Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sunnyview Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Failure to Complete Timely Criminal Background Checks: The facility failed to properly screen employees by not completing timely criminal background checks before employment for three of five personnel files reviewed, including an RN, a COTA, and a NA. Facility policy required screening during the hiring process for a history of abuse, neglect, or mistreating residents, including criminal background checks. HR confirmed that one employee's checks were completed too far in advance to rule out criminal activity in a timely manner and another employee's background check was not completed before the start of employment.
Failure to provide ADL assistance for hair and nail care affected three residents. One resident with CAD, HTN, and depression had disheveled long hair and a long beard and said he did not get a haircut; another resident with cancer, HTN, and depression had long, unclean, curling nails; and a third resident with CAD, HTN, and diabetes also had disheveled long hair and a long beard and said no one came to give him a haircut. Staff and therapy personnel confirmed the residents needed these services.
Failure to support family group formation and track a family concern. A resident family member reported interest in starting a family council for the secured unit and said he contacted administration and the LTC ombudsman, but the facility did not assist him or provide information to help form the group. The concern was not entered on the concern log, and the ANHA confirmed the facility was aware of the issue but did not assist with forming the family group.
An LPN on the Cardinal Unit left a laptop screen open and papers with resident personal information on top of the med cart outside a resident room, making the information visible to anyone passing by. The LPN confirmed the screen was not closed and the papers were left exposed, contrary to the facility policy for maintaining confidentiality during med administration.
Abuse of Two Cognitively Intact Residents by Nurse Aide: A nurse aide verbally and physically abused two cognitively intact residents during the overnight shift. One resident, who had quadriplegia, chronic pain, and muscle weakness, was cursed at, threatened with sexual profanity, and had the aide get in his face while turning off his call bell. Another resident, who had depression and cancer, was denied help with a urinal, cursed at, spit on, and had the urinal thrown across the room. Witness statements and resident interviews supported the allegations.
A resident with diabetes had repeated blood glucose readings above the provider-notification threshold while receiving NovoLOG sliding scale insulin, but the record showed no evidence that the physician was notified. The resident reported sometimes feeling dizzy, and the CRNP and RN confirmed the expected notifications were not documented.
Failure to provide ordered wound vac treatment for a resident with a stage IV sacral pressure ulcer. The resident’s CRNP ordered NPWT at 125 mmHg with dressing changes twice weekly, but the device had problems, was removed, and the TAR showed changes only once weekly instead of as ordered. The wound care nurse and DON confirmed the ordered treatment was not provided as directed.
Failure to Complete RD Nutritional Assessments: The facility did not complete required admission nutritional assessments by an RD for two residents. One resident had a femur fracture, falls, and pulmonary disease, and another had renal dialysis dependence, sepsis, and a colostomy. Facility policy required an RD assessment within 72 hours of admission, but staff reported the facility had no current RD on staff after the prior RD resigned, and the DON confirmed the assessments were not completed.
Respiratory care was not provided as ordered for two residents. One resident with COPD used a home non-invasive ventilator at night, but the mask was left sitting on the bedside stand instead of being stored in a bag as required. Another resident with chronic respiratory failure on continuous O2 had nasal cannula tubing that was dated beyond the required 2-week change interval, and an LPN confirmed both issues.
Inaccurate Bed Rail Assessments: The facility failed to complete ongoing accurate assessments for a resident’s right enabler side rail use. The resident had diagnoses including DM, hyperlipidemia, and depression, and the record showed quarterly bed rail evaluations stating bed rails were not recommended, yet a right enabler bar was observed on the bed and an RN confirmed the evaluations were not accurate.
Medication Storage and Labeling Deficiencies: Surveyors observed multiple opened meds and biologicals in medication carts and med rooms that were not dated as required, including eye drops, inhalers, nasal spray, and liquid Neurontin. They also observed ice build-up in a med room freezer and a blue tote stored under a sink. LPNs confirmed the findings and that the carts and med rooms were not being maintained in a safe, secure, and orderly manner.
Missing Qualified RD The facility failed to employ a qualified RD for the food and nutrition service. The FSGM could not identify the current clinical RD, and the NHA confirmed the prior RD had resigned and no replacement had been hired, leaving two full-time RD positions open and no RD on staff to complete the essential job functions.
Failure to provide resident-selected menu items: Two residents did not receive the food items listed on their meal tickets during lunch observations. One resident ordered 4 oz of tomato juice but did not receive it, and another resident’s tray did not match the requested items listed, despite the facility policy requiring resident food and beverage preferences to be identified on tray tickets.
The facility failed to maintain food service equipment in accordance with professional standards in one of five nursing unit nutrition pantries. A microwave in the Rehab Unit pantry had a build-up of dried food debris splatters throughout the interior surfaces, and the Rehab Unit Mgr confirmed the observation and the failure to maintain the equipment as required by facility policy.
An LPN failed to prevent cross contamination during a medication pass when a Buspar tablet for a resident was dropped onto informational papers on top of the med cart, then picked up with gloves and placed into the medication cup for administration. The resident had diagnoses of anemia, depression, and anxiety.
Missing Required Medicare and Medicaid Posting: A First Floor bulletin board had required posted information for residents and visitors, but it did not include written information on how to apply for Medicare and Medicaid benefits or how to receive refunds for previous payments covered by those programs. The omission was observed by surveyors and confirmed by the A/NHA.
Incomplete Controlled Medication Shift Counts: The facility failed to maintain accurate controlled medication accounting on three of six medication carts reviewed. Surveyors found missing signatures on narcotic count records at shift change on the Sunflower Unit East Hall cart, the Sunflower Unit [NAME] Hall cart, and the Dogwood Unit East Hall cart. An LPN, an RN, and the DON confirmed the omitted signatures during interview, despite policy requiring two nurses to complete and document counts at the beginning and end of each shift.
A resident with multiple medical conditions, including diabetes and a lower leg fracture, received IV cefazolin via a midline catheter, but the physician orders did not specify the type of IV access, flushing protocol, dressing change schedule, or end-cap changes. Facility policy required specific midline flushing and care procedures, and nursing documentation noted that the midline was flushing easily. During an interview, the DON confirmed that the orders were incomplete and that adequate treatment and care for the midline catheter were not provided.
A resident with high blood pressure, muscle weakness, heart failure, and a stage 2 coccyx pressure injury had a physician’s order for daily wound care, including cleansing with wound cleanser, drying, applying triad paste, and covering with bordered gauze. Review of the TAR showed that this treatment was not administered on two documented days, and the DON confirmed that the ordered pressure ulcer treatments were not provided as required.
A resident with PTSD, multiple sclerosis, and asthma, who was receiving Duloxetine and buspirone for PTSD and anxiety, reported that a male NA repeatedly entered her room in the early morning hours to check if she needed the restroom, which made her very uncomfortable due to a history of being raped at night during military service. Review of her trauma-informed care evaluation and care plan showed no identified PTSD triggers or related interventions. The social worker acknowledged that the facility did not provide trauma-informed care to eliminate or mitigate triggers that could cause re-traumatization.
The facility did not consistently monitor or record food holding temperatures as required, resulting in multiple meals being served without documentation of safe temperature ranges. Several residents and their representatives reported that food was frequently served cold, and staff confirmed the lack of temperature monitoring, creating a potential risk for foodborne illness.
Resident representatives were unable to reach facility staff or receive responses to their communications over several weeks due to unresolved phone system changes following administrative office relocation. The DON confirmed that the current phone situation prevented effective communication with key personnel.
A resident with an enteral feeding tube did not receive appropriate care, as the feeding bag lacked required labeling and the water bag used for flushes was outdated. An LPN and the DON confirmed these deficiencies, which were not in accordance with facility policy and physician orders.
A nurse aide was re-hired without documented completion of required abuse, neglect, and misappropriation training, as mandated by facility policy. The DON confirmed that training records did not show the employee received this education upon re-hire.
Two residents with cognitive impairments and a history of exit-seeking behaviors were able to elope from the facility due to failures in supervision, incomplete risk assessments, and non-functioning or unchecked electronic monitoring devices. Staff did not consistently update care plans or ensure monitoring systems were operational, resulting in one resident being found attempting to exit the building and another found outside with injuries after a fall.
A poster with Ombudsman contact information was observed to include only a phone number, lacking the required name, address, and email address. The NHA confirmed the omission, resulting in a deficiency for not fully posting all required contact details for the State Long-Term Care Ombudsman program.
A nurse aide trainee was allowed to work for more than four months without obtaining required certification, as confirmed by facility records and staff interview. The individual continued working as a nurse aide trainee well past the 120-day limit set by federal regulations.
Surveyors observed that food items in storage areas were not properly labeled or dated, including snacks, grits, chicken tenders, and soft pretzels. A refrigerator contained a soiled rag, and loose sugar was found on the dry storage floor. Meat was stored touching the freezer ceiling, and large icicles were present on the freezer floor. The hand washing sink lacked towels, and equipment such as the meat slicer and floor mixer were left uncovered, exposing them to contamination. The Food Service Director confirmed these failures in food labeling, sanitation, and hand hygiene supply maintenance.
The NHA and DON did not effectively manage the facility to prevent the elopement of two residents, despite being responsible for maintaining systems to ensure resident safety and regulatory compliance. This failure resulted in an immediate jeopardy situation, as identified through review of job descriptions, clinical records, and staff interviews.
Multiple residents reported delays in receiving meals, infrequent showers, and long wait times for call bell responses due to insufficient nursing staff. Staff confirmed that low staffing levels made it difficult to provide timely care, with some shifts having only three aides for 60 residents. The administrator acknowledged the facility's failure to provide adequate nursing and related services to meet residents' needs.
The facility did not provide required medically related social services to several residents with mental health conditions such as schizophrenia, depression, and anxiety. Documentation and interviews showed that residents did not receive consistent psychosocial support or follow-up, and there was no process in place to identify or track those needing regular psychiatric social services.
The facility did not ensure that monthly medication regimen reviews were reviewed by the attending physician for three residents with complex medical and psychiatric conditions. Instead, CRNPs completed and signed the reviews and made medication decisions, with no documented response from the attending physician as required by policy.
The facility did not employ a qualified Food Service Director for an extended period, with the individual in the role lacking required education or certification, and the RD only performing clinical duties without managing kitchen operations.
A resident was not allowed to share a room with their spouse or roommate of choice, and did not receive written notice before a change in room assignment was made, violating their rights.
A resident with mental health and seizure disorders, who had been placed in a private room for behavioral reasons, was moved to another room so that another resident with similar needs could have the private room. The transfer was made for facility convenience rather than the resident's needs, violating the resident's right to refuse non-requested transfers.
A resident with anemia, muscle weakness, and a need for personal care assistance was found to have their call bell out of reach while in bed. Facility staff confirmed the call bell was not accessible, failing to meet the resident's needs as required by policy.
A resident with anemia and recent weight loss required personal assistance with eating, as requested by a family member. The facility did not document or respond to this grievance, and staff confirmed the concern was not addressed, resulting in a failure to honor the resident's right to voice grievances.
A resident with dementia and a left below-knee amputation, who required staff assistance for toileting, was found lying in bed with a soiled gown and sheets saturated in urine, despite documentation indicating toileting assistance had been provided. The assigned nurse aide confirmed that the resident had not been assisted as required, resulting in neglect.
The facility did not ensure that necessary information, such as care plan goals, advanced directives, and ongoing care instructions, was communicated to the receiving health care provider for two residents who were transferred to the hospital and returned. The DON confirmed that this information was not provided as required.
A resident with hemiplegia and muscle weakness, who required a smoking apron for safety as documented in their care plan, was observed smoking without the apron. The staff member supervising was unaware of this requirement, resulting in the care plan intervention not being implemented.
A resident with dementia and a left below-the-knee amputation, who required staff assistance for toileting, was found lying in bed with soiled clothing and bedding after not receiving the necessary toileting care. Documentation indicated care was provided, but staff later confirmed that assistance had not been given as required by the care plan and facility policy.
Two residents with diabetes experienced either repeated refusals of prescribed insulin injections or had multiple instances of elevated blood glucose levels, but the nursing staff did not notify the physician as required by orders and facility policy. Instead, staff relied on a nurse practitioner to review blood sugar records, resulting in a failure to provide care and treatment according to physician instructions.
A resident with diabetes, hyperlipidemia, and chronic kidney disease was found to have a urinary catheter in use without a corresponding physician order on file, as required by facility policy. Staff confirmed that only a hospital order existed and no new order was obtained upon admission, resulting in a deficiency.
The facility did not consistently complete and send required dialysis communication forms for two residents with ESRD who received hemodialysis at an outside center. Multiple treatment days lacked complete documentation, and staff confirmed these omissions, resulting in incomplete communication between the facility and the dialysis center.
Two residents with PTSD did not have care plans addressing trauma-informed care or identifying triggers that could cause re-traumatization. Staff confirmed the absence of appropriate interventions and documentation for these residents.
A resident with dementia, anxiety, and severe cognitive impairment, who was grieving and exhibiting suicidal ideation, did not receive appropriate one-to-one supervision as required by facility policy. Although staff removed dangerous items and initiated frequent checks, the resident was left without continuous observation during an episode of active suicidal behavior, resulting in a deficiency in mental health care services.
A resident diagnosed with dementia did not receive the necessary treatment and services to address their condition, as required by care standards.
Nursing staff did not consistently document or verify controlled medication counts during shift changes on two medication carts, as required by facility policy. LPNs confirmed that no alternative verification methods were used, resulting in incomplete records for controlled substances.
A medication cart was found to contain an outdated Humalog insulin pen for a resident, despite facility policy requiring removal of expired drugs. An LPN confirmed the medication was not properly removed or stored.
A resident with dementia and a history of hoarding, who was care planned to receive only disposable eating items for infection control, was observed using reusable plate and silverware. An LPN confirmed the facility did not follow the care plan by failing to provide the required special eating equipment and utensils.
Failure to Complete Timely Criminal Background Checks
Penalty
Summary
Develop and implement policies and procedures to prevent abuse, neglect, and theft was cited after the facility failed to properly screen employees by not completing timely criminal background checks before employment for three of five personnel files reviewed. The personnel files reviewed were for RN Employee E4, COTA Employee E7, and NA Employee E8, and the facility policy stated that all potential employees would be screened during the hiring process for a history of abuse, neglect, or mistreating residents, including criminal background checks. Review of RN Employee E4's file showed a date of hire of 4/20/26 and two criminal background checks, one requested on 11/25/25 and another requested on 7/29/26. Review of COTA Employee E7's file showed a date of hire of 5/1/26 and a criminal background check requested on 6/25/26, after the start of employment. Review of NA Employee E8's file showed a date of hire of 5/12/26 and a criminal background check requested on 10/14/26. During interview, Human Resources Employee E9 confirmed that Employee E4's background checks were completed too far in advance to rule out criminal activity in a timely manner prior to employment and that Employee E7's background check was not completed prior to the start of employment.
Failure to Provide ADL Assistance for Hair and Nail Care
Penalty
Summary
The facility failed to provide ADL assistance for three sampled residents, specifically hair care and nail care services. The facility policy for ADL Care Mobility-Ambulation and Restorative Ambulation Program stated that ADL documentation is to be completed by the nurse aide or other licensed nursing personnel providing the assistance by the end of each shift. Review of the clinical record showed that Resident R9, who had diagnoses of CAD, HTN, and depression, had no documentation indicating he received a haircut. During observation, he was seen with disheveled long hair and a long beard, and he stated he did not get a chance to go down for a haircut and had never had a beard before. Staff Educator E20 later confirmed that Resident R9 needed hair services. Resident R12, who had diagnoses of cancer, HTN, and depression, also had no documentation indicating she received nail care. During observation, she was seen with long, unclean nails that were curling, and Occupational Therapist E21 confirmed her nails were curling and needed nail services. Resident R90, who had diagnoses of CAD, HTN, and diabetes, had no documentation indicating he received a haircut. During observation, he was seen with disheveled long hair and a long beard, and he stated he was supposed to get a haircut but no one ever showed up and that he wanted everything cut off. Social Worker E19 confirmed that Resident R90 had not received hair services.
Failure to Support Family Group Formation and Track Family Concern
Penalty
Summary
The facility failed to honor a resident family member’s right to organize and participate in a family group and failed to follow up on the family member’s concern. Resident Family R110 stated that in May 2026 he was interested in attending a resident group and starting a family group for the fourth floor. He reported that he spoke with administration and sent an email about the concern, but nothing had happened, and he had tried to work with the ombudsman but did not have contact information for other families and could not be on the unit continuously to locate them. He also stated that the facility did not assist him or provide information for starting a resident family group. Review of the resident rights agreement showed that a resident has the right to have family members or other resident representatives meet in the facility with the families or resident representatives of other residents. A letter from Resident Family R110 to the NHA stated that he had contacted the county LTC ombudsman about starting a Family Council for the secured nursing care unit and had discussed the idea with several family members who were interested in forming the council. However, the concern log from May 2026 to the current review did not include this concern. During interview, the ANHA stated that the NHA and ANHA were aware of the concern, that it was not included on the concern log, and that the facility did not assist Resident Family R110 with forming a family group.
Resident Information Left Visible on Medication Cart
Penalty
Summary
The facility failed to maintain the confidentiality of residents' medical information on one of five units, the Cardinal Unit. The facility policy on Medication Administration/Disposition stated that confidential resident health information is to be maintained during medication administration, with the electronic health record in privacy mode when the nurse is away from the medication cart and paper documentation kept in a closed binder. During an observation on the Cardinal Unit, an LPN left the laptop screen open and papers displaying resident personal information on top of the medication cart outside a resident room, making the information visible to anyone passing by. In an interview shortly afterward, the LPN confirmed that the laptop screen was not closed and that papers with resident personal information were left on the medication cart.
Abuse of Two Cognitively Intact Residents by Nurse Aide
Penalty
Summary
The facility failed to protect residents from abuse when a nurse aide, Employee E8, verbally and physically abused two cognitively intact residents during the overnight shift. Facility policy prohibited mistreatment, neglect, and abuse, and the report identified abuse as willful infliction of injury, intimidation resulting in physical harm, pain, or mental anguish. Both residents had BIMS scores of 15, indicating they were cognitively intact. Resident R92 had diagnoses including quadriplegia, chronic pain, and muscle weakness, and Resident R201 had diagnoses including depression and cancer. For Resident R92, the report states that after he complained about doors being slammed in the hallway while he was trying to sleep, Employee E8 entered the room, got in the resident’s face, raised both middle fingers, and told him to “f*ck you.” The aide then stepped back, pointed to his penis, and told the resident to “suck my d*ck.” Resident R92 reported that he wanted a supervisor and pressed the call bell several times, but Employee E8 turned it off and told him he had been doing this for 14 years. The resident stated the aide was so close to his face that he could feel spit, and the roommate verified the accusations. A witness statement from another resident also described Employee E8 as verbally confrontational and heard the aide use sexual profanity toward Resident R92. For Resident R201, the report states that the resident asked for help emptying his urinal and placing it back under his brief, and when Employee E14 was unsure how to do it, she requested help from Employee E8. Employee E8 reportedly told the resident that aides were not taught to do that with a urinal, repeatedly used profanity, got close to the resident’s face, and purposefully spit in his face. The aide then threw the urinal bottle at the wall across from the bed. RN supervisor and other staff statements described the resident’s account of the incident, including that Employee E8 cursed at him and spit in his face. Resident R201 later confirmed the allegations during interview and stated the aide grabbed his shoulder and spit in his face.
Failure to Notify Physician of Repeated High Blood Sugar Readings
Penalty
Summary
The facility failed to notify the physician of repeated hyperglycemic episodes for one resident with diabetes. The resident’s care plan directed staff to administer diabetes medication as ordered and monitor/document for side effects and effectiveness. The resident’s physician order for NovoLOG sliding scale insulin required staff to call the provider when blood glucose was over 401 mg/dl. The resident’s record showed multiple elevated blood glucose readings during insulin administration, including 408, 500, 440, 430, and 428 mg/dl. The clinical record did not include evidence that the physician was notified for any of those elevated readings. During interview, the resident stated he sometimes feels dizzy. The CRNP stated the facility was expected to notify a physician when the resident’s blood glucose was above 401 and did not recall any notifications for July. An RN and the Staff Educator confirmed there was no evidence the physician was notified for the elevated blood sugar readings documented in the record.
Failure to Provide Ordered Wound Vac Treatment
Penalty
Summary
The facility failed to provide proper treatment for a stage IV sacral pressure ulcer for one resident. The resident had diagnoses including cancer, depression, and a stage IV sacral pressure ulcer, and the care plan directed staff to administer treatments as ordered and monitor effectiveness. A wound care consult on 6/8/26 documented that the Certified Nurse Practitioner ordered wound vac therapy at continuous pressure of 125 mmHg with dressing changes twice a week, and the resident’s wound vac had been ordered but was still pending arrival at that time. A follow-up wound care consult on 6/11/26 documented that the wound vac had arrived and was applied, but nursing had difficulty with the device because it produced an error code and beeped throughout the night. Nursing removed the wound vac and used saline-moistened gauze with a dry dressing daily afterward. The physician order entered on 6/12/26 directed wound vac therapy dressings three times a week and as needed, with attachment at 125 mmHg every Monday, but the June 2026 Treatment Administration Record showed the wound vac was changed only on 6/15/26 and 6/22/26. The wound care nurse confirmed the consultant had ordered changes twice a week, but the resident’s wound vac was changed only once a week, and the ADON and DON confirmed the facility failed to provide the wound care treatment as ordered.
Failure to Complete RD Nutritional Assessments
Penalty
Summary
The facility failed to complete a comprehensive nutritional assessment by a registered dietitian for two residents. One resident was admitted with diagnoses including a left femur fracture, falls, and pulmonary disease, and an admission MDS was completed, but the clinical record did not show that a comprehensive nutritional assessment had been completed by an RD for that assessment. Another resident was admitted with diagnoses including dependence on renal dialysis, sepsis, and a colostomy, and although an admission MDS was completed, the record also did not reveal a comprehensive nutritional assessment completed by an RD for the MDS. Facility policy stated that residents were to receive an admission nutritional assessment by an RD, initiated within 72 hours of admission and completed by the ARD. During interviews, the Food Service General Manager was unable to identify the current clinical RD, and the Nursing Home Administrator stated the facility did not currently have an RD on staff because the prior RD resigned and a replacement had not been hired. The DON confirmed that the required admission nutritional assessments by an RD had not been completed for the two residents.
Respiratory Care Not Provided as Ordered
Penalty
Summary
Appropriate respiratory care was not provided for two residents. Facility policy for oxygen administration required oxygen equipment to be checked daily for correct setup and required tubing to be dated when initiated and changed at least every two weeks, or more often if malfunctioning or visibly soiled. Resident R111 had diagnoses of COPD, CAD, and anxiety, and physician orders included use of a home non-invasive ventilator at night with oxygen at 5 liters and specified ventilator settings. During an observation, the resident was resting in bed and the mask for the non-invasive ventilator was sitting on top of the bedside stand rather than being stored in a bag as required. An LPN confirmed the mask was not stored in a bag and that the facility failed to provide appropriate respiratory care. Resident R217 had diagnoses of chronic respiratory failure with hypoxia, CAD, and anxiety, and had physician orders for oxygen at 2 liters per minute continuously with oxygen set-up and tubing changed every 2 weeks on night shift. During an observation, the resident was resting in bed with oxygen via nasal cannula in place, and the tubing was dated 6/29/26. An LPN confirmed the tubing date and that the facility failed to provide appropriate respiratory care for the resident.
Inaccurate Bed Rail Assessments
Penalty
Summary
The facility failed to conduct ongoing accurate assessments to ensure that bedrails were being used to meet a resident’s needs and to evaluate the risks associated with bedrail use for one of three residents. The facility policy dated 1/27/26 stated that the resident assessment must include an evaluation of alternatives attempted before installation or use of a bed rail and whether those alternatives were effective, and that assessment is to be completed at admission, re-admission, quarterly, annually, with significant change in condition, and when bed rails are added or removed. Resident R3 was admitted to the facility with diagnoses including diabetes, hyperlipidemia, and depression. The clinical record showed a physician order dated 2/23/26 for a right enabler side rail for positioning, and quarterly bed rail evaluations dated 3/18/26 and 6/19/26 both stated that bed rails were not recommended at that time. The current comprehensive care plan identified an ADL self-care deficit related to decline in overall function secondary to illness and included side rails (right enabler) for positioning. However, during an observation on 7/26/26 at 11:21 a.m., a right enabler bar was observed on the resident’s bed, and an RN later confirmed on 7/30/26 at 2:50 p.m. that the bed rail evaluations were not accurate.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store drugs and biologicals in a safe, secure, and orderly manner in two medication carts and two medication rooms. In the Cardinal South Hall medication cart, surveyors observed 2 bottles of artificial tears, 2 bottles of latanoprost eye drops, and 1 bottle of brimonidine eye drops that had been opened but were not labeled with a date. LPN E3 confirmed these findings during interview and acknowledged that the Cardinal South Hall medication cart was not being maintained in a safe, secure, and orderly manner. In the Cardinal East Hall medication cart, surveyors observed 6 bottles of artificial tears, 2 bottles of latanoprost eye drops, 1 bottle of miebo eye drops, 2 tubes of erythromycin ophthalmic ointment, 1 bottle of timolol eye drops, 1 package of ipratropium bromide/albuterol, 1 Stiolto Respimat inhaler, 1 bottle of fluticasone nasal spray, 1 albuterol sulfate inhaler, and 1 Airsupra inhaler, all opened and not labeled with a date. In the Cardinal Units medication room refrigerator freezer, surveyors observed ice build-up, which LPN E3 confirmed. In the Roseview Medication Room refrigerator, surveyors observed 1 bottle of liquid Neurontin that had been opened and not labeled with a date, and a blue tote stored under the sink. LPN E13 confirmed these findings and acknowledged that the Roseview Medication Room was not being maintained in a safe, secure, and orderly manner.
Missing Qualified Registered Dietitian
Penalty
Summary
The facility failed to currently employ a qualified Registered Dietitian (RD) to carry out the functions of the food and nutrition service. The facility’s job description stated that the RD’s primary purpose was to plan, organize, coordinate, and evaluate the nutritional components of the dietary service and to complete clinical duties and documentation accurately and timely. During an interview, the Food Service General Manager was unable to identify the current clinical RD or confirm who was employed in that position. The Nursing Home Administrator later stated that the facility did not have an RD on staff because the prior RD had resigned, and confirmed that the prior RD resigned on 7/8/26. The Administrator further stated that the facility had been unable to hire a replacement and that two full-time RD positions remained available, confirming that the facility did not have an RD currently employed to complete the essential job functions of the position.
Failure to Provide Resident-Selected Menu Items
Penalty
Summary
The facility failed to provide resident selected menu items for two residents during lunch observations. The facility policy stated that individual dining, food, and beverage preferences are to be identified for all residents and that tray assembly tickets should identify allergies, food and beverage preferences, special requests, and adaptive equipment as appropriate. During a lunch observation, Resident R90, who had diagnoses of CAD, HTN, and diabetes and was ordered a regular CCHO diet with regular texture and consistency, was listed on the meal ticket to receive 4 ounces of tomato juice but did not receive it. A nurse aide confirmed that the tomato juice was not provided as indicated on the meal ticket. During another lunch observation, Resident R203, who had diagnoses of CAD, HTN, and hyperlipidemia and was ordered a no added salt diet with regular texture and regular consistency, had a meal ticket listing savory chicken noodle soup, barbecued beef, white bread, deli ham and cheese on white, potato chips, saltine crackers, hot chocolate, pear crisp, chocolate milk, and whole milk. The tray received instead included deli ham and cheese sandwich on white, peanut butter and jelly sandwich on white, hot chocolate, pear crisp, chocolate milk, and whole milk. An RN confirmed the tray did not match the resident's requested items, and the DON and Nursing Home Administrator later confirmed the facility failed to provide resident selected menu items for two of five residents.
Food Service Equipment Not Maintained in Rehab Unit Pantry
Penalty
Summary
The facility failed to maintain food service equipment in accordance with professional standards for food service sanitation in one of five nursing unit nutrition pantries, the Rehab Unit pantry. Facility policy dated 1/27/26 stated that all foodservice equipment is to be clean, sanitary, and in proper working order. During an observation on 7/30/26 at 1:55 p.m., the Rehab Unit nutrition pantry microwave was observed with a build-up of dried food debris splatters throughout the interior surfaces. During a later observation and interview on 7/30/26 at 2:26 p.m., the Rehab Unit Manager confirmed the observation and acknowledged that the facility failed to maintain food service equipment in accordance with professional standards in the Rehab Unit nutrition pantry.
Cross Contamination During Medication Pass
Penalty
Summary
The facility failed to prevent cross contamination during a medication pass for Resident R33. Review of the facility policy on Medication Administration/Disposition indicated staff were to follow established infection control procedures for medication administration. Resident R33 was admitted to the facility and, per the MDS dated 5/27/26, had diagnoses of anemia, depression, and anxiety. During a medication pass observation on 07/29/26 at 9:55 a.m., LPN E11 was preparing Resident R33's medications when a Buspar tablet was dropped onto informational papers placed on top of the medication cart. The LPN then put on gloves, picked up the tablet, and placed it into the medication cup for administration. During an interview at 10:19 a.m., LPN E11 confirmed the tablet had been dropped onto the papers on the medication cart and then picked up and placed into the medication cup.
Missing Required Medicare and Medicaid Posting
Penalty
Summary
The facility failed to display written information for residents and/or their responsible person on how to apply for Medicare and Medicaid benefits and how to receive refunds for previous payments covered by Medicare and Medicaid in the area where postings are available on the First Floor. During an observation on 7/30/26 at 10:30 a.m., the First Floor bulletin board was noted to have required posted information that was conveniently located for residents and visitors, but it did not include the required Medicare and Medicaid application and refund information. This was confirmed during an interview on 7/30/26 at 11:40 a.m. by the Assistant Nursing Home Administrator, who acknowledged that the facility failed to display the required written information.
Incomplete Controlled Medication Shift Counts
Penalty
Summary
The facility failed to implement procedures to promote accurate accounting of controlled medications on three of six medication carts reviewed: the Sunflower Unit East Hall Medication Cart, the Sunflower Unit [NAME] Hall Medication Cart, and the Dogwood Unit East Hall Medication Cart. Facility policy stated that Schedule II-V medications are to be counted by two professional nurses at the beginning and end of each shift, with documentation showing the count was completed and accurate, and that any discrepancy must be immediately communicated to the DON. During observation and staff interviews, surveyors found missing signatures on the Narcotic Count Records at shift change. On the Sunflower Unit East Hall Medication Cart, the oncoming nurse for the afternoon shift did not sign the count sheet on 5/10/26, which was confirmed by an LPN. On the Sunflower Unit [NAME] Hall Medication Cart, the oncoming nurse for the day shift and the oncoming nurse for the afternoon shift did not sign the count sheet on 5/12/26, which was confirmed by an RN. On the Dogwood Unit East Hall Medication Cart, the oncoming nurse for the day shift did not sign the count sheet on 5/10/26, and the DON confirmed this omission during interview.
Incomplete Orders and Care for Midline Catheter
Penalty
Summary
The facility failed to provide adequate treatment and care for a resident’s midline catheter by not ensuring complete and appropriate physician orders for its use and maintenance. Facility policy on Midline Catheter Care and Maintenance, last reviewed 1/27/26, required that midline catheters be flushed with 10 cc normal saline after each intermittent infusion, after discontinuing a continuous IV, or every shift when not in use, and specified that only RNs and LPNs with approved IV certification could perform midline care. The resident, who had diagnoses including hypertension, diabetes, and a left tibia fracture, was admitted on a specified date and later had a nursing progress note indicating that an IV infusion company was notified for midline placement. Subsequent physician orders for this resident’s IV therapy directed cefazolin sodium 2 grams IV every 8 hours for a wound infection for 7 days but did not include the type of IV access, instructions for flushing the IV, dressing change frequency, or changing the IV end cap. A nursing progress note documented that the resident was tolerating the IV and that the midline was flushing easily, but there were no corresponding detailed orders addressing midline care. In an interview, the Director of Nursing confirmed that the physician orders lacked these essential components and acknowledged that the facility failed to provide adequate treatment and care for the midline catheter for this resident.
Failure to Provide Ordered Pressure Ulcer Treatment
Penalty
Summary
The facility failed to provide ordered pressure ulcer treatment for a resident with a stage 2 coccyx pressure injury. The resident was admitted with diagnoses including high blood pressure, muscle weakness, and heart failure, and an MDS assessment was completed. A physician’s order dated 1/13/26 directed staff to cleanse the stage 2 coccyx wound with wound cleanser, pat dry, apply triad paste, and cover with bordered gauze daily. Review of the Treatment Administration Record showed that this ordered treatment was not provided on 1/15/26 or 1/23/26. In an interview on 2/5/26, the Director of Nursing confirmed that the facility failed to provide the pressure ulcer treatments as ordered for this resident. The deficiency was cited under 28 Pa. Code: 201.14(a) Responsibility of licensee, 211.10(c)(d) Resident care policies, and 211.12(d)(1)(2)(5) Nursing services.
Failure to Provide Trauma-Informed Care for Resident With PTSD
Penalty
Summary
Surveyors found that the facility failed to provide trauma‑informed care to a resident with a diagnosis of PTSD. The resident, who also had multiple sclerosis and asthma and was receiving Duloxetine for PTSD and buspirone for anxiety, reported that a male NA repeatedly entered her room around 3:00 a.m. to ask if she needed to use the restroom. The resident stated this made her very uncomfortable and disclosed that she had been in the military and developed PTSD after being raped in the middle of the night. Review of her Trauma Informed Care Evaluation showed no identified triggers, and her care plan also contained no PTSD triggers or related interventions. During interview, the social worker confirmed that the facility failed to provide trauma‑informed care to eliminate or mitigate triggers that could cause re‑traumatization.
Failure to Monitor and Record Food Holding Temperatures
Penalty
Summary
The facility failed to properly monitor and record food holding temperatures in the Main Kitchen, as required by facility policy. The policy specified that hot foods must be held above 135 degrees and cold foods below 41 degrees. A review of the Food Temperature and Evaluation Log for several days in December revealed that staff did not record the required holding temperatures for multiple breakfast, lunch, and dinner meals. This omission was confirmed by the Food Service Director, who acknowledged that the facility did not document the holding temperatures as required. Multiple resident representatives and residents reported concerns about receiving cold food, with several stating that food was often or always cold, particularly at lunch. These concerns were documented on several occasions and corroborated by resident interviews. The failure to monitor and record food temperatures created the potential for foodborne illness, as confirmed by staff interviews and facility documentation.
Failure to Ensure Resident Communication Rights Due to Phone System Issues
Penalty
Summary
The facility failed to ensure that residents and their representatives had the right to communication and access to persons and services within the facility. Review of facility policy confirmed that residents are entitled to such communication. However, concerns from resident representatives indicated repeated unsuccessful attempts to contact facility staff over a period of weeks, with voicemails and emails going unanswered and no correspondence or returned calls from the administration office. During staff interview, the DON explained that administrative offices had recently been relocated, requiring new phone extensions, but the process was delayed due to maintenance staff absence. The DON acknowledged that the current phone situation did not allow residents or their representatives to easily communicate with facility personnel.
Failure to Ensure Proper Labeling and Maintenance of Enteral Feeding Supplies
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with an enteral feeding tube. Review of the facility's policy required that the formula label include initials, date, and time when the formula was hung or administered, and that the label be checked against the order. Clinical record review showed that the resident was admitted with a right hip fracture, post-surgery, and pain, and had physician orders for enteral feeding and water flushes to maintain tube patency. During observation, the resident's enteral feeding bag was found without a label, initials, date, or time, and the water bag used for flushes was three days old. An LPN confirmed the absence of a label on the feeding formula and the outdated water bag. The DON also confirmed that the facility did not ensure appropriate treatment and services to prevent potential complications for the resident with an enteral feeding tube.
Failure to Document Required Abuse Training for Re-Hired Staff
Penalty
Summary
The facility failed to implement its written policies and procedures regarding abuse, neglect, and misappropriation training for staff, as evidenced by the lack of documentation showing that a nurse aide received required abuse training upon their most recent re-hire. Facility policy mandates that all employees complete abuse, neglect, and misappropriation/exploitation training upon hire and at least annually. However, a review of training records for one nurse aide did not include evidence of such training at the time of their re-hire. During interviews, the Director of Nursing confirmed the absence of documentation and acknowledged that the required training could not be verified for this employee.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Monitoring
Penalty
Summary
The facility failed to provide adequate supervision and prevent accident hazards, resulting in two residents eloping from the premises. One resident with dementia, severe cognitive impairment, and a history of exit-seeking behaviors was not properly assessed for elopement risk initially, and their care plan was not updated in response to repeated exit-seeking incidents. The resident repeatedly removed their electronic monitoring device, and staff failed to ensure the device was in place and functioning. Documentation showed that the device was not checked on several occasions, and when the resident was found attempting to exit the building, the wander guard was not on their person. Additionally, the facility's monitoring systems, such as the wander guard system on elevators, were not consistently checked or functioning, as evidenced by maintenance records and staff interviews. Another resident with paranoid schizophrenia and moderate cognitive impairment was also identified as an elopement risk and had a history of wandering. Despite being ordered to wear an electronic monitoring device, the resident was able to leave the facility undetected. Staff and witness statements indicated that the wander guard system did not alarm when the resident exited via the elevator, and the resident was later found outside the facility with injuries after a fall. Staff interviews revealed gaps in supervision and a lack of recognition when residents at risk for elopement left the premises. The facility's elopement risk assessment tool was found to be inadequate, lacking a comprehensive scoring system, and staff were not consistently reeducated on elopement prevention following incidents. There were also failures in updating individualized care plans and implementing new interventions after repeated elopement attempts. The combination of insufficient monitoring, lack of timely care plan updates, and failure to ensure the functionality of safety devices contributed to the residents' ability to elope, creating an immediate jeopardy situation.
Removal Plan
- The Facility is obligated to provide adequate supervision which does not rely on the Wander guard System and is based on the individual resident's assessed needs and the risks identified in the Exit Seeking Elopement Evaluation/ Wandering Tool, which does not replace an electronic monitoring device.
- Review and revise the elopement evaluation/wandering assessment to include comprehensive scoring system.
- Current residents in-house will be reassessed for exit seeking / elopement by the Director of Nursing/designee.
- Residents will be assessed for exit seeking/elopement by the admitting RN upon admission.
- Elopement binder will be revised upon completion of all assessments by the Director of Nursing/designee.
- Per results of assessments, care plans will be updated and implemented with resident-specific interventions by Director of Nursing/designee as warranted.
- Elopement policies will be reviewed and revised as necessary by Nursing Home Administrator/designee.
- Wander guard system will continue to be audited by Environmental Director/designee.
- Education of all facility staff will be conducted by Director of Nursing/designee on Elopement Risk and Supervision of residents.
- QA/QAPI will be conducted related to plan of correction for F689. Meetings will be conducted regularly.
Incomplete Ombudsman Contact Information Posted
Penalty
Summary
The facility failed to post complete contact information for the State Long-Term Care Ombudsman program as required. During an observation on Roseview Hallway, a poster was found displaying only the Ombudsman’s phone number, without the name, address, or email address. This deficiency was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the required information was not fully posted. The report cites this as a failure to meet regulatory requirements for providing residents with access to pertinent State agencies and advocacy groups.
Nurse Aide Trainee Worked Beyond Certification Timeframe
Penalty
Summary
The facility failed to ensure that a nurse aide trainee, Employee E28, became certified within the required four-month period as mandated by federal regulations. Documentation showed that Employee E28 was hired as a nurse aide trainee and completed the facility's nurse aide training program, but continued to work as a nurse aide trainee from July 2024 to July 2025, exceeding the 120-day limit for uncertified nurse aides. This was confirmed by a review of personnel records, timecards, and an interview with the Human Resource Director, who acknowledged that Employee E28 worked past the allowed timeframe without obtaining certification. The deficiency was identified for one of four nurse aides reviewed.
Deficiencies in Food Storage, Labeling, Sanitation, and Hand Hygiene in Main Kitchen
Penalty
Summary
The facility failed to comply with its own policies and professional standards regarding food storage, labeling, sanitation, and hand hygiene in the Main Kitchen. During observations, surveyors found that food items in various storage areas, including refrigerators and freezers, were not properly labeled or dated. Specifically, a meat and cheese stick snack, an opened box of grits, chicken tenders, and soft pretzels were all found without labels or dates. Additionally, a rag with brown and black substances was found in a refrigerator, and loose sugar was scattered on the floor in the dry storage area. Meat was stored in a way that it touched the ceiling of the walk-in freezer, and large icicles were found on the freezer floor. Further deficiencies included the lack of essential supplies at hand washing stations, as the hand washing sink in the Main Kitchen did not have towels for drying hands. Equipment such as a meat slicer and floor mixer were observed to be uncovered and not in use, leaving them exposed to potential contamination. These findings were confirmed by the Food Service Director, who acknowledged the failures in labeling, dating, sanitation, and hand hygiene supply maintenance.
Failure to Prevent Resident Elopement Resulting in Immediate Jeopardy
Penalty
Summary
The Nursing Home Administrator (NHA) and Director of Nursing (DON) failed to effectively manage the facility, resulting in the elopement of two residents. Review of job descriptions confirmed that the NHA was responsible for establishing and maintaining efficient and effective systems to safely meet residents' needs in compliance with regulations, while the DON was responsible for the organization and oversight of all nursing operations and supervision of resident care. Despite these responsibilities, the facility did not prevent the elopement of two residents, which created an immediate jeopardy situation. This failure was identified through review of job descriptions, clinical records, and staff interviews, and it was determined that the NHA and DON did not fulfill their essential job duties to ensure adherence to federal and state guidelines and regulations.
Insufficient Nursing Staff Resulting in Delayed Care and Unmet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple resident and staff interviews, as well as direct observations. Residents reported delays in receiving meals, with food often arriving cold due to late distribution. Several residents stated that they did not receive regular showers, particularly on weekends, and had to wash themselves or argue with staff to receive basic hygiene care. Residents also reported long wait times, up to 15-20 minutes, for staff to respond to call bells. Seven residents in a group interview expressed concerns about chronic understaffing. Staff interviews corroborated these concerns, with nurse aides reporting that they were sometimes responsible for as many as 60 residents with only three aides available. Staff stated that this level of staffing made it impossible to answer call lights promptly or provide showers as scheduled. The nursing home administrator confirmed that the facility did not have enough nursing staff to provide necessary care and services to maintain the highest practicable well-being of the majority of residents reviewed. These findings were cited as violations of state regulations regarding staffing and resident care.
Failure to Provide Medically Related Social Services for Residents with Mental Health Needs
Penalty
Summary
The facility failed to provide medically related social services to four residents with significant mental health diagnoses, including schizophrenia, major depressive disorder, mood disorder, anxiety disorder, and seizure disorder. Documentation review revealed that these residents did not receive consistent psychosocial support or follow-up for their mental health needs, despite recommendations for regular therapy and psychiatric follow-up. For example, one resident with paranoid schizophrenia and major depressive disorder had no current psychosocial support documented, while another with multiple mental health diagnoses had no consistent psychosocial reviews or follow-up after a physician appointment. Another resident was recommended for weekly psychiatric visits but had no documented interventions following behavioral incidents, and a fourth resident had no clinical documentation of psychosocial support after a recommendation for weekly therapy. Interviews with the facility's social worker confirmed that there was no established process for identifying residents in need of additional psychiatric social services, nor was there a maintained list of residents requiring regular psychosocial support. The social worker acknowledged that while a personal list was kept, it was not reflected in the clinical records of the affected residents and was not provided upon request. This lack of documentation and process resulted in the failure to provide necessary medically related social services as required by facility policy and regulatory standards.
Lack of Attending Physician Review of Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to provide evidence that monthly medication regimen reviews (MRR) were reviewed by the attending physician for three residents. For each resident, the clinical records showed that the MRRs were completed and signed by a Certified Registered Nurse Practitioner (CRNP), but there was no documented response or review from the attending physician as required. Specifically, for one resident with dementia, anxiety, and cognitive decline, the MRR did not include the attending physician's response, and the CRNP made decisions regarding gradual dose reduction for multiple psychotropic medications. Another resident with adult failure to thrive, hypertension, and dementia also had an MRR lacking the attending physician's review, with the CRNP making medication discontinuation decisions. A third resident with dementia, anxiety, depression, and Alzheimer's disease similarly had their MRR reviewed and signed by a CRNP, with decisions made about not completing gradual dose reductions for several medications, but without the attending physician's documented involvement. During staff interviews, it was confirmed that the facility did not ensure the attending physician reviewed the MRRs monthly for these residents, and that the reviews were instead conducted by nurse practitioners. This practice was not in accordance with facility policy and regulatory requirements, as the attending physician's review and response were missing from the medical records for all three residents involved.
Unqualified Food Service Director Employed
Penalty
Summary
The facility failed to employ a qualified Food Service Director (FSD) to manage the daily operations of the Dietary Department for nine out of twelve months. The individual serving as FSD during this period stated she had no relevant education or certification, specifically not being a Certified Dietary Manager. The Registered Dietitian (RD) employed at the facility confirmed her role was limited to clinical duties and did not include management of the kitchen operations. The Nursing Home Administrator acknowledged that there was no documented evidence to show that the FSD met the required qualifications for the position, as required by regulation.
Failure to Honor Resident's Roommate Choice and Provide Written Notice
Penalty
Summary
A deficiency was identified when the facility failed to honor a resident's right to share a room with their spouse or roommate of choice. Additionally, the resident did not receive written notice prior to a change being made regarding their room assignment. This action was not in accordance with the resident's rights as outlined in regulatory requirements.
Resident Rights Violation: Unwarranted Room Transfer for Staff Convenience
Penalty
Summary
A resident with diagnoses of schizophrenia, anxiety disorder, and seizure disorder was admitted to the facility and had been residing in a private room for an extended period due to behavioral reasons. According to the clinical record and census review, the resident occupied the private room from 6/21/24 to 7/10/25. Staff interviews revealed that the resident was moved out of the private room to accommodate another resident who also required a private room for behavioral reasons. The social worker confirmed that the decision to move the resident was based on facility needs rather than the resident's needs, and that the resident was not able to pay for the private room. The facility failed to ensure that the room change was not completed for staff convenience, as required by resident rights regulations. The social worker acknowledged that the move was made to meet facility needs and not the needs of the resident, despite being aware that both residents had similar behavioral concerns necessitating a private room. This action resulted in a deficiency related to the protection of the resident's right to refuse certain types of non-requested transfers within the facility.
Failure to Ensure Call Bell Accessibility for Resident
Penalty
Summary
The facility failed to accommodate the call bell needs of one resident. According to facility policy, the call system must be accessible to residents while in bed or other sleeping accommodations. A review of the clinical record showed that the resident had diagnoses of anemia, muscle weakness, and required assistance with personal care. During an observation, the resident's call bell was found hanging from the wall unit at the head of the bed, out of the resident's reach. A registered nurse confirmed that the call bell was not accessible or available for the resident's use, indicating the facility did not meet the resident's needs for call bell accessibility.
Failure to Address Resident Grievance Regarding Assistance with Eating
Penalty
Summary
The facility failed to follow up on a grievance raised by a resident's family member regarding the need for assistance with eating due to the resident's recent weight loss. Documentation review showed that the family member requested help for the resident, who had anemia and required personal assistance, but there was no evidence in the clinical record that the facility responded to this concern. Staff interviews, including with the Nursing Home Administrator, confirmed that the concern was not addressed, indicating a failure to honor the resident's right to voice grievances and to ensure prompt resolution as required by federal and state regulations.
Failure to Provide Required Toileting Assistance Resulting in Resident Neglect
Penalty
Summary
A deficiency occurred when a resident with a history of dementia, left below-knee amputation, and anxiety, who required staff assistance for toileting due to an activity of daily living (ADL) self-care deficit, was not provided the necessary care. The resident's care plan and facility policy required assessment and provision of appropriate transfer and toileting assistance. Documentation by a nurse aide indicated the resident was incontinent and received toileting hygiene assistance in the morning. However, during an observation later that morning, the resident was found lying in bed with a soiled gown saturated in urine, soiled bed sheets, and a noticeable odor of urine present. Further review confirmed that the assigned nurse aide did not assist the resident with toileting as required, despite documentation stating otherwise. The aide acknowledged that the resident was saturated in urine and that the sheets needed to be changed. This failure to provide necessary toileting assistance and hygiene resulted in the resident being left in a soiled condition, constituting neglect as defined by the facility's policies and state regulations.
Failure to Communicate Required Resident Information During Transfers
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider during facility-initiated transfers for two of three sampled residents. For both residents, the clinical records showed that they were transferred to the hospital and later returned to the facility. However, there was no documented evidence that the facility provided the receiving health care provider with essential information, including the residents' care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the residents' specific needs at the receiving facility. One resident had diagnoses of high blood pressure, hyperlipidemia, and required assistance with personal care, while the other had high blood pressure, hyperlipidemia, and muscle weakness. Despite these medical needs, the required communication and documentation were not present in the clinical records for either transfer. The Director of Nursing confirmed during an interview that the necessary information was not communicated for these residents.
Failure to Implement Smoking Safety Intervention per Care Plan
Penalty
Summary
The facility failed to implement the comprehensive care plan for a resident who required safety interventions while smoking. According to the resident's care plan and quarterly smoking assessment, the resident, who had diagnoses including high blood pressure, hemiplegia, and muscle weakness, was required to wear a smoking apron during smoking activities. However, during an observation, the resident was seen smoking in the designated area without the required smoking apron, despite this intervention being clearly documented in the care plan. Further investigation revealed that the staff member supervising the smoking session, a receptionist, was not aware that the resident was supposed to wear a smoking apron. The receptionist confirmed during an interview that they had never been informed of this requirement and acknowledged that the resident was not wearing the apron as indicated in the care plan. This failure to communicate and implement the care plan intervention resulted in noncompliance with facility policy and state regulations regarding resident care policies and nursing services.
Failure to Provide Required Toileting Assistance
Penalty
Summary
A deficiency was identified when a resident with a left below-the-knee amputation, dementia, and anxiety, who required staff assistance for toileting due to an activities of daily living (ADL) self-care deficit, did not receive the necessary care. According to the resident's care plan and facility policy, staff were required to provide assistance with toileting and document any refusals. On the date in question, documentation by a nurse aide indicated the resident was incontinent and had been provided with toileting hygiene assistance. However, during an observation later that morning, the resident was found lying in bed with a soiled gown saturated in urine, soiled bed sheets, and a noticeable odor of urine present. The nurse aide assigned to the resident confirmed that the resident was saturated in urine, the sheets needed to be changed, and that toileting assistance had not been provided. The Nursing Home Administrator also confirmed the failure to provide toileting assistance for this resident.
Failure to Notify Physician of Insulin Refusal and Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to notify the physician as required when two residents either refused prescribed insulin injections or experienced elevated capillary blood glucose (CBG) levels, as specified in physician orders and facility policy. For one resident with diagnoses including schizophrenia, anxiety disorder, seizure disorder, and type 2 diabetes mellitus, there were multiple documented refusals of prescribed Humalog insulin injections. However, the clinical notes did not indicate that the physician was notified of these refusals, contrary to facility policy and physician orders. For another resident with diabetes mellitus, hyperlipidemia, and PTSD, physician orders required notification if CBG levels exceeded certain thresholds. The resident's records showed several instances of CBG readings well above the specified threshold, but there was no documentation that the physician was notified of these elevated levels as required. The facility's policy on hyperglycemia management and the specific physician orders both mandated physician notification under these circumstances. Interviews with facility leadership confirmed that the nursing staff did not notify the physician as required, and instead relied on the nurse practitioner to review printed blood sugar records. The lack of timely physician notification for both medication refusals and elevated CBG levels constituted a failure to provide care and treatment according to physician orders and resident needs.
Failure to Obtain Physician Order for Urinary Catheter
Penalty
Summary
A deficiency was identified when the facility failed to obtain appropriate physician orders for a urinary catheter for one resident. The facility's policy requires that any resident admitted with an indwelling catheter, or who subsequently receives one, must be assessed for removal unless clinically necessary, and that proper physician orders must be obtained. Review of the resident's admission and care plan records indicated the presence of a catheter, but there was no corresponding physician order for its use after admission. The only order on file was from the hospital prior to admission. During observation, the resident was found with a catheter in use, and staff interviews confirmed that there was no specific physician order for the catheter in the facility's records. The Assistant Director of Nursing acknowledged that the required physician order had not been obtained as mandated by facility policy and state regulations. The resident had a medical history including diabetes, hyperlipidemia, and chronic kidney disease, and was being monitored for incontinence at the time of the deficiency.
Failure to Maintain Consistent Dialysis Communication
Penalty
Summary
The facility failed to provide consistent and complete communication with the dialysis center for two residents who required hemodialysis. According to facility policy, a communication form must be completed and sent with the resident to dialysis, and upon return, the form should be reviewed and post-dialysis information documented. For one resident with diagnoses including high blood pressure and End Stage Renal Disease, clinical records showed missing or incomplete dialysis communication forms on three separate treatment days within a specified period. A registered nurse unit manager confirmed these omissions. For another resident with similar diagnoses, the clinical record lacked complete communication forms for eight treatment days within a one-month period. Some forms were missing dates, and one treatment day had no form at all. A registered nurse confirmed the absence of these required forms, indicating the facility did not maintain consistent and complete communication with the dialysis center as required by policy.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for two residents with a diagnosis of post-traumatic stress disorder (PTSD). Facility policy requires the identification of triggers that may re-traumatize residents with a history of trauma. However, a review of the clinical record for one resident revealed the absence of a PTSD care plan with identified triggers, despite documentation of agitation, yelling profanities, and aggressive behavior. The resident's diagnoses of PTSD, depression, and insomnia were current at the time of review. Similarly, another resident with a diagnosis of PTSD did not have a care plan developed with goals and interventions related to PTSD. The care plan review did not include any trauma-informed strategies or identification of triggers. During staff interviews, it was confirmed that the facility failed to provide trauma-informed care to eliminate or mitigate triggers that could cause re-traumatization for both residents.
Failure to Provide Appropriate Supervision for Suicidal Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident who displayed mental and psychosocial adjustment difficulties, specifically suicidal ideation. The resident, who had diagnoses of dementia, anxiety, and cognitive decline, was grieving the loss of their spouse and had a history of severe cognitive impairment as indicated by a BIMS score of 4. On the day of the incident, staff removed potentially harmful objects from the resident's room after the resident expressed suicidal thoughts and behaviors, including statements about self-harm and intent to die. The resident's family confirmed concerns about suicidal ideation. The resident became agitated, and their roommate was relocated for safety. The resident was placed on every 15-minute checks for suicide prevention until being transferred to the hospital. Despite these interventions, the facility did not implement a one-to-one observation for the resident when they were actively suicidal, as confirmed by both the Nursing Home Administrator and the Nurse Practitioner. Facility policy and staff interviews indicated that one-to-one observation is expected in such situations to ensure the resident is not left alone. The failure to provide this level of supervision constituted a deficiency in ensuring the resident received appropriate treatment and services for their mental and psychosocial needs.
Failure to Provide Appropriate Dementia Care
Penalty
Summary
A resident who displays or is diagnosed with dementia did not receive the appropriate treatment and services as required. The facility failed to ensure that the necessary care was provided to address the resident's dementia-related needs. This deficiency was identified during the survey process, indicating a lapse in the delivery of care specific to dementia management for the affected resident.
Failure to Accurately Account for Controlled Medications on Medication Carts
Penalty
Summary
The facility failed to implement its own procedures for the accurate accounting of controlled medications on two medication carts, specifically the Cardinal East and Cardinal Southwest carts. According to the facility's policy, controlled medications are required to be counted by two professional nurses at the beginning and end of each shift, with documentation of the count and signatures to verify accuracy. However, a review of the narcotic count record logs revealed that nursing staff did not sign the records during shift changes on multiple occasions for both medication carts. Specific dates were identified where outgoing nurses failed to sign off, indicating that the required verification of controlled drug counts was not completed as per policy. Interviews with LPNs confirmed that there was no alternative method in place to verify narcotic counts other than the paper log, and that the required documentation was not completed. The deficiency was communicated to the Nursing Home Administrator, confirming that the facility did not follow its established procedures for controlled medication management as required by state regulations.
Outdated Medication Found in Medication Cart
Penalty
Summary
The facility failed to properly store medications in one of its medication carts, specifically the Dogwood [NAME] Medication Cart. During an observation, an outdated Humalog insulin pen belonging to a resident was found in the cart, with an open date of 6/17/25 and an expiration date of 7/14/25. Facility policy requires that discontinued, outdated, or deteriorated drugs be returned to the pharmacy or destroyed, but this was not followed. A Licensed Practical Nurse confirmed the presence of the outdated medication and acknowledged the failure to adhere to proper medication storage procedures.
Failure to Provide Special Eating Equipment as Care Planned
Penalty
Summary
A resident with diagnoses including dementia, acquired absence of the left leg below the knee, and anxiety was care planned to receive all disposable eating items from dietary services due to hoarding behaviors, which posed an infection control concern. Despite this care plan, the resident was observed using a reusable plate and silverware during a meal service. Staff confirmed that the facility failed to provide the required special eating equipment and utensils as specified in the resident's care plan, resulting in noncompliance with the established infection control measures for this individual.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 774 citations issued within 25 miles in the last 12 months — including the 14 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Butler
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Advanced Care Center Of Butler | 4.4 mi | — | 0 | 0 |
| Concordia Lutheran Health And Human Care | 7.3 mi | ★★★★★ | 0 | 0 |
| Embassy Of Saxonburg | 7.9 mi | ★★★★★ | 57 | 3 |
| Quality Life Services - Chicora | 9.7 mi | ★★★★★ | 33 | 0 |
| Quality Life Services - Sugar Creek | 11.7 mi | ★★★★★ | 13 | 1 |
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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 October 2026) and official state health department websites.