Above average — CMS composite of the measures below.
The next survey window likely opens around February 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 Third Avenue Health & Rehab Center during CMS and state inspections, most recent first.
A resident with diabetes and a left AKA, who was cognitively intact per MDS, was restricted from using the bathroom connected to the bedroom and instead was transferred to a commode in the shower room. The resident said they did not understand the reason for the restriction and preferred using the bathroom in the room; staff said the wheelchair would not fit, but observation showed it did fit through the doorway. The record lacked documentation that the resident was informed of the reason, risks, alternatives, expected duration, reassessment plan, or that the resident participated in the decision-making process.
Missing Required Admission Documentation: The facility failed to maintain required written admission information for a cognitively intact resident admitted with cervical myelopathy and generalized muscle weakness. The record lacked evidence that the resident and/or resident representative received and acknowledged key admission materials, including patient portion liability, daily rate cost structure, resident rights, appeal rights, consent to treatment, ancillary service choices, bed hold policy, and consequences for nonpayment. The NHA confirmed admission paperwork should be reviewed on admission, but documentation for this resident was not present.
A resident with dementia and CHF had a physician order for PRN Midodrine 5 mg PO TID for systolic BP less than 100 mm/Hg. Review of the MAR showed four missed doses even though the resident’s systolic BP readings were below the ordered threshold. The ADON acknowledged nursing staff did not follow acceptable standards of nursing practice related to medication administration and confirmed meds are to be given as prescribed and in accordance with physician orders.
Failure to provide ordered oxygen therapy: A resident with respiratory failure with hypoxia, emphysema, and pneumothorax had a continuous order for oxygen via NC, but was observed with an empty O2 tank attached to the wheelchair and later found asleep in bed without oxygen in use, with the concentrator and NC left away from the resident and tubing on the floor. The DON confirmed the empty tank, and later acknowledged the facility could not document how often O2 tanks were monitored or that oxygen was administered as ordered.
Delayed Availability of Prescribed Insulin: A resident with a blood sugar disorder was ordered nightly degludec insulin, but the medication was not available at the scheduled time and was not administered until early the next morning. The MAR and nursing note showed the dose was delayed, and the resident reported being awakened in the middle of the night for the injection. The DON confirmed pharmacy notifications were sent before the supply ran out, but there was no documented evidence the medication was obtained and available as ordered.
Delayed and missed meal trays occurred when a resident did not receive breakfast on time because a meal ticket was missing, and two other residents reported occasional missed trays. The FSD confirmed meal tickets are counted before meal service, but the resident’s tray was delayed until a meal was prepared and delivered after staff identified the omission.
Failure to implement a resident’s positioning program occurred when a resident with Parkinson’s disease and Lewy body dementia was observed in a Broda chair with marked left lateral neck and trunk flexion and no cervical or trunk support in place. The resident’s sister reported bringing a neck pillow because the facility had not provided appropriate support, and the care plan lacked clear, individualized instructions for the resident’s cervical contracture. OT documented the need for adaptive equipment to achieve midline positioning, but the discharge summary did not identify the specific devices needed, and staff training on positioning techniques, devices, and schedules was not documented.
A resident with cognitive intactness and mobility issues reported not receiving prescribed PRN Oxycodone after requesting it from both a female nurse and a female aide, with conflicting accounts involving a male nurse. The facility failed to identify or interview all staff referenced by the resident, did not obtain written statements from those who documented medication administration, and did not reconcile inconsistencies in the reports, resulting in an incomplete investigation of the alleged misappropriation.
The facility did not provide the required number of nurse aides on multiple shifts, as confirmed by staffing records and the DON, with no additional higher-level staff available to compensate for the shortfall.
The facility did not provide the required minimum number of LPNs per resident on multiple night and evening shifts, as confirmed by staffing records and the DON. No additional higher-level staff were available to compensate for these shortfalls.
The facility did not consistently provide the required minimum of 3.2 hours of direct general nursing care per resident in a 24-hour period, as evidenced by staffing records and confirmation from the DON. On several occasions, the nursing hours per resident fell below the mandated level.
A resident with severe cognitive impairment and a history of recurrent falls experienced multiple unwitnessed falls and serious injuries, including a traumatic subdural hemorrhage and fractures, due to the facility's failure to provide adequate supervision and individualized fall prevention interventions. Despite ongoing unsafe self-transfer attempts and ineffective redirection, the care plan was not updated to include enhanced supervision or appropriate interventions.
Surveyors observed mouse droppings in the main dining room and multiple kitchen areas, including dry storage and meal preparation zones, despite regular pest control services that failed to report rodent activity. The NHA confirmed the facility's responsibility to prevent food contamination, but evidence of rodents indicated a failure to maintain proper food storage and service practices.
Multiple observations of mouse droppings were found in resident rooms, the main dining room, and kitchen areas, despite regular visits from an external pest management company and no documented evidence of rodent activity. Several residents and staff reported seeing mice in the facility over the past few months, and facility leadership confirmed the absence of an effective pest control program.
A resident with chronic pain and osteoarthritis, who was cognitively intact, verbally refused a diuretic medication during a medication pass, expressing concern about its effects. An LPN, unaware that the medication was a diuretic, denied the resident's request and administered the medication despite the refusal, failing to honor the resident's right to participate in care decisions.
A resident with severe cognitive impairment and mobility limitations did not consistently receive restorative ambulation services as planned. Despite a care plan and physical therapy recommendations for regular ambulation with staff assistance, the resident was only ambulated on a few occasions, with missed sessions not being evaluated or addressed by licensed staff.
Surveyors found that two opened multi-dose insulin pens, Insulin Lispro and Insulin Glargine, were stored in a medication cart without being dated when first accessed, contrary to facility policy. An LPN and the Nursing Home Administrator confirmed the lack of required labeling for these medications.
The facility did not meet the required nurse aide to resident ratios on nine shifts, with specific deficiencies in staffing levels on various shifts across several days. The facility lacked the necessary number of nurse aides on the day, evening, and night shifts, and no additional higher-level staff were available to compensate for these deficiencies. An interview with the Nursing Home Administrator confirmed these staffing shortfalls.
The facility did not meet the required LPN to resident ratios on seven shifts, with insufficient LPN staffing on specific night and evening shifts. For example, one night shift had only one LPN instead of the required 1.2 for a census of 48. The Director of Nursing confirmed the shortfall, and no additional staff were available to compensate.
The facility did not meet the required 3.2 hours of direct nursing care per resident per day. On two occasions, the care hours fell short, with 3.12 and 2.90 hours provided. This was confirmed by staffing reviews and an interview with the DON.
A resident with Alzheimer's disease was mistakenly given insulin intended for another resident due to misidentification by an LPN on orientation. The error was not promptly addressed, and the resident's blood sugar was not monitored. Additionally, two residents did not receive prescribed wound treatments for four days. These deficiencies were confirmed by the DON.
A resident with Alzheimer's was mistakenly given insulin not prescribed to her due to a misidentification by an LPN on orientation. The error was reported internally but not to the physician or the resident's family, violating nursing services regulations.
A resident with Alzheimer's was mistakenly given insulin intended for another resident due to an LPN's failure to verify identity properly. The LPN, new to the facility, administered the medication without completing necessary competencies, leading to a medication error. The facility did not ensure the LPN was adequately prepared for unsupervised medication administration.
A facility failed to ensure timely delivery and administration of medications for a resident with cancer, resulting in a four-day delay in receiving prescribed Oxycodone and Ativan. The Nursing Home Administrator acknowledged the failure to meet the resident's needs.
A resident with Alzheimer's disease was mistakenly given insulin intended for another resident due to a failure in verifying identity. An LPN on orientation administered the medication without proper supervision or identity checks, leading to a significant medication error. The incident was not documented in the resident's clinical record, and the physician was not informed, highlighting a lapse in communication and documentation within the facility.
A resident with Alzheimer's disease was mistakenly given insulin not prescribed to her, and the error was not documented in her clinical records. The incident was reported internally, but the DON advised against documentation due to an upcoming health department revisit. The resident's records did not reflect the administration of glucagon or a high-calorie supplement given to address the error.
A resident with a history of cerebral conditions experienced severe pain following a fall, which was inadequately managed by the facility. Despite reporting pain levels of 10/10, the nursing staff failed to notify the physician for further pain management interventions. The resident's severe pain persisted over several days, and it was only after a new x-ray revealed a fracture that the resident was transferred to the hospital. The facility's Director of Nursing confirmed the failure to address the resident's pain effectively.
The facility failed to maintain a clean and orderly environment in the resident's main dining room. Observations revealed worn chairs, debris and deceased bugs in windowpanes, cobwebs and live spiders on blinds, and a sticky floor with a dirty garbage can. The Nursing Home Administrator confirmed these issues, acknowledging the need for a clean and homelike environment.
A facility failed to prevent the misappropriation of a resident's medication, hydrocodone-acetaminophen, due to inadequate documentation and reporting. Despite receiving the medication, it went missing, and the discrepancy was not reported until days later. The investigation confirmed the misappropriation but did not identify a perpetrator.
The facility failed to update a care plan for a resident with dementia, whose bed was placed against the wall for fall prevention, but this measure was not documented. Additionally, another resident on palliative care lacked an order and care plan. These deficiencies were confirmed by the DON and surveyors.
A facility failed to provide a discharge summary and medication disposition for a resident discharged with MRSA, pneumonia, and heart failure. The resident's record lacked a comprehensive summary of their stay, treatment, and post-discharge care plan. Additionally, there was no documentation regarding the disposition of the resident's medications. The nursing home administrator could not provide evidence of these documents during the survey.
A resident with hypertension was prescribed Metoprolol with specific parameters to hold the medication if certain vital signs were not met. However, the facility failed to document monitoring of the resident's blood pressure and heart rate before administering the medication, as confirmed by the DON.
Two residents in the facility were using Foley catheters without documented clinical justification. One resident had a history of dementia and a UTI linked to catheter use, while the other had kidney disease and failed void trials. Despite these conditions, their records lacked evidence supporting the need for continued catheter use, as confirmed by the DON.
A facility failed to create and implement a person-centered care plan for a resident with Alzheimer's, who showed dementia-related behaviors like spitting and agitation. The care plan did not address the resident's diagnosis or include individualized interventions based on their preferences and history. The facility also lacked evidence of providing necessary non-pharmacological care and specialized services.
A resident with Alzheimer's disease was administered alprazolam as needed for anxiety without documented clinical rationale for its continued use beyond 14 days. The medication was given multiple times over two months, and the physician failed to re-evaluate its necessity, as confirmed by the DON.
A facility failed to follow up on necessary dental services for a Medicaid resident, resulting in delayed dental checks and extractions. Despite a recommendation for continued care, there was no evidence of follow-up or completion of the extractions, impacting the resident's meal intake and nutritional status.
The facility failed to maintain an effective pest control program, as evidenced by open doors providing entry for pests and mice droppings found in the dietary dry storage room. The pest control reports lacked detailed information on services and outcomes. The DON confirmed the presence of rodent activity and the limited information in the pest control reports.
The facility failed to maintain sanitary practices for food storage and service, including improperly stored food items, missing baseboard molding exposing drywall, and mouse droppings in the dry storage room. A personal backpack was also found on a kitchen counter. These issues were confirmed by the Certified Dietary Manager and the Director of Nursing.
The facility failed to maintain a safe environment by leaving an unattended and unlocked treatment cart in a resident hallway, exposing prescription creams, ointments, and treatment supplies. Residents were observed ambulating near the cart, and the DON confirmed the cart should not have been left open and unattended.
Resident Not Fully Informed About Bathroom Use Restriction
Penalty
Summary
The facility failed to ensure Resident 8 was fully informed of, and participated in decision-making regarding, a restriction that prevented the resident from using the bathroom connected to the bedroom to void. Resident 8 was admitted with diagnoses including diabetes and a left above-the-knee amputation, and the admission MDS dated December 16, 2025, identified the resident as cognitively intact with a BIMS score of 14. During an interview, Resident 8 stated they did not know why they were unable to use the bathroom in their room and preferred using that bathroom rather than being transferred to a commode in the shower room down the hall. The resident reported that the only explanation given was that the wheelchair would not fit through the bathroom doorway. Observation showed Resident 8's wheelchair was able to fit through the doorway to the bathroom and was not blocking entry. Review of the clinical record and care plan found no documentation that the resident was informed of the reason for the restriction, the risks or safety concerns, alternative options, expected duration, or plans to reassess the resident's ability to use the bathroom in the room. The record also did not show the resident's understanding of the restriction or the resident's preferences. An OT stated the bathroom did not allow adequate space for certain transfer equipment and that the shower room provided more space for transfers, but the OT and DON were unable to provide documentation showing the resident was fully informed or involved in the decision-making process.
Missing Required Admission Documentation
Penalty
Summary
The facility failed to provide and maintain required written admission information and documentation for one of 17 residents reviewed, Resident 63. The facility policy titled Admissions Policy stated the facility would admit only individuals whose clinical, physical, psychosocial, and emotional needs could be met by the facility. The admission agreement reviewed included services, charges and fees, termination of the agreement, and miscellaneous areas to be reviewed with each newly admitted resident and/or resident representative, along with a signature page. Resident 63 was admitted with diagnoses including cervical myelopathy and generalized muscle weakness and was later discharged from the facility. The admission MDS dated January 5, 2026, showed the resident was cognitively intact with a BIMS score of 15 and that the resident and resident representative participated in the assessment process. However, the clinical record, including social service documentation and communication with the resident's family, did not contain documented evidence that required admission information was provided and acknowledged at admission. Missing documentation included written information regarding patient portion liability, daily rate cost structure, resident rights, appeal rights, consent to treatment, the right to choose ancillary services, bed hold policy, and consequences for failure to pay. The Nursing Home Administrator confirmed that admission paperwork is to be reviewed with each resident and/or resident representative upon admission, but no documented evidence was provided that this was completed for Resident 63.
Missed PRN Midodrine Doses Despite Low Blood Pressure Readings
Penalty
Summary
The facility failed to ensure a licensed nurse administered prescribed medication in accordance with the physician’s order and accepted standards of nursing practice for one resident. The resident had diagnoses including dementia and chronic combined systolic and diastolic congestive heart failure. A physician’s order dated February 7, 2026, directed Midodrine 5 mg by mouth three times daily as needed for systolic blood pressure less than 100 mm/Hg. Review of the MAR for February and March 2026 showed four occasions when Midodrine was not administered even though the resident’s systolic blood pressure was below the ordered threshold: 98/60 mm/Hg, 99/71 mm/Hg, 97/65 mm/Hg, and 98/66 mm/Hg. The facility policy required staff to verify the correct dose, route, rate, time, and resident before administration and to obtain vital signs when required by the order. During interview, the ADON acknowledged nursing staff did not follow acceptable standards of nursing practice related to medication administration and confirmed medications are to be administered as prescribed, in a safe and timely manner, and in accordance with physician orders.
Failure to Provide Ordered Oxygen Therapy
Penalty
Summary
The facility failed to consistently provide respiratory care and supplemental oxygen in accordance with physician orders and its oxygen administration policy for one resident. The policy required licensed clinicians with demonstrated competence to administer oxygen via the ordered route and to monitor oxygen delivery systems, including checking oxygen cylinder gauges to ensure an adequate supply was available. During an initial tour, the resident was observed seated in a wheelchair in the main dining room with an oxygen tank attached to the back of the wheelchair, and the tank gauge indicated it was empty; this was confirmed by the DON. The resident had diagnoses including respiratory failure with hypoxia, centrilobular emphysema, and pneumothorax. A physician order directed oxygen at 3 liters per minute via nasal cannula continuously. The resident’s admission MDS showed severe cognitive impairment with a BIMS score of 3 and extensive assistance needs for activities of daily living, bed mobility, and transfers, indicating reliance on staff to ensure ordered treatments were implemented. On a later observation, the resident was lying in bed asleep without oxygen in use, while the oxygen concentrator and nasal cannula were 3.5 feet away and the tubing and cannula were lying on the floor; this was confirmed by an LPN. The DON stated the facility could not provide documentation identifying the frequency of monitoring oxygen tanks and acknowledged the facility failed to ensure oxygen therapy was administered as ordered.
Delayed Availability of Prescribed Insulin
Penalty
Summary
The facility failed to ensure the timely acquisition and availability of a prescribed medication for one resident who was cognitively intact and had a diagnosis of a chronic medical condition in which the body cannot properly regulate blood sugar levels. Resident 7 was ordered degludec insulin to be administered nightly at 9:00 PM, but the medication was not available at the scheduled time on March 17, 2026. The Medication Administration Record and nursing documentation showed the insulin was not administered until 3:00 AM on March 18, 2026. At the time the insulin was finally given, Resident 7's blood glucose level was 346 mg/dL. The resident stated during interview that staff awakened him in the middle of the night to give the injection because the insulin had not been available at the scheduled time. The Director of Nursing confirmed the facility had sent pharmacy notifications requesting the degludec insulin before the supply was depleted, but there was no documented evidence that the facility ensured the medication was obtained and available as ordered.
Delayed and Missed Meal Trays
Penalty
Summary
The facility failed to ensure timely meal service for three residents by not effectively managing the food and nutrition services department and meal ticket process. During breakfast observation, one resident who was alert and oriented and preferred to eat in her room had not received her breakfast tray even though her roommate had already been served. The resident’s tray was not on the food cart outside the room, and a nurse aide confirmed she had delivered a tray to the roommate but did not see a tray for the resident. The Food Service Director confirmed the resident’s tray should have been on the cart for that room number and that the tray was delayed because a meal ticket was missing. The resident received breakfast after the Food Service Director had a meal prepared and delivered. During a resident group interview, two other residents reported they had experienced missed meal trays, with one stating it happened the prior week and the other stating it occurred occasionally. Both said that when they notify nursing staff, food and nutrition services sends a tray. The Food Service Director confirmed that meal tickets are printed for each resident for every meal and counted before meal service, but acknowledged the missing ticket caused the delayed breakfast tray. The Nursing Home Administrator confirmed meal trays are expected to be delivered in a timely manner and that a meal ticket is to be printed for each resident at each meal to ensure meal service accuracy and timeliness.
Failure to Implement Positioning Program for Resident With Cervical Contracture
Penalty
Summary
The facility failed to provide and ensure implementation of specialized rehabilitative services for Resident 12 related to positioning, including assessment, intervention, care planning, and staff training. The resident was admitted with Parkinson’s disease and neurocognitive disorder with Lewy bodies, and the quarterly MDS indicated the resident was dependent on staff for all ADLs, including positioning. The facility policy stated that OT/PT were responsible for evaluating positioning needs, developing the positioning program, providing positioning aids, and training nursing staff before nursing assumed responsibility for the program. During observation, Resident 12 was seen seated in a Broda chair with the chair reclined and with significant left lateral flexion of the neck and trunk. No cervical positioning device or visible trunk support was in place. Later the same day, the resident was observed being fed by his sister, who had applied a neck pillow because of concerns about worsening head positioning and its effect on swallowing. The sister stated the facility had not provided appropriate cervical support and that positioning devices were often not in place during visits. Record review showed no physician orders for positioning devices to address cervical alignment needs. The care plan identified impaired positioning and included armrest cushions and invert bilateral upper wing support, but it did not provide clear, measurable, individualized instructions and did not address the resident’s cervical contracture or specific interventions to maintain head and neck alignment. OT documented a left lateral neck contracture and recommended adaptive equipment to achieve midline positioning, and the discharge summary noted the resident could maintain midline positioning using adaptive equipment for more than eight hours, but it did not identify the specific devices or modifications needed for continued use. Therapy documentation did not show staff training on positioning techniques, devices, or schedules, and staff, including the NHA and PT, were unable to explain or demonstrate the care plan intervention. The Director of Rehabilitation confirmed cervical positioning devices were not identified in the discharge summary and that staff training had not been documented.
Incomplete Investigation of Medication Misappropriation Allegation
Penalty
Summary
The facility failed to conduct a complete and accurate investigation into an allegation of misappropriation of medication for a resident who was cognitively intact and admitted with ambulatory dysfunction due to a prosthetic joint infection. The resident reported not receiving prescribed PRN Oxycodone after requesting it from both a female nurse and a female aide during the night, with conflicting information later indicating a male nurse may have been involved. The facility's policy required that all allegations of misappropriation be thoroughly investigated, including identifying and interviewing all involved staff and witnesses, and obtaining written statements from them. Despite these requirements, the facility did not identify the staff members referenced by the resident, nor did it document efforts to determine their identities or reconcile the inconsistencies in the resident's account. The investigation included only a single witness statement from an LPN who was not directly involved in the medication administration. There was no evidence that the staff who documented administering the medication were interviewed or provided written statements. This incomplete investigation did not substantiate or disprove the resident's allegation, failing to meet the facility's own investigative standards.
Failure to Meet Minimum Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required minimum nurse aide to resident staffing ratios on 14 out of 63 reviewed shifts. Staffing records showed that on multiple dates, the number of nurse aides scheduled for day, evening, and night shifts did not meet the regulatory requirements based on the facility's census. For example, on several night shifts, the number of nurse aides was below the required ratio for the number of residents present, and similar shortfalls were noted on day and evening shifts. No additional higher-level staff were available to compensate for these deficiencies on the affected dates. This deficiency was confirmed through a review of weekly staffing records and an interview with the Director of Nursing, who acknowledged that the facility did not meet the required nurse aide to resident ratios on the specified dates. The report does not mention any specific residents affected or their medical conditions at the time of the deficiency.
Plan Of Correction
Step 1. The facility cannot retroactively provide the minimum number of Nurse Aide hours for cited dates. Step 2. Moving forward, the facility will continue to schedule staff to meet or exceed the mandated Nurse Aide ratio hours. We are actively recruiting Nurse Aides and offering sign-on bonuses for new employees and referral bonuses to current employees. The facility is advertising job postings on multiple recruiting platforms. The facility will make all good-faith efforts to utilize both internal and external resources to meet or exceed the staffing ratios. Step 3. To prevent this from reoccurring, the RDCS/designee reeducated the NHA, DON, and Scheduler on the updated staffing regulations in relation to the minimum staffing of Nurse Aide for the facility. Step 4. To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets or exceeds the minimum Nurse Aide hours needed for the facility. Audits will be completed 5x/week for 4 weeks, and then weekly for 2 months. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.
Failure to Meet Minimum LPN Staffing Ratios
Penalty
Summary
The facility failed to meet the required minimum LPN-to-resident staffing ratios on 19 out of 63 reviewed shifts. According to the reviewed weekly staffing records, the facility did not provide the mandated number of LPNs per residents on several night and evening shifts, with specific shortfalls noted for each date and census size. The required ratios were 1 LPN per 25 residents during the day, 1 per 30 in the evening, and 1 per 40 overnight, but the actual staffing fell below these thresholds on multiple occasions. No additional higher-level staff were present to compensate for the LPN shortfalls on the affected shifts. The Director of Nursing confirmed during an interview that the facility had not met the required LPN-to-resident ratios on the specified dates. The report does not mention any specific residents affected or provide details about their medical history or condition at the time of the deficiency.
Plan Of Correction
Step 1. The facility cannot retroactively provide the minimum number of LPN hours for cited dates. Step 2. Moving forward, the facility will continue to schedule staff to meet or exceed the mandated LPN ratio hours. The facility is actively recruiting LPNs and offering a sign-on bonus to new employees and referral bonuses to current employees. The facility has posted the job on multiple recruiting sites. The facility will make all good-faith efforts to utilize both internal and external resources to meet or exceed the staffing ratios. Step 3. To prevent this from reoccurring, the RDCS/designee reeducated the NHA, DON, and Scheduler on the updated staffing regulations in relation to the minimum staffing of LPNs for the facility. Step 4. To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets or exceeds the minimum LPN hours needed for the facility. Audits will be completed 5x/week for 4 weeks, and then weekly for 2 months. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations. P 5530
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to consistently provide the minimum required 3.2 hours of direct general nursing care per resident in a 24-hour period, as mandated by regulation effective July 1, 2024. A review of staffing levels and resident census revealed that on several specific dates, the facility's direct care nursing hours per resident fell below the required threshold, with recorded hours ranging from 3.11 to 3.18. These deficiencies were identified through documentation review and confirmed during staff interviews. An interview with the Director of Nursing further substantiated that the facility did not meet the minimum general nursing care hours on the dates in question. No additional details regarding the medical history or condition of individual residents were provided in the report. The findings are based solely on staffing records and staff confirmation.
Plan Of Correction
Step 1. The facility cannot retroactively correct the past nursing hour PPD. Step 2. Moving forward, the facility will continue to schedule staff to meet or exceed the mandated PPD requirement of 3.20. The facility is actively recruiting for all nursing positions, offering sign-on and referral bonuses. The facility will make all good-faith efforts to utilize both internal and external resources to meet or exceed the staffing ratios. Step 3. To prevent this from reoccurring, the RDCS/designee reeducated the NHA, DON, and Scheduler on the updated staffing regulations in relation to the minimum staffing of 3.20 hour PPD. Step 4. To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets or exceeds the minimum 3.20 hours PPD. Audits will be completed 5x/week for 4 weeks, and then weekly for 2 months. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.
Failure to Provide Adequate Supervision and Fall Prevention for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide adequate supervision and implement individualized fall prevention interventions for a resident with severe cognitive impairment and a history of recurrent falls. Despite being identified as high risk for falls and repeatedly attempting to self-transfer without assistance, the resident's care plan did not include interventions specifically addressing her poor safety awareness, severe cognitive impairment, or persistent unsafe behaviors. The interventions that were in place, such as a call bell reminder sign, anti-rollback devices, and Dycem application, were not sufficient to address the resident's needs, and re-education efforts were repeatedly used despite documentation that the resident was unable to benefit from such interventions due to her cognitive status. Progress notes documented a pattern of unwitnessed falls and self-transfer attempts over a period of several weeks, resulting in multiple injuries, including skin tears, lacerations, and ultimately a traumatic subdural hemorrhage and multiple fractures. Staff consistently noted that redirection was ineffective, and the resident continued to attempt to rise or transfer without assistance. Despite this ongoing pattern, the facility did not revise the care plan to include enhanced supervision, scheduled checks, or the use of assistive technology such as bed or chair alarms. The Director of Nursing confirmed that the facility did not provide adequate supervision or implement appropriate fall prevention interventions based on the resident's assessed needs. The failure to reassess and update the care plan in response to the resident's repeated falls and injuries resulted in significant harm, including hospitalization for serious injuries.
Rodent Activity and Food Storage Deficiency
Penalty
Summary
The facility failed to maintain acceptable practices for the storage and service of food, resulting in evidence of rodent activity in multiple areas of the kitchen and main dining room. Observations revealed over 50 mouse-like droppings on the floor underneath a cabinet in the main dining room, as well as additional droppings in the dry storage area under metal storage racks and in the meal preparation area near a wall crevice. These findings were directly observed by surveyors and confirmed by the Nursing Home Administrator, who acknowledged the facility's responsibility to prevent contamination, including rodent activity. A review of facility-provided documents showed that an external pest management company serviced the building about once a month, but their invoices from December 2024 through May 2025 did not report any rodent activity. Despite these regular services, active signs of mouse presence were found during the survey, indicating a lapse in effective monitoring and control of pests within food storage and preparation areas. No specific residents or patient medical histories were mentioned in relation to this deficiency.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple observations of mouse droppings in resident rooms, the main dining room, and kitchen areas. Despite having an external pest management company providing monthly services, there was no documented identification of rodent activity in the facility's records or invoices from December 2024 through May 2025. Direct observations on May 28, 2025, revealed mouse-like droppings in the bedrooms of several residents, including one resident who reported seeing mice in his room over the past few months. Additional droppings were found in the main dining room and kitchen, including under storage racks and near a wall crevice, suggesting possible entry points for rodents. Interviews with residents and staff further confirmed the presence of rodents, with several residents reporting sightings of mice in their rooms and common areas over the past few months. The Director of Maintenance and the Nursing Home Administrator acknowledged the lack of documented evidence of rodent activity and confirmed the facility's responsibility to maintain an effective pest control program. The deficiency was identified through direct observation, review of facility records, and resident and staff interviews.
Resident's Right to Refuse Medication Not Upheld
Penalty
Summary
A deficiency occurred when a resident, admitted with osteoarthritis and chronic pain and assessed as cognitively intact, was not afforded the right to participate in care and treatment decisions. During a morning medication pass, the resident expressed concern about taking a 'water pill' due to its diuretic effects and verbally refused the medication. Despite this, the LPN administering the medications denied the presence of a water pill and proceeded to administer Torsemide, a diuretic, to the resident against his expressed wishes. Further review revealed that the LPN was unaware that Torsemide is a diuretic, commonly referred to as a water pill by residents. The Nursing Home Administrator confirmed that the nurse failed to provide the resident with the opportunity to refuse the medication, thereby not upholding the resident's right to participate in treatment decisions and to be fully informed about their care and treatments.
Failure to Consistently Implement Restorative Ambulation Program
Penalty
Summary
The facility failed to consistently provide restorative nursing services as planned to maintain mobility for a resident with a history of obstructive hydrocephalus, anxiety, and depression. The resident, who was severely cognitively impaired and non-ambulatory upon admission, received physical therapy and was discharged with the ability to ambulate 25 feet with contact guard assistance. The discharge summary recommended continued ambulation with a rolling walker for short distances, and a care plan was developed to support walking in the resident's room with staff assistance. However, documentation showed that the resident participated in the ambulation program on only four out of eleven days, with reasons for missed sessions including refusal, deferred due to condition, and unavailability. There was no evidence that licensed staff were aware of or evaluated the resident's refusals or missed ambulation sessions at the time they occurred. The Assistant Director of Nursing was unable to provide documentation that the restorative ambulation program was implemented as planned or that missed sessions were addressed to ensure the resident's ambulation goals were met.
Failure to Date Opened Multi-Dose Insulin Pens
Penalty
Summary
Surveyors observed that the facility failed to follow its own policy and accepted professional standards regarding the labeling and storage of multi-dose medications. During an inspection of a medication cart on the Teal Hall unit, two multi-dose insulin pens—Insulin Lispro and Insulin Glargine—were found to be opened and available for use without being dated at the time of initial opening. The facility's policy requires that multi-use vials be dated when opened and discarded within 28 days unless otherwise specified by the manufacturer. This deficiency was confirmed through interviews with the LPN responsible for the cart and the Nursing Home Administrator, both of whom acknowledged that the required labeling practice was not followed.
Failure to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide to resident ratios on nine out of twenty-one reviewed shifts. Specifically, on January 30, 2025, the evening shift had 4.33 nurse aides instead of the required 4.36 for a census of 48, and the night shift had 2.97 nurse aides instead of the required 3.2. On January 31, 2025, the day shift had 4.13 nurse aides instead of the required 4.80, and the evening shift had 4.27 nurse aides instead of the required 4.36. Additionally, the evening shift on January 31, 2025, had 3.13 nurse aides instead of the required 3.20. On February 1, 2025, the day shift had 4.6 nurse aides instead of the required 4.7 for a census of 47. On February 3, 2025, the evening shift had 3.9 nurse aides instead of the required 4.27, and the night shift had 3 nurse aides instead of the required 3.13. Finally, on February 4, 2025, the night shift had 2.97 nurse aides instead of the required 3.27 for a census of 49. No additional higher-level staff were available to compensate for these deficiencies. An interview with the Nursing Home Administrator confirmed the facility's failure to meet the required staffing ratios on these dates.
Plan Of Correction
Step 1. The facility cannot retroactively provide the minimum number of Nurse Aide hours for cited dates. Step 2. Moving forward, the facility will continue to schedule staff to meet or exceed the mandated Nurse Aide ratio hours. The facility will make all good-faith efforts to utilize both internal and external resources to meet or exceed the staffing ratios. Step 3. To prevent this from reoccurring, the RDCS/designee reeducated the NHA, DON and Scheduler on the updated staffing regulations in relation to the minimum staffing of Nurse Aide for the facility. Step 4. To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets or exceeds the minimum Nurse Aide hours needed for the facility. Audits will be completed 5x/ week x4 weeks, and then weekly x2 months. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.
LPN Staffing Deficiency on Multiple Shifts
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratios on seven out of twenty-one reviewed shifts. Specifically, the night shifts on January 30, January 31, February 1, February 2, February 3, and February 4, 2025, did not have the minimum required LPN staffing based on the facility's census. For instance, on January 30 and 31, only one LPN was present on the night shift, whereas the required staffing was 1.2 LPNs for a census of 48 residents. Similarly, on February 1, the evening shift had 1.56 LPNs instead of the required 1.57 for a census of 47. The deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the shortfall in meeting the required LPN to resident ratios on the specified dates. No additional higher-level staff were available to compensate for this deficiency.
Plan Of Correction
Step 1. The facility cannot retroactively provide the minimum number of LPN hours for cited dates. Step 2. Moving forward, the facility will continue to schedule staff to meet or exceed the mandated LPN ratio hours. The facility will make all good-faith efforts to utilize both internal and external resources to meet or exceed the staffing ratios. Step 3. To prevent this from reoccurring, the RDCS/designee reeducated the NHA, DON and Scheduler on the updated staffing regulations in relation to the minimum staffing of LPNs for the facility. Step 4. To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets or exceeds the minimum LPN hours needed for the facility. Audits will be completed 5x/week x4 weeks, and then weekly x2 months. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to consistently meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per day. On January 31, 2025, the facility provided only 3.12 hours of direct care per resident, and on February 1, 2025, the care hours further decreased to 2.90 per resident. This deficiency was confirmed through a review of the facility's staffing levels and an interview with the Director of Nursing on February 13, 2025, who acknowledged the shortfall in meeting the required nursing care hours.
Plan Of Correction
Step 1. The facility cannot retroactively correct the past nursing hour PPD. Step 2. Moving forward, the facility will continue to schedule staff to meet or exceed the mandated PPD requirement of 3.20. The facility will make all good-faith efforts to utilize both internal and external resources to meet or exceed the staffing ratios. Step 3. To prevent this from reoccurring, the RDCS/designee reeducated the NHA, DON and Scheduler on the updated staffing regulations in relation to the minimum staffing of 3.20 hour PPD. Step 4. To monitor and maintain ongoing compliance, the NHA/designee will audit deployment sheets to ensure the facility staffing meets or exceeds the minimum 3.20 hours PPD. Audits will be completed 5x/week x4 weeks, and then weekly x2 months. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.
Medication Error and Wound Treatment Failures in LTC Facility
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of quality, as evidenced by a significant medication error involving a resident with Alzheimer's disease. The resident, who had severe cognitive impairment, was mistakenly administered insulin intended for another resident. The error occurred when an LPN on orientation misidentified the resident in the dining room and administered 12 units of insulin. The error was reported to the RN and the Director of Nursing (DON), but there was a delay in response and appropriate action. The resident's blood sugar was not monitored, and the physician was not contacted immediately. Instead, glucagon and a high-calorie supplement were administered without a physician's order. Additionally, the facility failed to implement physician's orders for wound treatments for two other residents. One resident with peripheral vascular disease and type 2 diabetes had a venous wound on the left calf, for which the prescribed treatment was not administered for four days. Similarly, another resident with a malignant neoplasm of the vulva had moisture-associated skin damage on the sacrum, and the prescribed treatment was also not administered for four days. These lapses in care were confirmed by the Director of Nursing during an interview. The deficiencies highlight a lack of adherence to professional standards and protocols, including timely assessment and documentation, as well as the implementation of physician's orders. The failure to provide necessary care and services in a timely manner, as well as the lack of proper documentation and communication, contributed to the deficiencies identified in the facility's nursing services.
Failure to Notify Physician and Family of Medication Error
Penalty
Summary
The facility failed to timely notify the physician and the resident's responsible party of a medication error involving a resident who was mistakenly administered insulin, which was not prescribed to her. The resident, who has Alzheimer's disease and a severe cognitive impairment, was given 12 units of insulin intended for another resident. This error occurred when an LPN on orientation misidentified the resident in the dining room, despite being advised that the resident would respond to her name. The LPN administered the insulin after the resident answered to the wrong name, and the error was witnessed by a nurse aide. The incident was reported internally to the RN and the Director of Nursing, but there was no documented evidence that the physician or the resident's representative was informed of the medication error. The facility's failure to notify the appropriate parties was confirmed during an interview with the Director of Nursing and the Nursing Home Administrator. This oversight is a violation of the nursing services regulation, as it is crucial to inform the physician and the resident's family of significant medication errors to ensure proper care and response.
Medication Administration Error Due to Inadequate Staff Competency
Penalty
Summary
The facility failed to ensure that licensed nursing staff possessed the necessary skills and competencies to administer medications accurately and safely, as evidenced by an incident involving a resident who was given medication not prescribed to them. The incident involved a resident with Alzheimer's disease who was mistakenly administered 12 units of insulin intended for another resident. This error occurred because the LPN, who was new to the facility, did not verify the resident's identity properly and relied on the resident's response to a name call, which led to the wrong resident receiving the medication. The LPN involved in the incident had only been employed at the facility for a few days and was on orientation. Despite this, she was left alone to manage the medication cart and administer medications without having completed the necessary competencies for medication administration. The LPN admitted to not checking the resident's photo for identification and did not seek assistance from other staff members to confirm the resident's identity before administering the insulin. The facility's failure to complete the medication administration competencies for the LPN before allowing her to administer medications unsupervised was confirmed by the Nursing Home Administrator and the Director of Nursing. This oversight led to the medication error, highlighting a deficiency in ensuring that nursing staff were adequately prepared and competent in their roles, particularly in medication administration.
Failure to Ensure Timely Medication Delivery
Penalty
Summary
The facility failed to implement procedures to ensure the timely acquisition and administration of medications for a resident who was readmitted with a diagnosis of malignant neoplasm of the vulva. Physician orders dated September 13, 2024, included Oxycodone for pain management and Ativan for anxiety, both to be administered as needed. However, the medications were not delivered by the pharmacy until September 17, 2024, resulting in a four-day delay. Consequently, the resident did not receive the prescribed medications during this period. An interview with the Nursing Home Administrator confirmed the facility's failure to provide medications as ordered, which did not meet the needs of the resident. This deficiency was identified through a review of pharmacy documentation, clinical records, and staff interviews.
Medication Error: Insulin Administered to Wrong Resident
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by an incident involving the administration of insulin to the wrong resident. Resident 1, who was admitted with a diagnosis of Alzheimer's disease and had severe cognitive impairment, was mistakenly given 12 units of insulin intended for another resident, Resident 2. This error occurred because Employee 2, an LPN on orientation, did not verify the resident's identity properly before administering the medication. The incident unfolded when Employee 2, LPN, was preparing medication for Resident 2 and asked another LPN, Employee 1, for the resident's location. Employee 1 informed Employee 2 that Resident 2 was in the dining room and would respond to her name. Employee 2 called out Resident 2's name, and Resident 1, who was not the intended recipient, responded. Without verifying the resident's identity through other means, such as checking a photo or asking for assistance, Employee 2 administered the insulin to Resident 1. This error was witnessed by Employee 3, a nurse aide, who questioned Employee 2 about the resident's identity. The error was reported to Employee 4, RN, who informed the Director of Nursing (DON). However, there was a delay in addressing the situation, as the DON advised not to document the error due to an upcoming Department of Health revisit. Additionally, there was no documentation of the incident in Resident 1's clinical record, nor was the physician informed or orders obtained to monitor the resident's blood sugar or provide appropriate treatment. This lack of documentation and communication further compounded the facility's failure to prevent significant medication errors.
Failure to Document Medication Error and Maintain Accurate Records
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for a resident diagnosed with Alzheimer's disease. On September 15, 2024, the resident was mistakenly administered short-acting insulin, which was not prescribed to her. The error was not documented in the resident's clinical record, and the facility's investigative report did not specify the insulin type, dosage, or the intended recipient of the medication. Additionally, there was no documentation of the resident's physician being notified or any side effects experienced by the resident. The incident was reported by a nurse aide to an LPN, who confirmed the error with the LPN responsible for the medication administration. Despite the error being communicated to the Director of Nursing (DON), the DON advised against documenting the incident due to an upcoming Department of Health revisit. The resident's Medication Administration Record for September 2024 did not reflect the administration of glucagon or Boost high-calorie supplement, which were given to counteract the insulin error. Interviews with the Nursing Home Administrator and DON confirmed the failure to document accurately and consistently in the resident's clinical records.
Failure to Provide Timely and Effective Pain Management
Penalty
Summary
The facility failed to provide timely and effective pain management for a resident, identified as Resident 52, who experienced severe pain following a fall. The resident, who had a medical history including cerebral infarction, transient cerebral ischemic attack, and cerebral atherosclerosis, was admitted with orders for acetaminophen to manage mild to moderate pain. On June 18, 2024, the resident fell and complained of left knee and thigh pain. Despite negative x-ray results for fractures, the resident reported severe pain levels of 10/10, which were not adequately addressed by the nursing staff. The occupational therapist documented the resident's severe pain and informed nursing staff, but there was no evidence that the nursing staff notified the attending physician to adjust the pain management plan. The resident continued to report severe pain over several days, yet the facility's records showed that only mild pain was documented and treated with Tylenol. It was not until June 25, 2024, that a new x-ray revealed an intertrochanteric fracture of the left femur, prompting the resident's transfer to the hospital for further evaluation. The Director of Nursing confirmed that the facility did not respond timely or effectively to the resident's increased reports of severe pain. The lack of appropriate documentation and communication regarding the resident's pain levels and the failure to notify the physician for further pain management interventions contributed to the deficiency in care provided to Resident 52.
Deficiency in Dining Room Cleanliness and Maintenance
Penalty
Summary
The facility failed to maintain a safe, sanitary, and orderly environment in the resident's main dining room area. Observations made on two separate occasions revealed that four grey-patterned chairs with leather-like seats were significantly worn. Additionally, the dining room windowpanes contained significant debris and deceased bugs, while the white-colored blinds covering the exit door window had cobwebs and live spiders adhered to the surface. The grey garbage can inside the dining room had splatter and debris adhered to the lid, and the floor was sticky. An interview with the Nursing Home Administrator confirmed these observations and acknowledged that the resident's dining area should be maintained in a clean and homelike environment.
Failure to Prevent Misappropriation of Resident Medication
Penalty
Summary
The facility failed to implement procedures to prevent the misappropriation of resident property, specifically medications, for one resident. Resident 49, who was admitted with diagnoses including a wedge compression fracture, anxiety, and dysphagia, had a physician order for hydrocodone-acetaminophen for pain management. However, the controlled substance inventory sheet did not properly document the receipt and verification of the medication, leading to a discrepancy in the medication count. On June 17, 2024, the facility received 30 tablets of hydrocodone-acetaminophen for Resident 49, but by June 25, 2024, both the medication and the controlled drug sign-out sheet were missing. The investigation revealed that the nursing staff failed to consistently complete shift-to-shift narcotic reconciliation according to facility policy. There was no evidence that the discrepancy in the narcotic medication count was reported to administration until several days later when a nurse attempted to administer the medication. Despite the facility's policy requiring immediate investigation and reporting of such incidents, the misappropriation of the medication was not identified or reported in a timely manner. The investigation concluded that the misappropriation was confirmed, but a perpetrator was not identified. The facility's failure to adhere to its own policies and procedures contributed to the deficiency.
Failure to Update Care Plans for Fall Prevention and Palliative Care
Penalty
Summary
The facility failed to timely develop and implement a person-centered care plan for Resident 26, who was admitted with a diagnosis of dementia and was severely cognitively impaired. The resident required assistance for activities of daily living, as indicated by a BIMS score of 0. An observation on July 30, 2024, revealed that the resident's bed was placed against the wall as a fall prevention measure. However, the resident's care plan, initially dated May 15, 2024, did not include this intervention. The Director of Nursing confirmed that the care plan did not accurately reflect the current fall prevention measures. Additionally, another resident, identified as Resident #37, was noted to be on palliative care without an order or a corresponding care plan. This indicates a failure to develop and implement appropriate care plans for residents receiving specialized care. The deficiencies were confirmed during interviews and reviews conducted by the surveyors, highlighting lapses in the facility's care planning processes.
Failure to Provide Discharge Summary and Medication Disposition
Penalty
Summary
The facility failed to complete a discharge summary for a resident who was discharged to home. The clinical record review revealed that the resident was admitted with diagnoses including MRSA infection, pneumonia, and heart failure, and was discharged without a comprehensive discharge summary. The summary should have included a recapitulation of the resident's stay, the course of illness, corresponding treatment, discharge instructions, and a post-discharge care plan. Additionally, there was no evidence regarding the disposition of the resident's prescription medications upon discharge. The record did not indicate whether the medications were exhausted, returned to the pharmacy, destroyed, or sent home with the resident. Furthermore, there was no documentation that the resident or their representative received a summary of the resident's stay, medication tips, treatments, functional mobility, nutrition, and activities. During an interview, the nursing home administrator could not provide documented evidence of a completed discharge summary or medication disposition for the resident.
Failure to Monitor Vital Signs Before Medication Administration
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards by not ensuring that licensed nurses accurately administered prescribed medication to a resident. The resident, who was admitted with diagnoses including stroke, hypertension, and anxiety, had a physician's order for Metoprolol tartrate to be administered twice daily with specific parameters to hold the medication if the systolic blood pressure was less than 110 or the heart rate was less than 60. Upon review of the Medication Administration Record for June and July 2024, there was no documented evidence that the nursing staff monitored the resident's blood pressure or heart rate prior to administering the medication, as required by the physician's order. This lack of documentation was confirmed by the Director of Nursing, indicating that the medication was not administered according to the prescribed parameters.
Lack of Clinical Justification for Foley Catheter Use
Penalty
Summary
The facility failed to clinically justify the use of Foley catheters for two residents, identified as Resident 7 and Resident 24. Resident 7 was admitted with diagnoses including dementia, dysphagia, and major depressive disorder. A hospital urology consult indicated a urinary tract infection due to the use of a Foley catheter, with recommendations for follow-up. However, the resident's clinical record lacked documented evidence to justify the continued use of the catheter, despite a urology consult noting failed void trials and the need to maintain the catheter. Similarly, Resident 24, admitted with kidney disease, was also using a Foley catheter without documented clinical justification. The resident's medication administration record showed admission from the hospital with a catheter, and nursing progress notes indicated failed void trials and an attempt to contact urology. However, there was no evidence of a scheduled urology appointment or clinical justification for the catheter's use. The Director of Nursing confirmed the absence of clinical diagnoses to justify the chronic use of Foley catheters for both residents.
Failure to Implement Individualized Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement an effective individualized person-centered care plan for a resident diagnosed with Alzheimer's disease, who exhibited dementia-related behavioral symptoms such as spitting, striking out, biting, and agitation. Despite the resident being severely cognitively impaired, as indicated in the Quarterly Minimum Data Set Assessment, the care plan in place did not address the resident's Alzheimer's diagnosis or the associated behaviors. The care plan lacked individualized interventions based on an assessment of the resident's preferences, social history, customary routines, and interests, which are essential for managing and modifying dementia-related behaviors. Furthermore, the facility did not provide evidence of necessary care and services, including interdisciplinary non-pharmacological approaches, purposeful activities, and specialized services tailored to the resident's abilities and behaviors. There was no documentation of specialized activities, nutrition, or environmental modifications being provided to enhance the resident's well-being. An interview with the Nursing Home Administrator confirmed the absence of an individualized person-centered plan to address the resident's dementia-related behaviors, highlighting a deficiency in meeting the resident's care needs.
Lack of Clinical Rationale for PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychoactive drugs by not providing a clinical rationale for the continued use of an as-needed psychotropic medication. Resident 29, who was admitted with Alzheimer's disease, had a physician's order for alprazolam to be administered as needed for anxiety, starting in April 2024, with no specified end date. The medication was administered multiple times in June and once in July 2024. Upon review, it was found that the physician did not document the clinical rationale for the continued use of the medication beyond 14 days, nor was there any re-evaluation of its necessity. This lack of documentation was confirmed during an interview with the Director of Nursing. The deficiency was noted under the regulations concerning pharmacy services, medical records, and the role of the medical director.
Failure to Follow Up on Dental Services for a Resident
Penalty
Summary
The facility failed to follow up with required dental services for a Medicaid resident, identified as Resident 37, who was admitted to the facility and had not received necessary dental care. Documentation from May 9, 2024, indicated that mobile dental services were delayed, resulting in the postponement of the resident's dental check and two extractions. The facility was informed that the dental service provider would reschedule, but there was no evidence of follow-up or completion of the extractions by the survey's end on July 31, 2024. The resident's last dental visit was on October 26, 2022, and although an Oral Hygiene Consult Sheet from May 16, 2024, showed no dental complaints, it recommended continued care and routine cleanings. The resident's meal intake and nutritional status were affected by the need for extractions, but there were no documented complaints of pain or discomfort related to this need.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program. During an environmental tour, it was observed that the doors to the kitchen, dry storage room, and mechanical room were open, including the door leading outside, providing entry for pests. Mice droppings were found on the floor and on a pest glue trap in the dietary dry storage room. The pest control company's invoice/report from March 6, 2024, lacked information on services provided and inspection results. The April 3, 2024, report indicated services were completed but did not identify the outcome of checks and bait stations related to rodent activity. The Director of Nursing confirmed the presence of rodent activity and the limited information in the pest control reports.
Failure to Maintain Sanitary Food Storage and Service Practices
Penalty
Summary
The facility failed to maintain acceptable practices for the storage and service of food, which increased the risk of food-borne illness. During a tour of the dry storage room, it was observed that the door was open, and a 5 lb. bag of chicken bread coating and a 25 lb. bag of flour were opened without any noted dates and were not securely closed. Additionally, a ziplock plastic bag containing an opened package of walnuts was found in a brown box on a metal shelf, along with another bag of opened walnuts and loose walnuts at the bottom of the box. The baseboard molding along the bottom of the wall of the dry storage room was missing, exposing drywall and a 1/2 inch gap between the wall and the floor, where mouse droppings and a glue trap were also observed. The dry storage room is located next to the kitchen, where a personal backpack was found on the metal kitchen counter next to the toaster and below the kitchen knives mounted on the wall. These observations were confirmed with the facility's Certified Dietary Manager and the Director of Nursing, who acknowledged that the kitchen and all food storage areas should be kept in a sanitary manner. The failure to maintain these areas in a sanitary condition and to properly store food items as per professional standards was identified as a deficiency, increasing the potential for contamination and microbial growth in food, which could lead to food-borne illness.
Unattended Treatment Cart Creates Accident Hazard
Penalty
Summary
The facility failed to maintain an environment free of potential accident hazards on one of three resident hallways (Rooms 9-16). During an environmental tour, an unattended and unlocked treatment cart was observed in the hallway. The cart had its second and sixth drawers open, exposing prescription creams, ointments, and treatment supplies. Additionally, a laptop and unopened curettes were found on top of the cart. Residents were seen ambulating and self-propelling in wheelchairs near the unattended cart. The Director of Nursing confirmed that the wound care consultant was performing wound care in a resident's room at the time and acknowledged that the cart should not have been left open and unattended, creating a potential accident hazard.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 499 citations issued within 25 miles in the last 12 months — including the 6 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 Kingston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Riverstreet Manor | 0.6 mi | ★★★★★ | 25 | 0 |
| Edenbrook On Second Ave | 0.6 mi | ★★★★★ | 14 | 0 |
| Maple Ridge Rehabilitation & Healthcare Center | 0.8 mi | ★★★★★ | 8 | 0 |
| Embassy Of Wyoming Valley | 1.2 mi | ★★★★★ | 31 | 0 |
| Allied Services Center City Skilled Nursing | 1.4 mi | ★★★★★ | 9 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.