service equipment and the kitchen environment in accordance with professional standards in the main kitchen. During observation of the kitchen, a small silver metal open rack shelving unit storing clean bowls, cups, and other assorted dishes next to the tray line had a buildup of dust between the metal wires. The two-door oven had brown stains on the bottom and on the glass doors, and a large amount of food debris was observed on the floor under the oven and stove, with black buildup in the tile grout in the corner by the oven. A large metal open wire rack storage shelving unit holding clean dishes had its lowest shelf 10 inches from the floor with no solid barrier between the shelf and the floor. The dishwasher room floor under the equipment appeared wet and dark brown, and a white pipe running under the unit was coated in a brown substance where it ran along the floor. Two coffee mugs were in the corner under the dishwashing machine. In the adjoining walk-in freezer and refrigerator, food debris was observed under the shelving units, a dark brown liquid was noted at the freezer threshold and into the refrigerator, and black buildup was present in the tile grout in the refrigerator corners. The floor under the ice machine had a white buildup with a cup underneath, and the floor edges near the wall by the ice machine had a large amount of brown buildup in the grout.
Inaccurate MDS Assessments for Antibiotic Use, Range of Motion, and Wound Infection
Penalty
Summary
The facility failed to ensure that MDS assessments accurately reflected residents’ clinical status for three residents. For one resident, a quarterly MDS dated January 9, 2026, indicated that he was taking an antibiotic, but the clinical record showed no evidence that he was on an antibiotic during the assessment period. A registered nurse confirmed that this entry was made in error, and the Nursing Home Administrator was informed of the finding during the survey process. For another resident, who was a bilateral leg amputee with diagnoses including abnormalities of gait and mobility and reduced mobility, annual and quarterly MDS assessments did not accurately capture his range of motion impairments. One assessment indicated no upper or lower extremity range of motion impairment, and another indicated impairment on only one side, despite his amputations and documented need for substantial to maximal assistance with toileting, standing, and transfers. For a third resident, a quarterly MDS assessed him as having a wound infection, but review of skin and wound notes and nursing documentation did not support a wound infection at the time of the assessment; the record instead showed skin impairments and later documentation of an antibiotic for a urinary tract infection. The Nursing Home Administrator confirmed that the wound infection coding was an error.
Failure to Follow Ordered Fluid Restriction
Penalty
Summary
The facility failed to provide the highest practical care related to a physician-ordered 1200 cc fluid restriction for a resident with a medical history that included acute kidney failure and chronic combined systolic and diastolic heart failure. The resident’s current physician orders included the fluid restriction with 120 cc allowed during morning medication pass and 120 cc during bedtime medication pass, and the care plan also identified a 1200 ml fluid restriction along with altered cardiovascular status, chest pain related to the medical history, and increased nutritional risk. Review of the resident’s fluid intake documentation for the prior 30 days showed multiple days when intake exceeded the ordered restriction, including documented totals of 1460 ml, 1600 ml, 1780 ml, 1260 ml, 1650 ml, 1700 ml, 2520 ml, 1500 ml, 1320 ml, 1420 ml, 2380 ml, 1320 ml, 1560 ml, 1760 ml, 1250 ml, 1240 ml, and 1540 ml. There was no documentation that the resident refused to follow the fluid restriction, and there was no documentation that the physician was made aware that the ordered fluid restriction had been exceeded on those dates. The Nursing Home Administrator confirmed that no further documentation was found showing refusal or physician notification.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement all fall prevention interventions for a resident identified as high risk for falls. Clinical record review showed the resident had a fall risk score of 14 on a Fall Report, and the care plan included interventions such as a chair alarm and encouraging the resident to use handrails or assistive devices properly. The annual MDS indicated the resident required supervision or touching assistance for sitting up from lying, standing from sitting, transferring, and walking 10 to 150 feet, and that the resident used a walker rather than a wheelchair. On the day of the fall, nursing documentation stated the RN heard the resident yelling for help and found her lying on her left side in front of her wheelchair in front of a room on the 700 hallway, while the resident lived on the 600 hallway. The record noted the resident was assisted from the floor into a wheelchair with two staff members. The facility’s investigation found the resident was in a different wheelchair without an alarm, and the care plan was later revised to include ensuring the resident was always seated in her assigned wheelchair and that the chair alarm was in place and activated.
Respiratory Care Not Consistently Documented or Provided for a Resident Using BiPAP/CPAP
Penalty
Summary
Safe and appropriate respiratory care was not provided for a resident with obstructive sleep apnea and a history of oxygen therapy. The resident’s care plan included BiPAP cleaning per facility policy and BiPAP use at bedtime with ordered settings, but the current physician orders reviewed contained no order for BiPAP, CPAP, or related respiratory equipment. Medical provider documentation noted a history of obstructive sleep apnea and stated that staff were to assist with BiPAP at bedtime. During observation, the resident’s BiPAP/CPAP device was found on the dresser next to the bed and not in use. On a later observation, the resident was in bed and the device remained on the dresser and unused; the resident stated she used the device at home but could not say whether she used it in the facility. An LPN stated the resident used the device overnight, while a concurrent observation confirmed the device was set up as a BiPAP and/or CPAP with a mask in a plastic bag and distilled water nearby. The DON later stated the resident did not use the device and that it had not been removed from the care plan. The facility provided no further documentation on the device.
Failure to Develop Trauma-Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to develop a trauma-informed plan of care for one resident with behavioral-emotional concerns and a documented PTSD diagnosis. The resident’s quarterly MDS dated September 4, 2025 identified PTSD, and the diagnosis had been on the facility’s diagnosis list since November 25, 2024. During interview on April 2, 2026, the resident described past trauma including rape by five men as a girl, abuse by her father, and being beaten by her husband. She stated that these traumatic events involved male relationships and that she could not accept personal hygiene, bathing, or toileting assistance from a male caregiver. The resident’s plan of care, initiated November 28, 2024, noted PTSD as caused by recent events and did not reference the traumatic events reported by the resident. The plan also did not include outside psychological resources, restriction of male caregivers for personal care, or medications to treat PTSD symptoms. Consulting psychological provider documentation noted Sertraline and Clonazepam were for PTSD, but did not document the traumatic events, potential triggers, or non-medicinal interventions to prevent triggers. Later psychological progress notes no longer listed PTSD, although the medications remained on the medication list. The DON and NHA were informed during interview that the resident’s plan of care and outside psychological treatment did not address her reported trauma and care preferences.
Medication Not Available for Ordered Potassium Chloride
Penalty
Summary
The facility failed to ensure the accurate acquiring and administration of medications for one resident who had an order dated December 26, 2025, for potassium chloride ER 20 MEQ, one tablet by mouth twice daily for low potassium. Review of the MAR showed the potassium was not documented as administered as ordered, and staff repeatedly recorded that the medication was on order, awaiting pharmacy, unable to be pulled from pharmacy, not available in Cubex, or not in the pack on multiple dates in January 2026. Facility documentation showed several Provider Notification Forms for the resident documenting missed doses of potassium chloride while awaiting pharmacy delivery or refill, including missed doses on January 12-13, January 15-16, and January 18-19, 2026. The physician responses on each form stated it was okay to administer when received from pharmacy. During interview, an RN stated that staff had pulled out the available potassium chloride from Cubex and pharmacy was notified of this.
Failure to Report Pharmacist MRR Irregularities and Obtain Timely Physician Response
Penalty
Summary
The facility failed to ensure the consultant pharmacist’s monthly medication regimen review (MRR) irregularities were reported to the attending physician and that the physician responded in a timely manner for one resident reviewed, Resident 5. The facility policy required the pharmacist to report irregularities to the attending physician, medical director, and DON, with written reports submitted within 72 hours. For the May 15, 2025 MRR, the pharmacist documented that the review was complete and referenced a nursing/physician report for irregularities, but the documentation did not specify whether the potential irregularity was reported to the nurse, the physician, or both. Facility staff later stated there was no consultant report available for the physician regarding this recommendation. The pharmacist identified that Resident 5 had multiple orders for the same PRN indication, including duplicate Tylenol Extra Strength orders with the same dose, frequency, and PRN indicator, and questioned whether one order could be discontinued. Although Resident 5 had physician visits on May 26, June 11, and June 19, 2025, the physician did not respond to the pharmacist’s recommendation until July 3, 2025, when one PRN Tylenol order was discontinued. Similar documentation issues were noted for the June 17 and September 16, 2025 MRRs, where the pharmacist again referenced nursing/physician reports without specifying who received them, and the facility did not have a report to the physician for those reviews. The September 2025 review also included a note to nursing to separate administration of two eye drops by three to five minutes and a recommendation for formal assessment of escitalopram and mirtazapine orders, but no separate report to the physician was provided.
Incomplete Weight Documentation in Resident Record
Penalty
Summary
The facility failed to ensure complete and accurate clinical documentation for one resident whose record showed a diagnosis history including heart failure, iron deficiency anemia, vitamin D deficiency, and gastrointestinal hemorrhage. The resident’s care plan identified nutritional risk due to medical history, fluctuating weights, and variable intakes, and included an intervention to weigh the resident per physician order for close monitoring. However, the current physician orders did not include a weight assessment order matching the care plan intervention. Dietary documentation noted a reweight with significant weight gain and stated that weekly weights were needed for close monitoring, and a provider notification form documented that the dietitian recommended weekly weights with the medical provider responding, "Ok!". Review of the electronic health record showed weights documented on only a few dates, with no evidence that weekly weights were completed as documented in the dietary note and provider response. After the issue was brought to facility staff’s attention, staff produced a separate weekly weights sheet listing the resident and multiple other residents; this sheet was not part of the clinical record, and the weights were to be transcribed into the resident’s record but were not, per the DON.
Incomplete transfer notices and missing appeal-rights information
Penalty
Summary
The facility failed to ensure that Discharge/Transfer Notices for three residents who were transferred to the hospital included all required information. For Resident 2, nursing documentation showed the RN assessed pain and arranged EMS transport to the hospital, and the resident’s daughter later reported that the resident had a hip fracture and was admitted. The written notice for Resident 2 did not include the required statement of appeal rights, including the name, mailing and email address, and telephone number of the entity receiving appeal requests, nor did it include information on how to obtain an appeal form, assistance completing it, or submitting the hearing request. The notice also incorrectly listed local county Ombudsman information instead of the Office of the State Long-Term Care Ombudsman. For Resident 6, the resident was sent to the hospital for a change in condition and returned later the same day, but there was no evidence that staff provided the alert and oriented resident with a copy of the written transfer notice and bed-hold information as soon as practicable after the transfer; the record only showed the information was sent to the responsible party. For Resident 10, the resident was sent to the hospital for a change in condition and admitted, but there was no evidence that the resident’s responsible party received a copy of the written transfer notice and bed-hold information as soon as practicable after the transfer; the record only showed the notice was signed by the resident. For Residents 6 and 10, the facility could not provide documentation that both the resident and the resident’s representative(s) were notified of the transfers, and both notices also lacked the required appeal-rights statement and correctly identified State Long-Term Care Ombudsman contact information.
Failure to Maintain Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to maintain posted daily nurse staffing data for a minimum of 18 months for three of three months reviewed, specifically January, February, and March 2026. A review of the facility binder containing daily nurse staffing postings showed missing postings for multiple dates and shifts in January, February, and March 2026, including several full days and specific second and third shifts. During an interview on April 2, 2026, at 10:45 AM, the Nursing Home Administrator and the DON confirmed that the facility could not produce documentation to verify that 18 months of postings were maintained.
Lack of Physician Documentation for Facility-Initiated Transfer
Penalty
Summary
The facility failed to ensure that the necessary resident information was documented by the physician to facilitate a facility-initiated transfer of a resident with dementia. The resident was admitted with a diagnosis of dementia and was later discharged to another skilled nursing facility because the facility determined it could not meet the resident's needs. Documentation from the Director of Nursing indicated that the resident exhibited behaviors such as attempting to elope, pulling fire alarms, threatening to let other residents out, inappropriate touching, entering other residents' rooms and taking items, and frequent falls despite interventions. Meetings were held with the resident's responsible party and the interdisciplinary team to discuss the need for transfer, and arrangements were made with the receiving facility, which had a secured unit. However, there was no evidence in the resident's clinical record of physician documentation prior to discharge that specified the necessity of the transfer for the resident's welfare, the specific needs that could not be met, the facility's attempts to meet those needs, or the services available at the receiving facility to address those needs. This lack of required physician documentation was confirmed during a telephone interview with the Nursing Home Administrator and Director of Nursing.
Failure to Provide Required Written Notice Prior to Facility-Initiated Discharge
Penalty
Summary
A facility-initiated discharge occurred for a resident who had a history of multiple elopement attempts, falls, wandering into other resident rooms, inappropriate touching of staff and other residents, removing clothing in common areas, and a sexual incident with another resident. The facility determined it could not meet the resident's needs and planned a transfer to another skilled nursing facility, with meetings held with the resident's responsible party to discuss these behaviors and the recommendation for transfer. Despite knowing about the planned transfer four days in advance, the facility failed to provide the resident's responsible party with a written notice of transfer prior to discharge. There was no documentation that the required notice, which should have included the reason for discharge, effective date, discharge location, information on appeal rights, and contact information for the State Long-Term Care Ombudsman, was given as mandated by regulations.
Non-compliance with Self-Closing Door Requirements
Penalty
Summary
The facility failed to maintain compliance with NFPA 101 standards regarding doors with self-closing devices. During an observation on March 19, 2025, at 10:48 a.m., it was noted that the door to the Dietary Dry storage area was being held open by an unapproved means, specifically a rubber wedge. This deficiency affected one of the eight smoke compartments within the facility. The issue was confirmed during an exit interview with the Facility Administrator and Facility Maintenance on the same day at 11:45 a.m.
Plan Of Correction
The Maintenance Director promptly took out the rubber wedge and closed the door to the dry food storage room. The facility Administrator educated both the Maintenance Director and the Food Service Director that, in accordance with life safety regulations, this door must never be propped open. To ensure compliance, the Maintenance Director will conduct weekly audits for a duration of four weeks, followed by monthly audits for three months, to verify that the dry food storage room door remains closed. The findings from these audits will be presented at the monthly Quality Assurance meeting for evaluation.
Obstruction of Ansul System Pull Station in Dietary Area
Penalty
Summary
The facility failed to protect cooking facilities in accordance with NFPA 101 standards. During an observation on March 19, 2025, it was noted that the door to the Dietary Dry storage area was held open, which obstructed access to the manual pull station for the ansul system. This deficiency was confirmed during an exit interview with the Facility Administrator and Facility Maintenance on the same day.
Plan Of Correction
- The Maintenance Director closed the door to the dry food storage area to ensure the ansul system was unobstructed without delay. - Both the Maintenance Director and the Food Services Director received training on the importance of keeping the ansul system clear in accordance with life safety regulations and compliance standards. - The Maintenance Director will conduct weekly audits for a duration of four weeks, followed by monthly audits for an additional three months, to verify that the ansul system remains unblocked. These audit results will be presented at the QA meeting for evaluation.
Failure to Maintain Sprinkler Systems
Penalty
Summary
The facility failed to maintain automatic sprinkler systems in three locations, affecting three of eight smoke compartments. During an observation on March 19, 2025, between 10:58 a.m. and 11:25 a.m., it was found that several sprinkler heads were loaded with dust. Specifically, the sprinkler head in the 200 Hall corridor near Resident Room 201 was observed at 10:58 a.m., the sprinkler head in the 300 Hall corridor near Resident Room 303 was observed at 11:02 a.m., and the sprinkler head in the 400 Hall corridor near Resident Room 407 was observed at 11:25 a.m. An exit interview with the Facility Administrator and Facility Maintenance confirmed the presence of dust on the sprinkler heads.
Plan Of Correction
- The Maintenance Director has cleaned the dust from the sprinkler heads situated in the 200 hallway by resident room 201, the 300 hallway by resident room 303, and the 400 hallway by resident room 407. - The facility Administrator provided training to both the Maintenance Director and the Environmental Services Director on the importance of keeping these sprinkler heads dust-free at all times. - The Maintenance Director will conduct weekly audits for a duration of four weeks, followed by monthly audits for four months, and will present the findings at the monthly Quality Assurance meeting for evaluation.
Failure to Maintain Smoke Barrier Doors
Penalty
Summary
The facility failed to maintain one set of smoke barrier doors, which affected two of the eight smoke compartments. During an observation on March 19, 2025, at 11:05 a.m., it was noted that the smoke barrier doors leading from 300 Hall into 500 Hall required adjustment to positively latch into the corresponding frame, specifically the left leaf of the doors. This deficiency was confirmed during an exit interview with the Facility Administrator and Facility Maintenance on the same day at 11:45 a.m., where it was acknowledged that the doors failed to latch into the frame.
Plan Of Correction
The Maintenance Director promptly modified the fire barrier door situated between the 300 and 500 areas to guarantee it latches correctly. The Maintenance Director received education from the facility administrator regarding the inspection of all smoke barrier doors to confirm their proper latching. The Maintenance Director will conduct weekly random audits of the smoke barrier doors for a duration of four weeks, followed by monthly audits for three months, and will present the findings at the monthly Quality Assurance meeting for evaluation.
Failure to Maintain Monthly Fire Extinguisher Inspections
Penalty
Summary
The facility failed to maintain portable fire extinguishers as required by NFPA 10, Standard for Portable Fire Extinguishers. During an observation on March 19, 2025, at 11:22 a.m., it was noted that the fire extinguisher located in the Mechanical Room on 300 Hall had not undergone monthly inspections since its last annual maintenance in November 2024. This deficiency was confirmed during an exit interview with the Facility Administrator and Facility Maintenance on the same day at 11:45 a.m.
Plan Of Correction
The Maintenance Director conducted an inspection of the fire extinguisher situated in the mechanical room along the 300 hallway. The Facility Administrator provided guidance to the Maintenance Director regarding the necessity of verifying that each fire extinguisher is inspected and documented on a monthly basis. The Maintenance Director is responsible for performing monthly audits and presenting the findings at the Quality Assurance meeting monthly for four months.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, and serve food in a manner that prevents the potential spread of foodborne illness. During an observation and review of the facility's cool down logs, it was found that the staff did not properly cool down four beef rounds according to the Hazard Analysis and Critical Control Points (HACCP) guidelines. The beef rounds were cooked and initiated for cooling, but the temperatures recorded did not meet the required cooling standards. The beef rounds did not reach the safe holding temperature of 40 degrees Fahrenheit within the specified time frame, and there was no documentation indicating further temperature checks. Despite this, the beef rounds were served to residents as roast beef. Additionally, an observation of the Unit 1 Nursing pantry revealed unsanitary conditions, including a microwave with dried, stuck-on food and expired food supplements available for resident use. The pantry contained 12 cartons of vanilla Glucerna with a use-by date that had already passed. These findings were confirmed through interviews and observations with the certified dietary manager and were reviewed with the Nursing Home Administrator.
Plan Of Correction
1. No residents were harmed. 2. The dietary manager reviewed temp logs, immediately had housekeeping thoroughly clean the microwave and removed the expired Glucerna from the cabinet. 3. The Dietary Manager educated dietary staff on the importance of food temps, thoroughly cleaning the microwaves and discarding expired food/drinks. 4. The Dietary Manager or designee will audit these areas of concern. These audits will be completed weekly for four weeks then monthly for four and brought to the monthly QA meeting for review.
Failure to Honor Advance Directive Choices
Penalty
Summary
The facility failed to honor the advance directive choices for a resident, identified as Resident 175. The clinical record review revealed that on August 1, 2024, the resident's responsible party indicated that the resident was a full code, meaning staff was to start CPR if necessary. However, on February 27, 2025, the responsible party completed a POLST form and a facility code status form, both indicating a Do Not Resuscitate (DNR) status for the resident. These forms were also signed by the physician on the same day, February 27, 2025. Despite the completion and signing of the DNR forms, there was no documentation that the facility changed Resident 175's code status order from full code to DNR until March 6, 2025. This oversight was identified during an interview with the Nursing Home Administrator on March 6, 2025, at 3:39 PM. The failure to update the resident's code status in a timely manner represents a deficiency in the facility's compliance with the requirements for honoring advance directives.
Plan Of Correction
1. All residents were unharmed, including Resident 175. Resident 175 Advanced Directive was reconciled and corrected immediately. 2. The Facility Administrator and the Interdisciplinary Team promptly assessed all existing residents to verify that their advanced directive and code status were accurate, up-to-date, and readily available to staff in the event of an occurrence. 3. All staff members received training on how to find the code status in the event of an occurrence. Additionally, all nurses were instructed and educated on the significance of updating residents upon their return from the hospital to ensure that the advance directives are accurate and up-to-date in case of an incident. 4. The Director of Nursing or designee will conduct weekly audits for a duration of four weeks, followed by monthly audits for three months. Physician Orders, Care Plan and spine of hard chart will be reviewed to verify accuracy and currency of each residents advance directive. The findings will be presented at the monthly Quality Assurance meeting for review.
Failure to Provide Required Payment Coverage Notification
Penalty
Summary
The facility failed to provide the required notification to a resident whose payment coverage changed. Specifically, for one of the three residents reviewed, identified as Resident 2, the facility did not issue the necessary CMS-10055 form after Medicare payment for the resident's care ended. The clinical record review indicated that Medicare payment for Resident 2's care ended on July 26, 2024, yet the resident remained in the facility without receiving the appropriate notification of potential liability for the non-covered stay. The review of the CMS-10123 form confirmed that the last covered day of Medicare payment was July 26, 2024, but there was no evidence that the CMS-10055 form was provided to Resident 2. An interview with the Nursing Home Administrator confirmed the absence of this documentation, indicating a lapse in the facility's compliance with the notification requirements for changes in payment coverage.
Plan Of Correction
1. No residents were harmed. Resident 2 expired so the facility was unable to provide the notice to the resident. 2. The social services department evaluated the accuracy of residents requiring a CMS-10055 form to verify that they had been notified timely regarding the termination of their Medicare coverage. 3. The facility administrator educated the social services department about the necessity of promptly notifying residents when their Medicare coverage has concluded, emphasizing that the resident must sign a CMS-10055 form as part of this notification process. 4. The facility administrator or designee will conduct weekly audits for a duration of four weeks, followed by monthly audits for three months. This process aims to confirm that residents are informed about the Medicare cut-off date and are signing the CMS-10055 form. The results of these audits will be presented at the monthly Quality Assurance meeting for evaluation.
Deficiencies in Maintaining a Homelike Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment on one of its nursing units, specifically Nursing Unit 2. Observations revealed several deficiencies, including a six-foot section of wall in a resident's room with a large, black linear stain and marring. Additionally, the egress area leading to the laundry building was littered with partially smoked cigarette butts, despite the facility being non-smoking. These observations were confirmed during a meeting with the Nursing Home Administrator. Further observations on Nursing Unit 2 included marred and gouged drywall near the bathrooms of two residents, as well as significantly peeling fake leather on love seats in the lounge area. The dining room walls near the hallway and courtyard door were also gouged at both foot and table height. These findings were discussed with the Nursing Home Administrator, highlighting the facility's failure to maintain a safe, clean, and homelike environment as required by regulations.
Plan Of Correction
1. No residents were harmed. Resident 24's room under the window was repaired and painted. The noted cigarette butts by the egress leading to the laundry facility were immediately cleaned up by the housekeeping staff. Resident 50's bathroom wall was patched and painted. Resident 54's bathroom was patched and painted. The furniture in the Unit 2 lounge was immediately disposed of and replenished with a love seat and chairs collected throughout the facility. The Unit 2 dining room was also patched and painted. 2. The Facility Administrator, Maintenance Supervisor, and Housekeeping Supervisor conducted a visual inspection of the facility and its grounds to pinpoint any areas requiring repair or furniture that might need to be replaced. 3. The Facility Administrator educated the Maintenance and Housekeeping departments to maintain a consistently safe, comfortable, and clean environment for the residents at all times. Maintenance and the Housekeeping Supervisor will complete weekly rounds of the facility and present any noted issues or repairs in the morning meeting. 4. The Facility Administrator and/or designee will conduct random audits on a weekly basis for a duration of four weeks, followed by monthly audits for three months. This process aims to ensure that all residents are provided with a clean and comfortable environment. All completed audits will be presented at the monthly Quality Assurance meeting for evaluation.
Failure to Conduct Required FBI Background Check for New Employee
Penalty
Summary
The facility failed to develop and implement an abuse prohibition policy that required a thorough investigation of prospective employees' employment history. Specifically, the facility did not conduct an FBI background check for Employee 7, a cook, who had not lived in the state where the facility is located for more than two consecutive years. This oversight was identified during a review of Employee 7's personnel record, which showed that the employee was hired 129 days prior to the review without the necessary FBI background check being completed. Interviews with Employee 8 from human resources and the Nursing Home Administrator confirmed that the facility did not complete the FBI background check within the required 90 days of employment. Despite this, Employee 7 had been providing services and had access to residents since being hired. This failure to adhere to the facility's policy on background checks represents a deficiency in ensuring the safety and protection of residents from potential abuse, neglect, or exploitation.
Plan Of Correction
1. No residents were harmed. Employee 7, who served as a dietary cook, was promptly removed from the schedule and will not be permitted to return until fingerprints are collected for the personnel record. 2. The human resources department conducted an audit of employee files to verify that all "out of state" employees had successfully undergone FBI fingerprint background checks. 3. The facility administrator educated the HR department of the essential requirements to ensure that "out of state" employees are completing the required fingerprint background checks. The HR Director will complete a new hire checklist sheet to ensure all FBI/fingerprint background checks are completed within 90 days of hire. 4. The Facility Administrator or designee will conduct weekly audits for a duration of four weeks, followed by monthly audits for an additional three months, to verify that fingerprint background checks are being performed on "out of state" new hires in a timely manner. All audit findings will be presented at the monthly Quality Assurance meeting for evaluation.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for two residents, leading to deficiencies in their care. Resident 44 experienced an incident during a shower where staff did not follow the care plan interventions for her known behavior of making false accusations. Despite being agitated and expressing discomfort, the staff continued with the shower instead of stopping and reapproaching later, as outlined in her care plan. The care plan also lacked an intervention for two staff to provide care due to her behavior, which contributed to the incident. Resident 5, who has an implanted pacemaker, did not have a care plan addressing the care or precautions related to the pacemaker or its associated transmitting device. The resident's medical records lacked information about the device, and staff were not adequately informed about its operation or troubleshooting. Additionally, there was no care plan related to the resident's anticoagulation therapy with Eliquis, nor was there evidence of monitoring for side effects such as bleeding, which was only addressed after surveyor questioning. These deficiencies were identified through clinical record reviews and interviews with residents and staff. The facility's failure to develop and implement appropriate care plans for these residents resulted in inadequate care and monitoring, as evidenced by the surveyor's findings and subsequent discussions with the Nursing Home Administrator and other staff members.
Plan Of Correction
1. No residents were harmed. Employee 3 and 6 were educated to reapproach residents when they show signs of agitation. Resident 44 care plan was updated to reflect her plan of care. Resident 5 care plan was updated and reviewed to reflect the plan of care. 2. The Director of Nursing reviewed residents care plans to ensure they reflect their current plan of care. 3. The Director of Nursing provided education to the RNAC and nursing staff regarding the significance of revising care plans to align with the individualized needs of the residents. All updated care plans or resident information will be found on PCC in the Kardex section of the EMR. 4. The Director of Nursing or designee will perform care plan audits weekly for a period of four weeks, subsequently transitioning to monthly audits for three months. The results will be reported at the monthly Quality Assurance meeting for assessment.
Incomplete Discharge Summary for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to provide a comprehensive discharge summary for a resident, identified as Resident CR1, who was discharged to home with home health services. The discharge summary, dated January 6, 2025, lacked critical information about the resident's medical condition during their stay, specifically omitting details about a Stage 3 Pressure Ulcer on the sacrum. The documentation inaccurately stated that there was no wound care or treatment, despite previous records indicating the presence of a significant wound requiring attention. This deficiency was identified through a closed clinical record review and staff interview, revealing that the discharge summary did not include a full recapitulation of the resident's stay, including diagnoses, course of illness, treatment, therapy, and pertinent consultation results. The omission of this vital information was discussed with the Nursing Home Administrator on March 7, 2025, highlighting the facility's failure to meet the regulatory requirements for discharge summaries.
Plan Of Correction
1. Resident CR1 was not harmed. 2. The Director of Nursing reviewed discharged residents for the last two months to ensure necessary components were documented on the discharge summaries. 3. The Director of Nursing educated the RN supervisors of the importance of including all essential elements on the discharge summary, specifically emphasizing the need to document any wound care treatments provided during their care at the facility. 4. The Director of Nursing will audit discharge summaries weekly for four weeks, then monthly for three months to ensure essential elements, specifically any wound treatments are indicated on the discharge summary.
Failure to Implement Restorative Nursing Programs
Penalty
Summary
The facility failed to provide necessary care and services to maintain or improve the ability to perform activities of daily living for two residents. Resident 5 was discharged from therapy on January 27, 2025, with recommendations for a restorative nursing program (RNP) that included sit-to-stands at grab bars. However, the RNP was not initiated until March 3, 2025, due to it being "missed," as confirmed by the Director of Therapy. This delay in implementing the RNP meant that Resident 5 was not receiving the recommended exercises to maintain her abilities during this period. Similarly, Resident 44 was discharged from skilled therapy services with a recommendation to continue with a restorative nursing program for ambulation, which included walking up to 100 feet with a roller walker and contact guard assistance. However, there was no evidence of an active RNP in her clinical record until March 5, 2025, after the surveyor's inquiry. The facility did not initiate the RNP for Resident 44's ambulation skills following the termination of skilled therapy services, as confirmed by the Nursing Home Administrator.
Plan Of Correction
1. Resident 5 and 44 were unharmed. Resident 5 is currently completing an RNP program. Resident 44 is currently completing an RNP program. 2. The Therapy Director completed an audit on any residents discharged from therapy services to indicate if they needed or had an RNP program in place. 3. The Therapy Director conducted an education with the therapy staff to ensure that the RNP is implemented upon the patient's discharge from therapy services, if necessary. 4. The Therapy Director or designee will conduct weekly audits for a duration of four weeks, followed by monthly audits for three months, to verify the implementation of the RNP for the resident, if required. The Therapy Director will bring the audit to the monthly QA meeting for review.
Failure to Implement Physician Orders for Two Residents
Penalty
Summary
The facility failed to implement physician orders for two residents, leading to deficiencies in their care. For Resident 52, the facility's consultant optometrist diagnosed significant dry eye syndrome and prescribed artificial tears to be administered twice daily. However, the clinical records showed no evidence that the staff implemented this treatment plan. This was confirmed during an interview with the Nursing Home Administrator, indicating a lapse in following the prescribed care plan for Resident 52. Similarly, for Resident 21, there were physician orders to obtain and document daily weights. The review of Resident 21's weight documentation revealed multiple instances where the staff failed to record the resident's weight on specified dates in January, February, and March 2025. This lack of documentation was also confirmed during an interview with the Nursing Home Administrator, highlighting a failure to adhere to the physician's orders for monitoring Resident 21's weight.
Plan Of Correction
1. Resident 52 was not harmed and physician orders were updated to reflect plan of care. Resident 21 was not harmed and was reviewed. 2. The Director of Nursing reviewed residents physician orders to ensure accuracy. 3. The Director of Nursing educated nursing staff on the importance of issuing physician order in the residents' charts and to follow physician orders for the plan of care for each resident's needs. 4. The Director of Nursing or designee will complete weekly audits for four weeks then monthly for three months to ensure compliance that the physicians orders are being entered and completed for each residents needs. The Director of Nursing will bring audits to the monthly QA meeting for review.
Failure to Timely Implement Wound Care Recommendations
Penalty
Summary
The facility failed to provide recommended interventions consistent with professional standards of practice to promote the healing of a pressure ulcer for a resident. The resident was admitted with a skin tear on the sacrum, which was documented by nursing staff. However, subsequent medical provider documentation did not mention the skin tear, and a comprehensive skin assessment later identified a Stage 3 pressure injury. Despite recommendations from a wound care service to treat the pressure ulcer, the facility did not initiate these treatments in a timely manner. The care plan for the resident, which included interventions for skin integrity and the pressure ulcer, was not initiated until after the resident was discharged. Additionally, physician orders for the treatment of the sacral pressure ulcer were dated after the resident's discharge, and there was no evidence in the medication/treatment administration record that the recommended treatments were completed. The facility could not provide documentation that staff were aware of or had implemented the wound care recommendations before the resident's discharge.
Plan Of Correction
1. Resident CR1 was discharged and was unharmed. 2. The Director of Nursing reviewed any current residents who have pressure ulcers to ensure proper treatments are in place and physician orders are being followed for proper wound care treatment. 3. The Director of Nursing provided education to the nursing staff regarding the significance of implementing appropriate wound care treatments and documentation tailored to each resident's needs and ensuring adherence to the established treatment plan. 4. The Director of Nursing or designee will complete weekly wound care audits for four weeks then monthly for three months and present the audits in the monthly QA meeting.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care and services for two residents, as evidenced by observations, clinical record reviews, and staff interviews. For Resident 54, there was a physician's order to provide oxygen at 2 liters per minute via nasal cannula continuously, change the oxygen tubing every Saturday night, and ensure all tubing and nebulizer equipment was bagged when not in use. However, observations on multiple days revealed that the oxygen concentrator was set at 2.5 liters per minute, the nebulizer pipe was unbagged, and the tubing was dated February 23, 2025, indicating it had not been changed as required. Resident 54 confirmed that staff was supposed to change the tubing weekly. Similarly, for Resident 36, there were orders to change the nebulizer tubing and bag every Saturday night shift, label the tubing with the date, time, and staff initials, and ensure all equipment was bagged when not in use. Observations showed that the nebulizer pipe was unbagged, and the tubing was also dated February 23, 2025, suggesting it had not been changed for over a week. An unopened bag dated February 23, 2025, was found on the resident's bedside stand, indicating that the necessary equipment was available but not utilized. These findings were reviewed with the Nursing Home Administrator.
Plan Of Correction
1. Resident 54 tubing was changed immediately. Resident 36 tubing was changed immediately. 2. The Director of Nursing completed an audit on all residents requiring oxygen tubing including any needed devices that require oxygen tubing to be changed. 3. The Director of Nursing provided education to nursing staff to ensure all tubing is changed weekly. All residents requiring a tubing change is in the physician orders to be changed Every Saturday, nightshift. 4. The Director of Nursing and or designee will complete weekly random audits for four weeks and then monthly for three months to ensure tubing is being changed weekly. The Director of Nursing will bring audits to the monthly quality assurance meeting for review.
Failure to Implement Behavioral Health Interventions
Penalty
Summary
The facility failed to provide appropriate behavioral health interventions for a resident, identified as Resident 44, to maintain the highest practicable mental well-being. The clinical record review revealed that Resident 44 exhibited behavioral symptoms not directed towards others, such as physical symptoms and verbal/vocal symptoms. Despite these behaviors, the facility did not develop a care plan that included an intervention for two staff to provide care due to the resident's known behavior of making false accusations. The plan of care initiated on December 7, 2024, included instructions for staff to remove themselves and reattempt care when the resident was calmer, but these interventions were not implemented during an incident on February 28, 2025. During an interview, Resident 44 expressed dissatisfaction with the approach used by staff during her shower care, describing it as "slam bam." The resident recounted the incident multiple times, indicating distress. Employee 3, a nurse aide, confirmed witnessing the incident and noted that Resident 44 became agitated, falsely accusing staff of hurting her shoulder and damaging her hearing aids, which were not present during the shower. The facility's failure to implement the care plan interventions and develop a comprehensive plan addressing the resident's behavioral health needs led to the deficiency identified by the surveyors.
Plan Of Correction
1. Resident 44's care plan was updated to indicate behavioral health interventions. 2. The Social Services Director reviewed the care plans of any residents with a behavior health concern and updated the care plans as needed to indicate behavioral health interventions. 3. The Facility Administrator educated the social services department on the importance to list any behavior health interventions in the care plan to reflect the residents' needs and interventions. DON will add any interventions to the task section in PCC. 4. The Facility Administrator or designee will complete weekly audits for four weeks then monthly for four months to ensure behavior health interventions are listed on the plan of care. These audits will be brought to the monthly QA meeting for review.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to securely store medications and ensure proper medication labeling, leading to deficiencies in nursing services and pharmacy services. During a medication administration pass, an LPN crushed a Rosuvastatin tablet for a resident, despite the medication resource indicating that the tablet should be swallowed whole. The LPN confirmed that there were no instructions on the medication labeling from the pharmacy to indicate that the medication should not be crushed, and she was unaware of this precaution. Additionally, a registered nurse confirmed that the facility's medication resource also stipulated that Rosuvastatin should not be crushed. This indicates a failure in ensuring that all medication labeling included appropriate precautionary instructions. Furthermore, an observation in the main dining area of Unit One revealed a yellow-colored, round pill on the floor behind a television stand. An LPN was unable to identify the pill and proceeded to dispose of it. This incident highlights a failure in securely storing medications, as the pill was found in a common area accessible to residents and staff. The findings were reviewed in a meeting with the Nursing Home Administrator, indicating a lapse in the facility's medication storage protocols.
Plan Of Correction
1. Resident 46 was not harmed. Facility Supervisor checked with Pharmacist about Resident 46's medication tablet and the Pharmacist indicated that the medication "could be crushed" in tablet form. Resident was not harmed due to the tablet of medication being crushed. 2. The Director of Nursing reviewed any residents who required medications to be crushed to ensure contraindications was labeled on the medication label. 3. The Director of Nursing educated the Nurses on the importance of reviewing medications for proper labeling and securing medications to ensure no pills are left on the floor. 4. The Director of Nursing and or designee will complete weekly random audits for one month and monthly audits for three months to ensure proper labeling and medications are secure. These audits will be brought to the monthly quality assurance monthly meeting.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide necessary dental services for a resident, identified as Resident 52, who had dental concerns. Resident 52, who used a partial dental plate, reported that it no longer fit, and there were discussions about its replacement, but no clear timeline was provided. The resident, who had several missing front teeth, was covered by Medicaid since August 2024. Despite experiencing left-sided dental pain and visible swelling in November 2024, which required antibiotic treatment, there was no evidence of a professional dental evaluation for the infection. A progress note from February 2025 indicated that the resident had cracked and missing teeth and required extractions before a new partial denture could be fabricated. The Nursing Home Administrator confirmed that the resident was admitted in March 2024, but the facility did not offer or obtain consent for dental services until July 2024. There was no evidence of professional dental services being provided from March 2024 to February 2025, despite the resident's dental infection in November 2024. This lack of timely dental care and failure to address the resident's dental needs led to the deficiency identified in the report.
Plan Of Correction
1. Resident 52 received dental services. 2. The Facility Administrator completed a facility wide audit of current residents for dental services. 3. The Director of Nursing completed an education with nursing staff on ensuring that residents receive dental services. 4. The Facility Administrator and or designee will complete a weekly random audit for four weeks then monthly for three months and bring the completed audits for dental services to monthly QA meeting for review.
Failure to Implement Enhanced Barrier Precautions for Resident with Dialysis Catheter
Penalty
Summary
The facility failed to implement appropriate enhanced barrier transmission-based precautions for a resident with a tunneled dialysis catheter, as required by the facility's infection prevention and control program. The deficiency was identified during an observation and review of clinical records, which revealed that the resident was not on enhanced barrier precautions (EBP) despite having a medical device that necessitates such precautions. The facility's policy, aligned with CDC guidelines, mandates the use of EBP for residents with indwelling medical devices during high-contact care activities to prevent the spread of multi-drug resistant organisms. The resident in question had a current physician's order for hemodialysis and a tunneled dialysis catheter placed in the right chest, as documented in both hospital and nursing records. However, there was no evidence in the clinical record or during the observation that EBP were being implemented for this resident. Specifically, there were no signs indicating EBP precautions, no personal protective equipment available in the room or at the doorway, and no instructions for staff to consult the nurse prior to providing care. An interview with the Nursing Home Administrator confirmed that the resident was not on EBP, contrary to the facility's policy. This oversight was noted as a deficiency in the facility's infection prevention and control practices, which had been previously cited in an earlier survey. The failure to adhere to the established infection control protocols for residents with indwelling medical devices represents a lapse in maintaining a safe and sanitary environment as required by federal regulations.
Plan Of Correction
1. Resident 75 was immediately placed on Enhanced Barrier Precautions with isolation set up. 2. The Director of Nursing and IP reviewed all residents in need of EBP to ensure they had the proper isolation signage and set up. 3. The Director of Nursing completed an education with the nursing department to ensure EBP is in place for any residents who are contraindicated for Enhanced Barrier Precautions. 4. The Director of Nursing or designee will complete weekly random audits for four weeks, then monthly for four months, and bring the EBP audits to the monthly QA meeting for review.
Failure to Rotate Emergency Water Supply
Penalty
Summary
The facility failed to adhere to its established procedures for ensuring water availability in essential areas during a loss of normal water supply. The policy titled "Water Availability," last reviewed on June 13, 2024, mandates that the facility must rotate its emergency water supply regularly. However, during an observation on March 5, 2025, it was found that multiple boxes of emergency water stored on Nursing Unit 1 and in the facility's main kitchen were past their manufacturer's best by dates. Specifically, six out of nine boxes on Nursing Unit 1 and four out of ten boxes in the main kitchen were expired, with dates ranging from July 31, 2024, to September 30, 2024. Interviews with facility staff, including Employee 8 and the Nursing Home Administrator, revealed a lack of clarity and oversight regarding the disposal of expired water. Employee 4, the certified dietary manager, confirmed the presence of additional expired water boxes in the main kitchen storage. The facility did not provide evidence of regular rotation of the emergency water supply, as required by their policy, leading to the deficiency in ensuring water availability during emergencies.
Plan Of Correction
1. Expired was immediately discarded. 2. The Dietary Manager completed an audit of all emergency water to ensure no other water was expired. Dietary Manager ordered more water to replenish expired water. 3. The Dietary Manager educated the dietary department to check emergency water supply and discard of water that is expired and to note to the Dietary Manager to order to replenish. 4. The Dietary Manager or designee will complete weekly random audits for four weeks and then monthly for three months and bring emergency water supply audits to the monthly QA meeting.
Facility Fails to Meet Minimum Nurse Aide Staffing Requirements
Penalty
Summary
The facility failed to meet the required minimum staffing levels for nurse aides across multiple shifts, as evidenced by a review of nursing staffing hours and staff interviews. Specifically, the facility did not ensure a minimum of one nurse aide per 10 residents on five of 21 day shifts and four of 21 evening shifts. Additionally, the facility failed to maintain a minimum of one nurse aide per 15 residents on nine of 21 overnight shifts. These deficiencies were identified during specific periods, including October 13 to 19, 2024, December 29, 2024, through January 4, 2025, and February 28, 2025, through March 6, 2025. The report details specific instances where the number of nurse aides scheduled was insufficient for the resident census. For example, on October 13, 2024, there were only 6.38 nurse aides for a census of 75 residents, requiring 7.5 aides. Similar shortfalls were noted on other dates, such as December 31, 2024, and January 4, 2025, across various shifts. These staffing inadequacies indicate a consistent failure to comply with the mandated nurse aide-to-resident ratios, potentially impacting the quality of care provided to residents.
Plan Of Correction
1. Nursing Staff care hours will be reviewed daily for the current day and for the remainder of the week during morning meeting for compliance with current regulations of a minimum of 1 CNA per 10 Residents during the day, 1 CNA per 11 residents during the evening shift, and 1 CNA per 15 Residents on the overnight shift. 2. Will continue to actively hire and advertise open positions to meet current regulations. 3. The facility will continue to use per diem staff to fill in open shifts and ask current LPNs, current CNAs, and RNs to fill in open CNA shifts. 4. DON/designee will complete weekly audits on CNA staffing ratio for four weeks and then monthly for three months and bring to the monthly QA meeting for review.
LPN Staffing Deficiency Across Multiple Shifts
Penalty
Summary
The facility failed to meet the required staffing levels for Licensed Practical Nurses (LPNs) across multiple shifts, as evidenced by a review of nursing staffing hours and staff interviews. Specifically, the facility did not ensure a minimum of one LPN per 25 residents on eight of 21 day shifts reviewed, one LPN per 30 residents on eight of 21 evening shifts reviewed, and one LPN per 40 residents on three of 21 overnight shifts reviewed. This deficiency was identified during specific periods, including October 13 to 19, 2024, December 29, 2024, through January 4, 2025, and February 28, 2025, through March 6, 2025. The findings revealed that on several occasions, the number of LPNs scheduled was insufficient for the resident census. For instance, on October 18, 2024, there were 3.03 LPNs scheduled for a census of 76 residents, whereas 3.04 LPNs were required. Similar shortfalls were noted on other dates, such as December 29, 2024, and January 1, 2025, where the number of LPNs scheduled did not meet the required staffing levels. These discrepancies in staffing levels were consistent across day, evening, and overnight shifts, indicating a systemic issue in maintaining the mandated LPN-to-resident ratios.
Plan Of Correction
1. Nursing Staff care hours will be reviewed daily for the current day and for the remainder of the week during morning meeting for compliance with current regulations of a minimum of 1 LPN for 25 Residents during the day, 1 LPN per 30 Residents during the evening shift and 1 LPN per 40 Residents on overnight shift. 2. Will continue to actively hire and advertise open positions to meet current regulations. 3. The facility will continue to use per diem staff to fill in open shifts and ask current LPNs, and RNs to fill in open LPN shifts. 4. DON/designee will complete weekly audits on LPN staffing ratio for four weeks and then monthly for three months and bring to the monthly QA meeting for review.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per day for eight out of the 21 days reviewed. This deficiency was identified through a review of nursing staffing hours and staff interviews. Specifically, the facility did not meet the required hours on several dates, including October 13 and 14, 2024, December 29 to 31, 2024, and January 2 to 4, 2025. The hours per resident per day on these dates ranged from 2.74 to 3.19, falling short of the mandated 3.2 hours. This information was confirmed during an interview with the Nursing Home Administrator on March 7, 2025.
Plan Of Correction
1. Nursing Staff PPD care hours will be reviewed daily for the current day and for the remainder of the week during morning meeting for compliance with the state regulation of the nursing hours guidance for a staff PPD of 3.2. 2. The facility will continue to actively hire and advertise open positions to meet current regulations. 3. The facility will continue to use per diem staff to fill open shifts and ask current RN's, LPN's and CNA's to fill open shifts. 4. DON and or designee will review PPD staffing hour weekly for four works then monthly three months and bring audits to the monthly QA meeting for review.
Failure to Provide Timely Medicare Coverage Termination Notices
Penalty
Summary
The facility failed to provide timely notification to residents whose payment coverage changed, as required by Medicare regulations. Specifically, for Resident 58, the facility did not deliver the Notice of Medicare Non-Coverage (NOMNC) at least two calendar days before Medicare-covered services ended. Resident 58's Medicare coverage ended on January 16, 2024, and the resident initialed the notice on the same day, indicating that the notice was not provided within the required timeframe. Similarly, for Resident 83, the facility also failed to deliver the NOMNC at least two calendar days before the end of Medicare-covered services. Resident 83's Medicare coverage ended on February 28, 2024, the same day the resident signed the notice, again failing to meet the required notification period. The deficiency was confirmed through clinical record reviews and staff interviews, including discussions with the Director of Nursing and the Nursing Home Administrator. The failure to provide timely notifications as required by Medicare regulations was evident for both residents, indicating a lapse in the facility's compliance with notification procedures. This deficiency directly impacts the residents' awareness and ability to appeal the termination of Medicare-covered services.
Failure to Maintain a Safe Environment in Beauty Shop
Penalty
Summary
The facility failed to maintain an environment free of potential accident hazards in the beauty shop. During an observation, the beauty shop door was found open with no employees present. Inside the beauty shop, there were several hazardous items including a large bottle of shampoo, conditioner, hair color with warning labels, two pairs of hair-cutting shears, a razor, a plugged-in curling iron that was warm to the touch, and a tart burner with hot melted liquid. Additionally, the water temperature at the hair washing station was measured at 121.6 degrees Fahrenheit. The beautician was found to be in a resident's room and was unaware that the beauty shop needed to be secured when unattended.
Failure to Maintain Sanitary Food Service Equipment
Penalty
Summary
The facility failed to maintain food service equipment in a sanitary manner and proper working order in the main kitchen. An observation revealed that the hood system over the stove/cooktop area contained thick visible dust buildup. Additionally, the dishwasher was observed running at a wash temperature of 126 degrees Fahrenheit, which is below the required temperature. There was no sanitizing agent connected to the dishwasher, and the dietary manager acknowledged the low wash cycle temperature. A review of the kitchen's Dish Machine Temperature Log showed that the wash temperature had not met the required temperature since March 31, 2024. The log indicated that temperatures below 150 degrees Fahrenheit should be reported to the dietary manager and maintenance. Despite this, the log consistently recorded wash cycle temperatures below the required threshold. A maintenance order dated April 1, 2024, revealed that the dishwasher was not getting up to temperature, and although the drain was fixed, the temperature issue persisted. The findings were reviewed with the Nursing Home Administrator and Director of Nursing, and a company was contacted to address the issue after the surveyor's discussion.
Failure to Implement Enhanced Barrier Precautions and Ensure Hygienically Clean Laundry
Penalty
Summary
The facility failed to implement appropriate enhanced barrier transmission-based precautions for three residents who required them. Resident 51 had a long-occurring pressure ulcer and an indwelling urinary catheter, but there was no documented evidence or observation indicating the use of enhanced barrier precautions. The Director of Nursing and the Administrator confirmed that the facility had not implemented these precautions for any residents, including Resident 51, until after the surveyor's questioning. Resident 23, who required an indwelling Foley catheter, also did not have any enhanced barrier precautions in place. The assigned licensed practical nurse was unaware of the need for such precautions. Similarly, Resident 20, who had a PICC line for intravenous antibiotic therapy following hip surgery, did not have enhanced barrier precautions implemented. The nurse assigned to Resident 20's care was also unaware of the need for these precautions, and there was no plan of care addressing this requirement. Additionally, the facility failed to ensure hygienically clean resident laundry processing. The laundry/housekeeping supervisor could not provide information on how water temperatures were monitored, the weight capacity of the washing machines, or whether the chemicals used included a sanitizing agent. The facility lacked a mechanism to ensure that laundry was processed according to CDC guidelines, and there was no evidence that hot water temperatures reached the required levels or that any chemicals used sanitized the fabrics.
Failure to Provide Adequate Care for Resident with PICC Line
Penalty
Summary
The facility failed to provide the highest practicable care for a resident with an indwelling central line catheter. The policies provided by the facility did not address the development of a plan of care, limb restriction measures, or emergency procedures necessary while the PICC line is in use. Clinical record review revealed that the presence of the PICC line was not documented upon the resident's arrival at the facility. Additionally, nursing documentation did not specify which arm was affected when the resident complained of arm pain. Observations and interviews confirmed the absence of an emergency kit in the resident's room and the lack of a comprehensive plan of care addressing the PICC line. Further review of the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed multiple instances where staff failed to document the completion of medications and treatments related to the PICC line. These included missed doses of Vancomycin, normal saline flushes, weekly dressing changes, and measurements of the arm circumference and external catheter length. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed these findings, indicating a significant lapse in the facility's adherence to prescribed care protocols for the resident's PICC line.
Failure to Identify and Care Plan PTSD Triggers
Penalty
Summary
The facility failed to identify and care plan triggers related to a resident's diagnosis of Post-Traumatic Stress Disorder (PTSD). Clinical record review for the resident revealed a diagnosis of Chronic PTSD since admission. During an interview, the resident disclosed that loud noises and bright lights were triggers due to his combat experience. However, the resident's care plan did not identify these triggers. This deficiency was confirmed during an interview with the Nursing Home Administrator and Director of Nursing.
Failure to Develop and Implement Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement an individualized person-centered care plan for a resident diagnosed with dementia. Clinical record review revealed that the resident was admitted on March 30, 2023, with a diagnosis of dementia. The admission Minimum Data Set Assessment dated March 27, 2023, indicated that a care plan for dementia and cognitive loss would be developed. However, a review of the resident's current care plan showed no indication that such a care plan had been created or implemented. This deficiency was confirmed during an interview with the Administrator and Director of Nursing on April 17, 2024, at 2:15 PM. The findings were reviewed with the Administrator and Director of Nursing on April 17, 2024, at 2:15 PM.
Failure to Ensure Monthly Drug Regimen Review by Consultant Pharmacist
Penalty
Summary
The facility failed to ensure that the consultant pharmacist reviewed the drug regimen of each resident and reported any irregularities to the attending physician monthly. For Resident 26, the consultant pharmacist identified a potential medication irregularity that required evaluation for a gradual dose reduction of her antianxiety medication, Xanax, on November 26, 2023, and her antidepressant medication, Effexor, on December 26, 2023. However, Resident 26's clinical record did not contain evidence that a physician received the report pertaining to the Xanax medication until December 26, 2023, and there was no evidence that the physician received a report pertaining to the Effexor medication at all. These concerns were confirmed during an interview with the Nursing Home Administrator and the Director of Nursing on April 19, 2024, at 12:34 PM. For Resident 24, the clinical record review indicated that there was no monthly review completed for February 2024. Further review of Resident 24's clinical record revealed no evidence that the consultant pharmacist reviewed Resident 24's drug regimen in February 2024. These findings were confirmed by the Nursing Home Administrator and the Director of Nursing during an interview on April 19, 2024, at 10:52 AM.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure a medication error rate below five percent, resulting in a medication error rate of 7.69 percent based on 26 medication opportunities with two medication errors. The errors were observed during a medication administration pass involving two residents. Employee 1, a licensed practical nurse, did not follow the manufacturer's guidelines for the BD AutoShield Duo safety pen needle. Specifically, Employee 1 did not check if the needle was attached correctly by dialing up two units of insulin and ensuring liquid appeared before administering the insulin to the residents. During the medication administration pass, Employee 1 administered Insulin Aspart Flexpen to Resident 132 and Humalog Kwikpen to Resident 24 without verifying the correct attachment of the safety pen needle or ensuring the presence of liquid. These actions were confirmed during an interview with Employee 1. The failure to follow proper procedures for insulin administration led to the identified medication errors, contributing to the facility's elevated medication error rate.
Failure to Administer COVID-19 Vaccine to Resident
Penalty
Summary
The facility failed to ensure the administration of a COVID-19 immunization for one of five residents reviewed for immunization concerns. Specifically, Resident 45 did not receive a COVID-19 vaccine after October 27, 2022, despite having signed consents for vaccination on April 27, 2023, and November 2, 2023. The clinical record review revealed no evidence of the vaccine being administered, and there was conflicting documentation regarding whether the resident refused the vaccine. Interviews with staff confirmed the absence of proper documentation to support the claim that Resident 45 refused the vaccine, and the resident herself stated she was not opposed to receiving it. The facility's policy required that residents be educated about and offered the COVID-19 vaccine, with proper documentation of consent and administration. However, the facility did not adhere to this policy for Resident 45. The registered nurse infection control prevention coordinator and other staff could not provide evidence that the vaccine was offered or administered as required. This deficiency was confirmed through interviews with the Nursing Home Administrator and the Director of Nursing, who acknowledged the lack of proper documentation and the inability to identify the staff member responsible for the erroneous refusal documentation.
Failure to Accurately Assess Entrapment Risk with Specialized Mattress and Side Rails
Penalty
Summary
The facility failed to perform an accurate assessment for possible entrapment with the use of a specialized mattress and side rails for a resident diagnosed with dementia. The resident's bed had bilateral half side rails, and the air mattress in use was observed to shift side to side, creating a larger gap between the side rail and the mattress. Despite this observation, the facility's side rail entrapment assessment inaccurately indicated that the mattress fit securely without shifting. The occupational therapist confirmed that the mattress was not secured and admitted that the assessment was based on the typical bed frame and mattress used in the facility, without physically measuring the entrapment zones in the resident's room. The resident, admitted with a diagnosis of dementia and severe cognitive impairment, had a history of falls and fluctuating levels of consciousness. The facility's policy required an assessment of the space between the mattress and side rails to reduce the risk of entrapment, but it did not specify actions when side rails were deemed inappropriate or unsafe. The failure to accurately assess and address the entrapment risk was confirmed during an interview with the occupational therapist and the facility administrator.
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.
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What surveyors actually found near you
We read the 71 citations issued within 25 miles in the last 12 months — including the 1 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 Sayre
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Elderwood At Waverly | 3 mi | ★★★★★ | 2 | 1 |
| Athens Nursing And Rehabilitation Center | 3.1 mi | ★★★★★ | 30 | 0 |
| Chemung County Health Center - Nursing Facility | 13.4 mi | ★★★★★ | 0 | 0 |
| St. Joseph's Hospital - Skilled Nursing Facility | 13.5 mi | ★★★★★ | 3 | 0 |
| Robert Packer Hospital Skilled Care And Rehabilit | 15.5 mi | ★★★★★ | 15 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.