Below 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 Wecare At Sycamore Rehabilitation And Nursing Cent during CMS and state inspections, most recent first.
The facility failed to ensure ordered medications were available and administered as prescribed for two residents. One resident did not receive scheduled doses of the anticoagulant Eliquis when staff documented the dose as held and noted the drug was on order from the pharmacy with no supply available. Another resident missed multiple scheduled doses of Clonazepam for anxiety when staff documented the medication as out of stock, noted a rejected attempt to obtain it from the Omnicell EKIT, and recorded that doses were not given because the medication was not on hand while awaiting pharmacy supply.
A resident who was documented as unable to understand her rights and responsibilities was found sitting in a wheelchair at the nurses’ station with a yellow shawl wrapped around the chair and tied in a knot, effectively restraining her, and she could not explain what had occurred. The resident’s daughter reported being told that staff had tied the shawl because they were worried the resident might lean forward and fall, despite facility policy stating that fall risk alone is not a medical symptom justifying restraint use. The clinical record contained no practitioner order or assessment supporting the use of a restraint to treat a medical condition, and leadership later confirmed that the resident had been inappropriately restrained.
Food storage, sanitation, and tray-line monitoring deficiencies were identified in the kitchen, dining room, and a unit pantry. Surveyors observed dirty and damaged kitchen and dining equipment, expired and unlabeled food items, uncapped pipes with a sewage-like odor, food debris and stains in storage and refrigeration areas, and missing tray-line food temperature records for multiple meal services; an employee stated the missing temperatures were unaccounted for.
A facility failed to honor resident choice regarding smoking for three residents. One resident who was cognitively intact and independent said he wanted to smoke and had seen staff smoking near the building, but was told smoking was not permitted for him; records showed he was educated about the non-smoking policy and later found smoking on the premises. Another resident said it was unfair that staff could smoke while he could not, and a third resident identified as a smoker was not permitted to smoke after admission. The NHA and DON confirmed residents were prohibited from smoking while staff were allowed to smoke on facility property.
Failure to monitor psychotropic medication use: Three residents had active orders for antipsychotic, antidepressant, and PRN antianxiety medications, but the clinical records did not show evidence of monitoring for side effects or, for one resident, ongoing monitoring of target behaviors and non-medicinal interventions. The DON confirmed that the care plan for one resident did not address antipsychotic side effects and did not include PRN antianxiety monitoring.
The facility failed to fully document pre-employment screening for an LPN, an activity aide, and an RN, with missing or incomplete records of prior employment verification and reference checks. The facility also did not thoroughly investigate a resident’s unexplained swollen and bruised hand; records showed the resident had left hand swelling, bruising, tenderness, and abnormal imaging, but no staff witness statements were obtained to determine how the injury occurred.
Incomplete Bed Rail Entrapment Assessments: The facility failed to fully assess entrapment risks for multiple residents using enabler bars or assist devices. Records showed that several residents had bed mobility orders and devices in place with headboards and footboards, but the documented checks did not include all required entrapment zones, including Zone 6 for some residents. For one resident with cognitive impairment, there was also no evidence of ongoing reassessment or documentation that the bedrail remained properly installed. Interviews with the DON, NHA, and Director of Rehab confirmed the gaps in assessment.
A resident’s medication pass resulted in a 9.68% error rate, including one incorrect dose and two omissions. An RN did not administer scheduled Vitamin D and Refresh Tears because they were unavailable, prepared Clear Lax in less than the ordered amount, and omitted Baclofen and Mometasone Furoate from the pass; the RN later stated she did not see the two omitted meds and did not report the omissions until questioned.
The facility failed to provide ordered meds as directed for some residents, including a monthly B12 injection that was not documented as given and lisinopril that was administered despite SBP being below the hold parameter. The facility also had no care plan focused on a resident’s implanted pacemaker and sent a nonverbal resident with expressive aphasia to a neurology appointment without assistance, resulting in the resident being returned without an assessment after the RN supervisor approved the transport.
Failure to Investigate and Prevent Repeated Falls The facility did not thoroughly investigate or implement effective fall-prevention interventions for three residents with repeated falls. One resident with impaired cognition, poor mobility, and noncompliance had multiple unwitnessed and witnessed falls, but the records did not show new interventions or a clear investigation of reported bed-related falls. Another resident with gait and balance issues had falls from a wheelchair and on the floor, yet the documented interventions were delayed or not reflected in the care plan. A third resident had repeated bathroom falls tied to self-transfers, call-bell nonuse, and unsafe footwear, but the record did not show timely new interventions after the earlier events.
The facility failed to ensure that nursing staff had documented competencies for enteral tube feedings, lift use, catheter care, med admin, PPE donning and doffing, and dressing changes. Competency records could not be provided for an LPN and an RN, and only wound care competency was documented for another LPN and RN. The NHA and DON confirmed there was no documentation showing these staff had the needed competencies for the residents' care needs.
The facility failed to maintain infection control on multiple units. A resident with COVID-19 on the dementia unit was not kept isolated, was seen in common areas and the dining room without a mask, and other residents on the unit were not tested after additional cases occurred. On another unit, staff entered a resident’s room for CRO-related contact precautions without gowns, and on a third unit, staff caring for residents with ESBL/EBP needs did not consistently use or remove PPE correctly, with confusion about the posted precautions.
The facility failed to maintain documentation of staff COVID-19 vaccination status and failed to show that staff were offered the vaccine or given information on how to obtain it for three staff members, including a housekeeper, an LPN, and a nurse aide. The DON stated she could not provide evidence of staff screening, education, vaccine offering, or current vaccination status, and no documentation was available for the employees reviewed.
A resident’s room light remained on because the switch was located out of reach behind his bed. He stated he slept with the light on every day because he could not turn it off and had stopped asking staff for help because they were busy. Survey observations on multiple days found him in bed with the light on, and the concern was reviewed with the NHA and DON.
A resident with dementia who required substantial to maximum assistance for toileting had a grievance filed by the responsible party after a nurse aide allegedly refused bathroom assistance and the resident's linens were left soiled. The grievance file did not include the required acknowledgment, investigation details, findings, or resolution, and the responsible party stated no one responded to the complaint.
Incomplete and untimely transfer notices: The facility failed to provide complete written discharge/transfer and bed-hold notices to responsible parties for several residents sent to the hospital, and some notices were not sent within the required timeframe. In multiple cases, staff notified family by phone and documented the transfers, but the written notices were missing required information such as the LTC Ombudsman email address, were not signed by the representative, or were mailed late. The facility also failed to include the transferred residents on its Ombudsman notification list.
A resident’s MDS was inaccurately coded to show antibiotic use when the record showed no antibiotic during the assessment period. The resident’s MDS was also inconsistent regarding upper extremity function, with one assessment showing no impairment and a later quarterly MDS showing bilateral impairment despite the RN assessment coordinator confirming there was no decline in ROM. The RN assessment coordinator acknowledged both coding errors.
The facility failed to keep one resident’s care plan current after an indwelling urinary catheter and psychotropic med were discontinued, and failed to document another resident’s participation in care plan meetings. The second resident denied attending any care plan meetings, and the record lacked his signature on the admission conference form. MDS and social services notes showed ongoing housing-related discussions and community transition planning, but staff confirmed there was no care conference documentation to support resident participation.
A resident who required substantial to maximum assistance for personal hygiene was observed with long, disheveled hair and said he had been waiting for a haircut and preferred short hair. His care plan noted he wanted to use the facility beautician, but the DON could not provide documentation of a haircut in the past year or explain the lack of service, and there was no evidence the service was offered or refused.
Failure to Provide ROM Programs for Two Residents: The facility failed to provide ROM services for two residents with documented ROM impairments. One resident reported limited movement in a hand and said she was not doing any exercise and was unaware of a home exercise program, while the DON said there was no documentation that she completed the program and no one assigned to ensure it was done. Another resident had MDS-documented upper and lower extremity ROM impairments, and the PTA/rehab director stated the active assist ROM program was only developed and started after the surveyor asked about it.
A resident admitted with a urinary catheter for neurogenic bladder had the catheter removed, but the bowel/bladder pattern tool was incompletely documented and left without a recommendation or staff signature. Although the day 4 assessment said the resident was appropriate for toileting, there was no evidence of a toileting program or bladder program in the care plan or task record, and the resident continued to have urinary incontinence episodes.
Failure to maintain nutritional status was identified for a resident with marked weight loss and fair PO intake. The resident’s weights declined significantly after admission, yet the record showed no new nutritional interventions, inconsistent weekly weights, no update to the care plan despite continued loss, and no documented SLP eval after a referral. The resident was later observed in bed with the lunch tray in front of her and not actively eating.
Respiratory care was not provided consistent with professional standards for a resident with COPD and oxygen concerns, and respiratory equipment supplies were not kept in a safe and sanitary manner. A suction unit in the main dining room had expired sterile water bottles and debris on the cart, and a resident was observed in bed with a NC delivering oxygen at 3.0 LPM despite no physician order for oxygen in the chart; the DON confirmed the missing order.
A resident receiving dialysis had active orders for dialysis care, arm restrictions, catheter site monitoring, and a 1200 ml fluid restriction, but staff did not post any alerts for the left arm access and the resident was observed with a large cup of ice water at bedside. Record review showed the resident exceeded the ordered fluid allowance on multiple days, and an LPN confirmed there was no indication of the left arm restriction while staff also provided the fluid.
The facility failed to provide trauma-informed, culturally competent care for two residents with PTSD by not identifying triggers or developing comprehensive, person-centered care plans. One resident had documented PTSD, cognitive impairment, and a history of trauma as a teenager, while the other had a history of being mugged, dementia, anxiety disorder, and increased paranoia. Neither resident had a care plan addressing PTSD, triggers, or individualized interventions until after surveyor questioning.
Unsecured and unidentified pills were found in the bottom drawers of a medication cart used during med pass on two nursing units, along with a significant buildup of debris. An LPN stated that third shift cleaned the carts, but all shifts were responsible for keeping the cart clean.
Essential kitchen equipment was not kept in safe operating condition in the main kitchen. Staff were serving breakfast from a steam table with a long-standing leak, with a pan placed underneath to catch water. In the basement walk-in cooler, a ceiling light receptacle had no bulbs, water was dripping and pooling on the floor, and an alternate light source was being used from an electrical cord outside the cooler. The NHA and maintenance director were not aware of the leak or the source of the water.
Improper garbage and refuse disposal was observed at the main dumpster area. Surveyors found dryer lint, plastic cups, paper debris, straws, cigarette butts, a plastic bag, an empty milk carton, dried leaves mixed with paper products, and medical gloves on and around the dumpster, with additional paper debris in a ground grate. The findings were reviewed with the NHA and DON.
Failure to Properly Post Daily Nurse Staffing Information: The facility did not accurately post daily nurse staffing data in a prominent, readily accessible location for residents, staff, and visitors. Observations showed the posting was placed on Sycamore Boulevard and did not include the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care. The DON confirmed staff were not including the actual hours worked on the posted staffing information.
Several residents reported receiving cold food, with meal trays arriving at inconsistent times and some not receiving their ordered items. Observation and temperature testing confirmed that food items were served below required temperatures, with puree eggs and bread tasting cold, milk tasting warm, and coffee tasting tepid. These findings were reviewed with the NHA and DON.
Multiple residents reported not receiving snacks when requested outside of scheduled meal times, with staff stating that no snacks were available in nourishment rooms. Observations confirmed the absence of snacks on all nursing units, and the food service director acknowledged the issue.
A resident who experienced an unwitnessed fall was not monitored according to the facility's neurological assessment protocol. Although initial assessments were performed and documented, required follow-up assessments throughout the night were missed. Staff interviews confirmed the lapse in following established post-fall monitoring procedures, and the resident was later found deceased, with chronic diastolic heart failure listed as the cause of death.
The facility failed to provide required notifications to residents whose payment coverage changed, affecting three residents. A resident did not receive the necessary CMS10123 or CMS10055 notices when her payment source changed from Medicare. Another resident's representative signed a CMS10055 notice but did not select an option box. A third resident received a verbal CMS10123 notice instead of a written one, despite no circumstances preventing timely written notice.
The facility failed to provide adequate bathing assistance to residents dependent on staff for activities of daily living. Five residents did not receive showers according to their preferences and care plans, with some receiving only bed baths or having inconsistent documentation of bathing activities. These deficiencies were reviewed with the Nursing Home Administrator and DON.
The facility failed to adhere to physician orders and medication protocols for several residents, including missing documentation of medication administration, inappropriate use of Midodrine, and lack of monitoring for Oxycodone administration. Additionally, a resident with a cardiac pacemaker lacked proper documentation and care plan interventions, while another resident's PICC line care was inadequately managed, lacking emergency procedures and proper documentation. These deficiencies indicate significant lapses in medication administration and care coordination.
The facility failed to provide appropriate pain management for two residents by not adhering to physician-ordered pain medication protocols. One resident received Oxycodone for pain levels that did not match the prescribed scale, and another resident was given medication for a pain level below the prescribed threshold. These discrepancies were discussed with the facility's administration.
The facility failed to obtain informed consent and educate residents or their representatives about the risks of bed rails for four residents. Additionally, the facility did not assess all potential entrapment zones for two residents, missing zone six, which could pose a risk. These deficiencies were confirmed through staff interviews.
The facility did not conduct annual performance reviews or provide the required 12 hours of in-service training for three nurse aides. Employee 10 lacked a review due in September 2024, Employee 11 had no evaluation after November 2023, and Employee 12, along with the others, did not receive mandatory training. The Nursing Home Administrator confirmed these deficiencies.
The facility failed to include laboratory reports in the clinical records of three residents. Despite physician notes indicating completed lab work, the results were not available in the records. Only the medical director and one other physician had access to view lab results, contributing to this deficiency.
The facility failed to store food properly in the main kitchen, with ground beef thawing above eggs and several food items past their use-by dates. The director of dining services confirmed the findings and discarded the items.
The facility failed to implement Enhanced Barrier Precautions for residents with chronic wounds or indwelling devices, as required by CMS guidelines. Observations showed that a resident with an indwelling urinary catheter and another with a central venous catheter and leg wounds lacked EBP. Additionally, an LPN did not follow proper hand hygiene protocols, and a resident on contact precautions for ESBL had no care plan addressing these precautions.
A facility failed to honor a resident's advance directive choices. Despite a completed POLST form indicating CPR should be performed, the facility did not update the resident's DNR order until identified by a surveyor. This issue was discussed with the DON and the Nursing Home Administrator.
A facility failed to report an allegation of narcotics theft involving a resident and a registered nurse to the appropriate authorities. Despite receiving emails from two nurses about the incident, the Director of Nursing did not notify the required agencies, violating facility policy and state regulations.
A facility failed to ensure accurate assessments for a resident, as an MDS assessment incorrectly indicated that the resident received insulin injections, despite the resident not having a diabetes diagnosis. This error was confirmed by the Nursing Home Administrator.
A facility failed to provide an ongoing program of activities for a resident who was dependent on staff for emotional, intellectual, physical, and social needs. Despite the care plan's interventions, the resident was observed sitting at the nurses' station without her busy blanket and attended only three activities over two months. The activity director confirmed the limited engagement, indicating a deficiency in meeting the resident's needs.
A facility failed to maintain or improve a resident's range of motion (ROM). Initially assessed with no impairments, the resident later showed limited ROM in both upper and lower extremities. Despite being discharged from physical and occupational therapy, the facility did not document any further assessment or intervention to address the decline. This was confirmed by the Nursing Home Administrator.
A facility failed to assess and implement individualized interventions for a resident frequently incontinent of bowel and bladder. The resident, dependent on staff for toileting due to impaired balance, had no attempts at a toileting program or interventions in place. The care plan noted the resident's self-care deficit but lacked specific interventions for incontinence. An interview with the Nursing Home Administrator and DON confirmed the absence of further assessment or interventions to promote continence.
The facility failed to provide appropriate respiratory care for three residents. One resident received oxygen without a physician's order, while another had discrepancies in oxygen settings and improperly stored equipment. A third resident had an oxygen concentrator set incorrectly and equipment was not properly dated or stored. These issues were confirmed by the DON and Nursing Home Administrator.
A facility failed to provide appropriate care for a resident requiring dialysis, as there was no emergency kit or signage to prevent complications from the dialysis access site. The resident, who received dialysis through a central venous catheter, was unaware of any equipment in his room for emergencies. Clinical records lacked orders for an emergency kit, and the care plan incorrectly referenced a graft. An LPN confirmed the absence of necessary materials, and a physician's order for an emergency kit was only added after surveyor intervention.
The facility failed to ensure nursing staff had the necessary competencies for managing medical devices such as indwelling catheters, Life Vests, and central venous catheters. This affected residents with complex medical needs, as staff lacked documented skills to manage these devices, confirmed through interviews and record reviews.
Failure to Ensure Availability of Ordered Medications
Penalty
Summary
The facility failed to ensure medication availability for residents in accordance with its policy on the Electronic Emergency Kit (EKIT) and pharmacy services. The policy, reviewed February 10, 2026, states that the EKIT is intended to provide access to medications needed before the next pharmacy delivery to meet residents' immediate needs, with contents determined by the pharmacy and facility and maintained per state regulations. For Resident 3, clinical record review showed a physician order for Eliquis 2.5 mg twice daily from March 9, 2026, to April 7, 2026. On April 7, 2026, the 8:00 AM dose was documented on the MAR with code 17 (Held per MD order), and nursing documentation that morning indicated the Eliquis was on order from the pharmacy. The Nursing Home Administrator and DON confirmed there was no evidence that Resident 3 received the Eliquis as ordered because nursing staff determined there was no supply of the medication available for administration. For Resident 2, clinical records showed physician orders for Clonazepam 0.5 mg at 8:00 AM for anxiety and 1 mg at 4:00 PM daily, active from early October 2025 through April 11, 2026. Review of the April 2026 MAR revealed missed administrations on multiple dates and times, with staff using code 17 to indicate the medication was not given. Nursing documentation noted that the Clonazepam was out of stock, that the pharmacy rejected an attempt to obtain the medication from the Omnicell (EKIT), and that doses were not administered because the facility was awaiting pharmacy supply or the medication was not on hand, with the RN supervisor made aware. The Nursing Home Administrator and DON confirmed that these doses were not administered due to an interruption in medication availability to nursing staff.
Inappropriate Use of Shawl as Physical Restraint Without Medical Justification
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident was free from the use of a physical restraint that was not required to treat a medical condition, contrary to facility policy and state regulations. The facility’s policy on identifying involuntary seclusion and unauthorized restraint states that residents are to be free from physical restraints not required to treat a medical condition, defines physical restraints, and specifies that risk of falling is not considered a medical symptom warranting restraint use. The policy also requires a practitioner’s order and documentation of circumstances when a restraint is used as a last resort. For the resident involved, the clinical record contained an active physician’s order indicating that she was not capable of understanding her rights and responsibilities. Nursing documentation showed that on a specific evening, the RN supervisor entered the nursing unit and was informed by nurse aide staff that the resident was found sitting in her wheelchair at the nurses’ station with her yellow shawl wrapped around the wheelchair and tied in a knot. The resident was unable to verbalize what had happened. The resident’s daughter reported that the facility notified her that staff had observed her mother in her wheelchair with the shawl tied in a knot behind the chair, and she understood that staff allegedly restrained her mother due to concern that she might lean too far forward and fall out of the chair. The clinical record did not contain a physician’s order for the use of a restraint and there was no evidence of an assessment to justify restraint use to treat a medical symptom. The Nursing Home Administrator and DON confirmed that the facility’s investigation determined the resident had been inappropriately restrained in her wheelchair.
Food Storage, Sanitation, and Temperature Monitoring Deficiencies
Penalty
Summary
The facility failed to store food items in a safe and sanitary manner and failed to maintain kitchen and dining equipment in a sanitary condition in the main kitchen, main dining room, and the Country Kitchen Pantry Area on one nursing unit. During observation, surveyors found black-colored buildup and cobwebs on a wall-mounted heating/cooling unit near the dishwasher room entrance, dried food stains on the ceiling and walls, disposable gloves stored over a stainless-steel prep area, dust on top of a commercial coffee machine with peeling covering, a broken overhead light cover in the dishwasher area, and dust and debris on top of the dishwasher, including a discarded plastic bottle cap and a hair and beard retainer. They also observed dried stains on the wall and floor under the sink adjacent to the dishwasher, a black plastic receptacle holding used kitchen rags without a liner or bag, and expired raisins in dry storage from August 2025. Additional observations included an old bathroom room being used for storage, uncapped floor pipes with cloth rags in one pipe and a sewage-like odor, crackers on the floor next to the pipe, empty snack bags on shelving, an uncapped second pipe behind storage shelving, butter condiment packs on the floor in the walk-in cooler, ice accumulating on a box of pasta in the freezer, and a detached seam in the freezer ceiling. In the main dining room, surveyors observed a missing drawer, worn countertop edges exposing particle board, debris in a drawer containing salt and pepper shaker lids, loose plastic lids scattered in a cupboard, expired hand sanitizer, and cobwebs on six of seven chandelier lights. In the pantry area on the Little League Nursing Unit, surveyors found unlabeled and undated glass containers, black stains on the refrigerator handle, dried-out cheese and meat in an unlabeled plastic container with tongs, dried food stains and pooling liquid inside the refrigerator, and an unlabeled white-powdery substance near the sink. The report also documented missing tray-line food temperatures for multiple breakfast, lunch, and dinner services across December 2025 and February 2026, and Employee 17 stated the missing temperatures were unaccounted for.
Resident Smoking Choice Restrictions
Penalty
Summary
The facility failed to ensure that residents could make choices regarding significant aspects of their lives, including smoking, for Residents 28, 39, and 101. During the entrance conference, the NHA and DON confirmed that smoking was prohibited for residents, while staff were allowed to smoke on facility property. Resident 28 stated that he wanted to smoke, had seen people smoking outside the dialysis provider’s office, and had observed facility staff smoking in the outside parking area near the front entrance when he went to dialysis three times a week. He reported that he was told the facility was smoke-free and that smoking was not permitted for him, despite being independent, cognitively intact, and without mobility limitations on his MDS. Nursing documentation showed he was educated that the facility was non-smoking, was told to leave the property to smoke, became angry, and was later found smoking on the premises; his physician also ordered a nicotine patch. Resident 39 stated that he desired to smoke and thought it was unfair that staff were allowed to smoke while he was not. He reported seeing multiple staff smoking outside and said he could not have a cigarette. The record showed the facility admitted him under a non-smoking agreement, and a nursing note documented that his sister found a cigarette in his room and gave it to the nurse, after which he was educated that the facility was non-smoking. Resident 101 was identified in the record as a smoker, but the facility’s plan of care only included administering a smoking cessation patch if ordered, and the NHA and DON confirmed that he had not been permitted to smoke since admission. The NHA and DON confirmed the above findings regarding residents’ inability to smoke while staff were allowed to smoke near the building.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to monitor the use of psychotropic medications for three residents reviewed for potentially unnecessary medications. Resident 4 had active orders for brexpiprazole 0.5 mg in the morning for depression, lorazepam 0.5 mg every 4 hours as needed for anxiety for 14 days, mirtazapine 15 mg in the morning for depression, and fluoxetine 40 mg in the morning for depression. A physician order directed staff to monitor target behaviors such as delusions or hallucinations, unstable mood, tearfulness, adjustment difficulty, withdrawal, and the use of non-medicinal interventions, but the clinical record did not show monitoring for potential side effects from the psychotropic medications after February 9, 2026. The DON confirmed that monitoring for potential side effects and distressing target behaviors was not continued, that the care plan did not instruct staff to monitor for potential side effects from the antipsychotic medication, and that no care plan was developed for the PRN antianxiety medication. Resident 14 had active orders for Lexapro 5 mg daily for depression and Risperdal 0.5 mg daily and 0.25 mg daily for schizophrenia, but the clinical record did not contain evidence that staff monitored for potential side effects from the antipsychotic medication. Resident 15 had an active order for Seroquel 25 mg twice daily for agitation, and the clinical record also lacked evidence of monitoring for potential side effects from the antipsychotic medication. The DON confirmed these findings for both residents during interview.
Incomplete employee screening and inadequate investigation of unexplained injury
Penalty
Summary
The facility failed to develop written procedures for screening prospective employees that included all necessary components, and it failed to maintain documentation of employment history screening for three newly hired employees. The Nursing Home Administrator confirmed that the facility’s human resources and abuse prohibition program and policies did not include actions for obtaining information from previous and/or current employers, such as dates of employment, position or title, and disciplinary actions, whether favorable or unfavorable. Review of personnel records showed that Employee 5, an LPN hired on November 4, 2025, had a Professional References document with no documentation that the human resources director confirmed the dates of employment alleged by the employee or that references provided favorable, unfavorable, or refused comments. Employee 6, an activity aide hired on November 18, 2025, had no Professional References document in the personnel record, and the only notation on the application page stated, “All verified,” without documentation of what was verified or whether any reference provided favorable, unfavorable, or refused comments. Employee 7, an RN hired on February 3, 2026, had no documented history of previous employment including employer names, contact information, or dates of employment, and the Professional Reference Sheet listed three health care providers without documentation of who was contacted, what employment was verified, or whether any contacted person provided favorable, unfavorable, or refused comments. The facility also failed to thoroughly investigate an injury of unknown origin for Resident 15. Nursing documentation showed that Resident 15, admitted on April 1, 2025, was observed on November 4, 2025, with a swollen, blue/purple left knuckle and later assessed as having swelling and tenderness at the first base knuckle, with guarding of the hand. The physician was notified and ordered a stat X-ray, which showed no acute fracture or dislocation but an irregular alignment of the ulna that could represent dislocation, prompting transfer to the emergency department for further testing and treatment. The resident returned from the emergency department early the next morning with documentation indicating a contusion, and later that day the facility received a call from the emergency department stating that radiology identified an anomaly not seen by the provider and recommended immediate return for re-evaluation and ortho/trauma consult. Review of the facility’s investigation into the swelling and bruising of Resident 15’s left hand showed that no witness statements were obtained from staff regarding how the injury may have occurred. The facility policy required immediate reporting, assessment, notification, and an investigative process to determine the cause, circumstances, and any individual involved, including interviews with staff on duty and potential witnesses. The Director of Nursing confirmed that the facility did not complete a thorough investigation into Resident 15’s swollen and bruised left hand to rule out the potential for abuse and/or neglect.
Incomplete Bed Rail Entrapment Assessments
Penalty
Summary
The facility failed to assess all potential risks for entrapment for four residents reviewed for accident hazards and failed to conduct ongoing assessments to assure appropriate maintenance with bedrail usage for two residents. The cited policy required a complete bed system audit at installation or removal, measurement of open spaces between bed system components, assessment of the seven potential zones for entrapment, and quarterly reassessment with ongoing monitoring. The record review and observations showed that Residents 5, 8, 9, and 16 had enabler bars or assist devices in use with headboards and footboards present, but the documented assessments did not fully evaluate all required entrapment zones. For Resident 16, the annual MDS dated January 30, 2026, showed a BIMS score of 4, indicating cognitive impairment. On March 10, 2026, the resident was observed with a right-sided enabler bar attached to the bed, and the physician order dated December 4, 2025, authorized the device for bed mobility. The facility documentation from February 22, 2024, showed an enabler bar configuration form with the resident’s name, but the room listed was a previous room and the type of rail was written as halo's. The form checked Zones 1, 2, 3, 4, and 7, but Zone 6 was not checked, and there was no additional documentation showing Zone 6 was assessed or that ongoing assessments were completed to evaluate risks associated with bedrail use or to check that the rails remained properly installed. For Resident 8, the bed had bilateral assist bars, a footboard, and a headboard, but the Bed System Measurement Device Test Results Worksheet completed about one year earlier assessed only Zone 1 and did not show a thorough assessment of all potential entrapment zones or regular checks for gaps caused by changes in weight, movement, bed position tendencies, or device shifting. For Resident 5 and Resident 9, physician orders directed bilateral enabler bar use for bed mobility, but the worksheets for each resident assessed only Zones 1 through 4 and did not include Zone 6, which would include the space between the device and the edge of the headboard bilaterally. Interviews with the DON, NHA, and Director of Rehab confirmed the missing assessments and that therapy staff did not assess the enabler bars for entrapment zone risks.
Medication administration errors exceeded the allowable rate
Penalty
Summary
The facility failed to ensure a medication error rate of less than five percent for Resident 51, with the surveyor determining a 9.68 percent error rate based on 31 medication opportunities and three medication errors. During observation of the medication administration pass, Employee 10, an RN, stated that Resident 51’s scheduled Vitamin D and Refresh Tears were not available in the medication cart and would not be administered. Employee 10 also prepared Clear Lax 17 grams but filled the measuring cap only about three-quarters full rather than to the top of the white section indicated on the bottle, and she confirmed that the amount prepared was less than the ordered dose. Employee 10 prepared additional medications for Resident 51, including iron, Senna-plus, vitamin B12, Claritin, duloxetine, metoprolol tartrate, potassium chloride, ropinirole, torsemide, spironolactone, diltiazem, Zyprexa, and Voltaren gel. Before entering the resident’s room, she confirmed she had 15 tablets in the medicine cup plus the Miralax and Voltaren gel. Clinical record review showed active 9:00 AM orders for Baclofen 10 mg, two tablets three times a day, and Mometasone Furoate nasal spray, two sprays in both nostrils daily, which were omitted during the pass. Employee 10 later stated she did not see the two additional medications and did not attempt to report the omissions until questioned.
Medication Administration and Care Plan Failures
Penalty
Summary
The facility failed to provide the highest practical care related to physician-ordered medications for multiple residents. For one resident, a monthly vitamin B12 injection order was not documented as administered on two occasions, and there was no documentation explaining why the medication was not recorded as given. For another resident with essential hypertension, lisinopril was documented as administered on several occasions even though the recorded systolic blood pressures were below the physician’s hold parameter of less than 120, and there was no documentation explaining why the medication was given outside the ordered parameters. The facility also failed to implement resident-directed care consistent with the care plan for a resident with an implanted cardiac pacemaker. Clinical records showed a history of ventricular tachycardia, atrial fibrillation, left bundle branch block, bradycardia, and a pacemaker inserted after AV node ablation. The resident reported having had an internal pacemaker for about 20 years and having a pacemaker machine at home, but not while at the facility. Review of the care plan showed no plan focused on the pacemaker, including its type, intended heart rate, or monitoring needs. In addition, the facility failed to follow the care plan for a nonverbal resident with expressive aphasia who used an iPad to communicate. The resident was sent to a neurology appointment without assistance, and the transportation driver asked the RN supervisor whether it was acceptable to send the resident without support; the RN supervisor said yes. The resident was returned to the facility without being assessed because the resident was nonverbal and had no means of communication, and the neuroscience office was told the facility did not have enough staff to send to appointments.
Failure to Investigate and Prevent Repeated Falls
Penalty
Summary
The facility failed to thoroughly investigate and implement interventions to prevent falls for three residents with repeated fall concerns. The cited policy required staff and the practitioner to review each resident’s fall risk factors, document where and when falls occurred, identify possible causes within 24 hours, and identify interventions to prevent subsequent falls. The deficiency involved Residents 14, 39, and 101, each of whom had multiple falls documented in their clinical records and incident investigations. Resident 14 had a history of impaired cognition, confusion, altered mobility, poor vision, deconditioning, bilateral foot drop, and noncompliance with using an assistive device or requesting assistance with transfers. After an unwitnessed fall in which he was found on the floor in the hallway outside his room and stated he fell out of bed, the investigation identified no new interventions and did not show any alteration of his bed despite his report. Later investigations documented that he was found on the floor beside his bed, on the floor in his room, and on the floor after sliding out of his chair. The records noted factors such as confusion, gait imbalance, impaired memory, noncompliance with safety interventions, weakness, self-removal of safety devices, and noncompliance with care plan and safety instructions, but the record did not show thorough investigation or corresponding new interventions after the repeated falls. Staff also reported a fall mat in use, but there was no physician order or care plan intervention supporting that device. Resident 101 was admitted with gait and balance issues and was identified as high risk for falls. After one fall, the investigation documented a referral to PT, but the clinical record did not show that Resident 101 was screened after the fall. After another fall in which she was found on the floor in front of her wheelchair and was observed scooching herself up and leaning out of the wheelchair with the cushion, the investigation documented dycem under the wheelchair cushion as the intervention, but the record showed that dycem was not actually implemented until after a later fall and was not added to the care plan until after surveyor questioning. A later fall occurred when she fell out of her wheelchair in the hallway, and the investigation noted only that she was on the therapy caseload. Resident 39 had repeated falls associated with toileting and self-transfer attempts. He was found on the bathroom floor after trying to go to the bathroom without ringing the call bell, and the investigation did not document a new intervention. He later fell again in the bathroom after not ringing the bell even though it was in reach and after self-transferring; another investigation noted he tripped on his oxygen cord, but again no new intervention was documented. After another fall, staff educated him that his slippers were not safe and that he needed non-skid socks, but the record did not show that the socks were provided or that the slippers were removed or replaced. Only after a later fall was a new intervention documented to keep him in an area where he could be monitored closely.
Missing Nursing Competency Documentation
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies and skill sets to care for residents requiring enteral tube feedings, lift use, catheter care, medication administration, donning and doffing PPE, and dressing changes. Review of facility documentation showed 119 residents receiving medications, 28 residents who utilized lifts, nine residents with indwelling urinary catheters, 17 residents with dressing changes, two residents with enteral tube feedings, and eight residents on transmission-based precautions. When competencies were requested for Employees 13, 14, 10, and 16, the facility could not provide any competency documentation for Employee 13, an LPN, or Employee 10, an RN. For Employees 14, an LPN, and Employee 16, an RN, the only competency documented was wound care. The Nursing Home Administrator and DON confirmed that there was no documentation showing these four employees had specific competencies and skill sets related to the listed resident care needs.
Infection Control Failures Across Multiple Units
Penalty
Summary
The facility failed to ensure an environment free from the potential spread of infection on Maple Court, Sycamore, and Little League units. The facility’s COVID-19 testing policy required testing of residents after close contact and broad-based testing during an outbreak, but the outbreak that began on February 2, 2026 was not followed by testing of other residents on Maple Court after additional cases appeared from March 2-5, 2026. The Director of Nursing stated that residents on the dementia unit would not stay in their rooms and would not wear masks, and that dining room and activities continued on that unit. Resident 15 tested positive for COVID-19 on March 5, 2026 and had a physician order for airborne precautions, strict isolation, and all services in the room until March 15, 2026, but there was no care plan addressing the diagnosis until after surveyor questioning. Observation of Resident 15 showed the resident walking throughout Maple Court, talking to other residents, entering other residents’ rooms, and sitting in the dining room with four other residents without a mask. On March 11, 2026, Resident 15 was observed seated with seven residents in a circle near the nurses’ station, again without attempts by staff to keep the resident separated or masked. The room had no sign alerting staff or visitors that airborne precautions were in place. An occupational therapist entered Maple Court without a mask and was within a few feet of Resident 15 while working with another resident. The DON confirmed that staff were not required, only encouraged, to wear masks. On Sycamore, Resident 4 had a physician order for contact precautions related to CRO, and a sign on the door instructed staff to implement contact precautions. During direct care, an LPN and a nurse aide donned gloves and repositioned Resident 4 in bed but did not don gowns before entering or providing care. The LPN stated they forgot to don a gown and acknowledged they should have done so. The resident’s record did not contain a care plan addressing the CRO infection or contact precautions. On Little League, Resident 51 had an active order for contact precautions for ESBL. During medication and treatment administration, an RN entered the room with gown and gloves, provided care including blood pressure assessment and application of medicated gel, then left the room without removing PPE before entering the hallway and discarded PPE in an uncovered trash receptacle on the medication cart. There were no bins visible in the room or by the door for PPE disposal. The RN later returned to the room and again exited without removing PPE before entering the hallway. For Residents 11 and 37, both had orders and care plan interventions for ESBL contact precautions, but the doorway displayed an Enhanced Barrier Precautions sign and a tote with PPE. A therapy staff member assisting Resident 11 wore gloves only and no gown, stating she believed the EBP sign was for the roommate. The RN also expressed uncertainty about the EBP sign, showing a discrepancy between the clinical record and the posted precautions.
Missing Staff COVID-19 Vaccination Documentation
Penalty
Summary
The facility failed to maintain documentation of staff COVID-19 vaccination status and failed to provide evidence that staff were offered the COVID-19 vaccine or given information on how to obtain it for three of three staff reviewed: Employee 11, a housekeeper; Employee 18, an LPN; and Employee 19, a nurse aide. During an interview, the DON stated she was unable to provide evidence that the facility maintained staff documentation of screening, education, offering of COVID-19 vaccinations, or current vaccination status, and said she had contacted the previous infection preventionist to locate the documentation but had not received a response. The surveyor reviewed these findings with the DON, and there was no evidence available for the three employees noted.
Failure to Accommodate Resident’s Room Light Needs
Penalty
Summary
The facility failed to reasonably accommodate Resident 7’s needs and preferences by not providing access to the light switch in his room, which was located on the wall behind his bed and out of his reach. During observation and interview on March 10, 2026, Resident 7 stated that the light above his bed was on all the time, that he slept with it on because he could not reach the switch to turn it off, and that he had stopped asking staff for help because they were busy. Additional observations on March 11 and March 12 showed Resident 7 in bed with the light on. The surveyor reviewed this concern with the NHA and DON during an interview on March 11, 2026.
Failure to Address Resident Grievance Promptly
Penalty
Summary
The facility failed to address a grievance promptly and to implement effective actions to resolve a reported grievance for one resident. The facility policy required grievances to be addressed promptly, acknowledged within three business days, investigated thoroughly, and resolved in writing within one week unless extenuating circumstances were documented. Review of the grievance file for the resident showed that the required summary of the grievance, steps taken to investigate, pertinent findings or conclusion, and corrective action were not completed, and the resident's responsible party stated that no one acknowledged the grievance or provided information about investigation steps or resolution. The resident was admitted with a diagnosis including dementia, and the most recent MDS indicated the resident required substantial to maximum assistance for toileting. The resident's responsible party reported filing a grievance after the resident requested to use the bathroom and a nurse aide refused, stating the resident would be changed at bedtime, and also reported that the resident's linens were soiled and no one came to change them. The grievance was reviewed with the Nursing Home Administrator and DON, and the report identified the deficiency under 483.10(j) Grievances.
Incomplete and Untimely Transfer Notices
Penalty
Summary
The facility failed to provide complete written discharge/transfer notices to responsible parties for residents transferred to the hospital, and for some residents the notices were not provided in a timely manner. For one resident, the daughter reported she did not receive any written notice about the transfer or the bed-hold policy when her mother went to the hospital. The record showed the resident had increased work of breathing and low oxygen levels despite oxygen, the physician directed transfer to the ER, EMS transported the resident, and the daughter was notified by phone. The business office manager later documented that copies of the discharge/transfer notice and bed-hold policy were mailed, but the notices were not scanned into the record and the resident’s daughter did not sign the forms. The discharge/transfer notice also lacked an email address for the State Long-Term Care Ombudsman. For another resident, staff documented a fall, weakness, abnormal lab values, and physician-directed transfer to the ER, with the son notified by phone and the bed-hold policy explained verbally. The business office manager stated she mailed the written notices after each transfer, but the cover letter did not include the ombudsman email address. For a third resident, chest pain prompted a hospital transfer after the resident requested to go to the hospital and the physician ordered the transfer; staff notified the stepdaughter by phone, but the written discharge/transfer and bed-hold notices were not mailed within 24 hours as required. The business office manager believed she had 48 hours to mail the notices, and the ombudsman email address was again omitted from the cover letter. For a fourth resident, the record showed a physician order to send the resident to the emergency department, but there was no documentation that the discharge/transfer notice or bed-hold policy notice was provided in writing to the resident or responsible party. The facility’s email to the State Long-Term Care Ombudsman did not list this resident among those transferred for the month. Interviews with the business office manager and the nursing home administrator confirmed the findings for these residents, and the report also states the facility did not notify the Ombudsman for the listed transfers.
Inaccurate MDS Coding for Antibiotic Use and Upper Extremity Function
Penalty
Summary
The facility failed to ensure that Resident 43’s MDS assessments accurately reflected her status. A quarterly MDS dated February 1, 2026, coded the resident as receiving an antibiotic medication during the last seven days of the assessment period, but clinical record review found no evidence that she received an antibiotic during that time. In addition, a significant change MDS showed no impairment of the resident’s upper extremities, while her next quarterly MDS later coded bilateral upper extremity impairment. The RN assessment coordinator confirmed in interview that the antibiotic coding was in error and that the resident did not have a decline in range of motion, and also confirmed that the functional limitation coding on the MDS was incorrect.
Failure to Update Care Plan and Document Resident Participation
Penalty
Summary
The facility failed to revise Resident 3’s comprehensive care plan to reflect changes in her condition and care needs. Her care plan initially addressed an indwelling urinary catheter related to neurogenic bladder, but the catheter was discontinued shortly after the plan was initiated. A later care plan addressed psychotropic medication use, but that medication was also discontinued months later. The care plan for the catheter and psychotropic medication was not discontinued until after the surveyor brought the issue to the facility’s attention during a meeting. The facility also failed to ensure Resident 28 and/or his responsible party participated in care plan meetings. Resident 28 stated that he did not hear anything about care plan meetings and denied participation. Although an electronic multidisciplinary admission conference form indicated that he attended a meeting, the form did not contain his signature next to the resident attendee section. Social services documentation showed that staff and VA-related contacts were working on housing opportunities, including paperwork, identification, social security corrections, housing applications, and a VA housing appointment. A quarterly MDS indicated that Resident 28 participated in assessment and goal setting, but the record also stated that no LCA referrals were made because they were not wanted by the resident. The MDS RAI manual was reviewed and noted that close collaboration with the LCA is needed for community transition planning. Staff interviews confirmed there was no care conference documentation from the MDS assessment to show that Resident 28 participated in the review, and they confirmed the MDS data did not reflect his wishes because he did want referrals to agencies that provide housing in the community.
Failure to Provide Hair Care Assistance for Dependent Resident
Penalty
Summary
The facility failed to provide ADL assistance to a dependent resident who required substantial to maximum assistance for personal hygiene. Resident 7 was observed in bed with long, disheveled hair and stated he had been waiting to get his hair cut and preferred short hair because he was in the military. The clinical record showed he was admitted on March 2, 2023, his care plan initiated March 3, 2023 noted that he wished to use the facility’s beautician, and a later plan of care initiated July 22, 2025 documented an ADL self-care performance deficit with substantial to maximum assistance needed for personal hygiene. The DON was unable to provide documentation that Resident 7 had received a haircut in the last year or explain why he had not, and there was no evidence that the facility offered the service or that Resident 7 refused it.
Failure to Provide ROM Programs for Two Residents
Penalty
Summary
The facility failed to provide services to maintain range of motion for two residents with ROM concerns. Resident 3 stated that she had an impairment to her left hand that limited the range of motion in two fingers, and she reported that since coming off therapy she did not get any exercise. The facility later provided a home exercise program for Resident 3 that had been given to her on February 5, 2026, but it addressed only lower extremity exercise. The DON stated that the program was for Resident 3 to do on her own, that there was no documentation showing she completed it, and that no one was assigned to ensure she did it. Resident 3 also stated that she did not do any exercise and was unaware of the home exercise program. Clinical record review for Resident 45 showed an MDS assessment indicating bilateral upper and lower extremity ROM impairments. A PTA/rehab director provided an active assist ROM program for Resident 45 and stated that it had just been developed and initiated that day after the surveyor asked about it. The facility failed to provide Resident 3 and Resident 45 with ROM programs to help maintain and prevent a decrease in their current level of ROM, and the DON confirmed these findings.
Failure to Manage Urinary Incontinence and Bladder Program
Penalty
Summary
The facility failed to provide appropriate treatment and services related to incontinence management for one resident. The resident was admitted with a urinary catheter in place due to neuromuscular dysfunction of the bladder, and the catheter was discontinued the next day. A three-day bowel and bladder pattern tool was completed, but staff did not document after 3:00 PM on one day and after 2:00 PM on another day, and the section for a recommendation regarding urinary continence was left blank with no staff signature showing review of the form. The DON stated that after the three-day pattern tool is completed, a licensed nurse should compile the findings onto bowel and bladder assessment day 1, 2, and 3 forms and then complete a day 4 assessment to determine whether the resident is appropriate for toileting or should be checked and changed. The resident’s day 4 assessment indicated she was appropriate for toileting, but her task record and care plan showed no evidence that she was on a toileting program at any time after catheter removal. The resident stated she still has urinary incontinence episodes if she is not taken to the bathroom timely, and task documentation showed she was incontinent of urine at least once daily on six days of the past 30 days. There was no documented evidence that the facility developed a bladder program to improve her incontinence, and the DON confirmed these findings.
Failure to Maintain Nutritional Status
Penalty
Summary
Failure to implement interventions to maintain nutritional status was identified for one resident who experienced significant weight loss after admission. The resident’s weights showed a decline from 202.4 pounds on December 3, 2025, to 186 pounds on December 23, 2025, which was documented as a 16.4-pound, 8.1 percent severe weight loss in three weeks. The registered dietitian’s December 26, 2025 assessment confirmed an 8.6 percent weight loss in 30 days, noted fair intake of 25 to 49 percent, and set a goal of weight stability. Although subsequent weights confirmed continued loss, the physician assistant’s December 29, 2025 note described the resident as obese and needing weight management without acknowledging the severe weight loss, and the dietitian’s December 29 note documented the weight loss and weekly weight checks, but no new nutritional interventions were identified. The resident’s record did not show an interdisciplinary decision that the weight loss was desired and beneficial. Weekly weights were not consistently obtained as documented in the record, including gaps between January 3 and January 15, 2026, and again between January 15 and January 31, 2026. The care plan, which had focused on obesity and maintaining weight within five percent of 186 pounds, was not updated after the resident fell below that goal and continued to lose weight, including a drop to 158.4 pounds on February 13, 2026. A later dietitian assessment listed a referral to speech-language therapy, but there was no evidence of an SLP evaluation before the surveyor observed the resident in bed with her lunch tray in front of her and not actively eating. A physician order for weekly weights was entered on February 26, 2026, but no weights were obtained afterward, and the surveyor reviewed these concerns with the DON on March 13, 2026.
Respiratory Care and Oxygen Order Deficiency
Penalty
Summary
Respiratory care was not provided consistent with professional standards of practice for a resident with COPD and oxygen concerns, and respiratory equipment supplies were not maintained in a safe and sanitary manner. During observation of the main dining room, a suction unit on a red wheeled cart was found with two bottles of sterile water that were expired, and the cart shelving had extensive debris. For Resident 7, who was admitted with a diagnosis of chronic obstructive pulmonary disease, observations showed the resident in bed with a nasal cannula in place and oxygen running at 3.0 LPM, but review of the clinical record found no physician order authorizing staff to administer oxygen. The DON confirmed that no such order existed.
Dialysis Care and Fluid Restriction Not Followed
Penalty
Summary
Provide safe, appropriate dialysis care and services for a resident who required dialysis. Resident 28 had active physician orders for dialysis three times a week, vital signs before and after dialysis, no blood pressure in the right arm, monitoring of the catheter site for pain, redness, swelling, and bleeding, and a renal diet with a 1200 ml fluid restriction. The resident stated he had a left arm dialysis access and reminded staff not to use his left arm for blood pressure checks or blood work, and he reported one prior episode of bleeding from the access site after he forgot to limit lifting after dialysis. He also stated that he did not have dietary or fluid restrictions, and a large cup of ice water was observed at his bedside. The room had no signage or alerts to inform caregivers of the resident's left arm restrictions. Documentation review showed the resident consumed more than the ordered fluid allowance on multiple days in March 2026, including 1320 ml, 1080 ml, 840 ml, and several days at 960 ml. Staff confirmed there was no indication of left arm restrictions even though the dialysis access was in the left arm, confirmed the right arm blood pressure restriction, and acknowledged the 16-ounce cup of fluid provided by facility staff. The LPN also stated that residents on fluid restrictions typically were not included during water pass activities.
Failure to Address PTSD in Care Plans
Penalty
Summary
The facility failed to identify triggers related to two residents’ PTSD diagnoses and failed to provide culturally competent, trauma-informed care or interventions to eliminate or mitigate re-traumatization. Resident 12 had a documented diagnosis of PTSD dated March 10, 2023. A quarterly MDS dated January 23, 2026, indicated the resident had a BIMS score of 10, showing cognitive impairment, and also confirmed the PTSD diagnosis. A psychosocial evaluation dated July 30, 2025, documented that the resident identified trauma as a teenager, and provider documentation from February 9, 2026, and March 10, 2026, noted PTSD. Review of Resident 12’s current care plan showed no plan addressing PTSD, triggers, person-centered interventions, or interventions to alleviate individualized triggers. Resident 43 was admitted on December 9, 2022, and a psychiatric progress note dated April 4, 2023, documented a history of being mugged, along with dementia, anxiety disorder, and increased paranoia. Review of Resident 43’s current care plan on March 10, 2026, showed no care plan to address PTSD, identify triggers, or provide person-centered interventions until after surveyor questioning. The facility failed to develop a comprehensive, person-centered care plan for both residents related to PTSD.
Unsecured and Unidentified Medications Found in Medication Cart Drawers
Penalty
Summary
The facility failed to properly store resident medications on two of six nursing units reviewed, the Little League Nursing Unit and the Sycamore Nursing Unit. During observation of the medication pass on March 12, 2026, a medication cart used by an LPN contained several unsecured and unidentified medication tablets in the bottom of the drawers that held pre-packaged pill packets, including a pink round pill, a white round pill, a blue oblong tablet, a half pink tablet, a half white round pill, a large white round pill, a smaller white round pill, a scored pink pill, and numerous other loose medications. The drawers also contained a significant accumulation of debris. In a concurrent interview, the LPN stated that third shift cleaned the carts, but all shifts were responsible for ensuring a clean cart. The findings were reviewed with the NHA and DON later that day.
Unsafe Kitchen Equipment and Electrical Leak
Penalty
Summary
Essential kitchen equipment was not maintained in a safe, operating condition in the facility's main kitchen. During an initial tour of the main kitchen, staff were observed serving breakfast from a steam table while a large cooking pan more than halfway filled with water was placed on the floor under the steam table. Employee 17, the dietary manager, stated there had been a leak from the steam table since at least December 2025. In the basement walk-in cooler for the main kitchen, a light receptacle in the ceiling had no bulbs, water was observed dripping from the receptacle and pooling on the floor, and an alternate light source was being used from a light attached to an electrical cord coming from outside the cooler. The Nursing Home Administrator stated they were not aware of the leak, and the maintenance director stated there was no power to the light when tested and they were not aware of the issue or the source of the leak.
Improper Garbage and Refuse Disposal at Dumpster Area
Penalty
Summary
The facility failed to properly contain and dispose of garbage at the observed trash dumpster. During an observation of the main dumpster, surveyors found a significant accumulation of dryer lint on the ground behind the dumpster closer to the building, along with various debris discarded on the ground including plastic cups, paper debris, two straws, multiple cigarette butts, a plastic bag, an empty milk carton, and a large accumulation of dried leaves mixed with paper products. A medical glove was hanging off the dumpster and another medical glove was discarded on the ground, and multiple paper debris were observed in a grate in the ground. This information was reviewed with the NHA and DON.
Failure to Properly Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to accurately post daily nurse staffing information as required. On March 10, 2026, observation showed the posted nursing time was located on Sycamore Boulevard rather than in a prominent place readily accessible to all residents, staff, and visitors, even though the facility has six nursing units: Little League, [NAME], Sycamore, Maple Court, Grampian, and Maple Lane. On March 11, 2026, further observation showed the posted nursing time did not include the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care. The Director of Nursing confirmed on March 12, 2026, that staff were not including the actual hours worked on the posted nursing time.
Failure to Serve Food at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to serve food that was palatable and at safe, appetizing temperatures on four of six nursing units. According to the facility's policy, hot foods should be served at or above 135 degrees Fahrenheit and cold foods at or below 41 degrees Fahrenheit. Multiple residents reported that their food was frequently cold, with some stating that meal trays arrived at inconsistent times and that they sometimes did not eat the food if it was cold. One resident also reported not always receiving the food she ordered. A new admission confirmed that her food had been cold at times. Observation of a breakfast meal revealed that the meal cart left the kitchen and arrived at one unit at 7:34 AM, with trays being passed between 7:41 AM and 8:21 AM. Food temperature testing conducted by the surveyor and the food service director showed that puree eggs were 91.2°F and tasted cold, puree bread was 97.8°F and tasted cold, milk was 59.2°F and tasted warm, and coffee was 102.7°F and tasted tepid. These findings were reviewed with the Nursing Home Administrator and DON.
Failure to Provide Snacks Outside Scheduled Meal Times
Penalty
Summary
The facility failed to accommodate residents who wished to eat outside of scheduled meal service times on all six nursing units. Interviews with three residents revealed that they did not receive snacks, with staff informing them that there were no snacks available in the nourishment rooms. Observations of the nutrition rooms on each nursing unit confirmed that no snacks were available for residents who wanted to eat at non-traditional times. The food service director verified these findings during the survey, and the information was reviewed with the Nursing Home Administrator and Director of Nursing.
Failure to Complete Required Neurological Assessments After Unwitnessed Fall
Penalty
Summary
The facility failed to provide the highest practicable care regarding neurological assessments for a resident who experienced an unwitnessed fall. According to facility policy, neurological assessments are required following such incidents, with specific intervals for monitoring and documentation. The resident was found face down on the bathroom floor with lacerations to both elbows. The registered nurse assessed the resident's neurological status and contacted the on-call physician, who provided instructions regarding medication and monitoring for changes in neurological status. The nurse documented neurological assessments at 9:30 PM, 10:00 PM, 10:30 PM, and 11:00 PM, but no further assessments were recorded at the required intervals throughout the night. Review of the resident's clinical record and facility investigation confirmed that neurological assessments were not documented at 12 AM, 1 AM, 3 AM, and 5 AM, as required by facility policy. Staff interviews verified that the established protocol for post-fall neurological monitoring was not followed. The resident was later found deceased in the early morning hours, with the death certificate citing chronic diastolic heart failure as the main cause of death. The deficiency was confirmed by both nursing staff and the Nursing Home Administrator.
Failure to Provide Required Payment Coverage Notices
Penalty
Summary
The facility failed to provide the required notifications to residents whose payment coverage changed, affecting three residents. For Resident 72, the facility did not provide the necessary CMS10123 or CMS10055 notices when the payment source for her care changed from Medicare. This was confirmed during an interview with the Nursing Home Administrator and the Director of Nursing, who could not provide evidence of the appropriate notices being given. Resident 101's representative signed a CMS10055 notice, but failed to select an option box indicating whether they wished to continue receiving care or have the bill submitted to Medicare. This oversight was confirmed by the Nursing Home Administrator. For Resident 119, the facility provided a CMS10123 notice, but it was issued verbally rather than in writing at least two days before the end of Medicare coverage, despite no circumstances preventing timely written notice. This was confirmed by the Nursing Home Administrator.
Failure to Provide Adequate Bathing Assistance
Penalty
Summary
The facility failed to provide adequate bathing assistance to residents who were dependent on staff for activities of daily living. Specifically, five out of six residents sampled did not receive showers according to their preferences and care plans. Resident 22, admitted in September 2023, was assessed as dependent on staff for bathing but only received one shower and seven bed baths in the last 30 days, despite her preference for showers twice a week. Similarly, Resident 92, admitted in January 2024, also received only one shower and seven bed baths in the same period, with no documentation of refusal. Resident 7, who requires substantial assistance, was observed multiple times in her wheelchair without evidence of having received a shower on the scheduled day. The task documentation for Resident 7 indicated 'not applicable' for her shower, and there was no record of staff attempting to provide bathing assistance. Resident 43, who is cognitively impaired, was also not provided showers according to their preference, receiving bed baths instead on multiple occasions from January to February 2025. Resident 70, dependent on staff for bathing, had inconsistent documentation regarding showers, with several instances of bed baths being provided instead. There were also multiple occasions where staff documented refusal or did not document any bathing activity, without evidence of re-approaching the resident. These findings were reviewed with the Nursing Home Administrator and Director of Nursing, highlighting the facility's failure to adhere to residents' bathing preferences and care needs.
Medication and Care Plan Deficiencies in LTC Facility
Penalty
Summary
The facility failed to provide the highest practicable care for several residents by not adhering to physician orders and medication administration protocols. For Resident 42, there was no documentation of medication administration on a specific date, indicating a lapse in following prescribed treatment for conditions such as hyperlipidemia and GERD. Similarly, Resident 70's medication administration records showed missing documentation on two occasions, and the resident was inappropriately given Midodrine despite blood pressure readings that contraindicated its use. Resident 33's care was compromised as staff did not monitor her respiratory rate before administering Oxycodone, a medication that requires careful monitoring due to its potential effects on respiration. Resident 109 was observed with edema and wearing a compression stocking without a physician's order or a care plan intervention, indicating a lack of coordinated care and documentation. Resident 112, who had a cardiac pacemaker, did not have an active physician order or care plan intervention acknowledging the device, which is crucial for his ongoing cardiac management. Resident 114's care was deficient in several areas, including improper documentation and administration of Vancomycin via a PICC line, and the absence of emergency procedures and equipment related to the PICC line. Additionally, Resident 22 experienced chest pain, and the facility failed to complete physician-ordered vital sign checks, which are critical for monitoring her condition. These deficiencies highlight significant lapses in medication administration, documentation, and adherence to physician orders, impacting the quality of care provided to the residents.
Inappropriate Pain Management for Residents
Penalty
Summary
The facility failed to provide the highest practicable care regarding physician-ordered pain medications for two residents. For Resident 6, there were multiple overlapping orders for Oxycodone to manage different levels of pain, but the facility did not identify the duplication of orders for a pain scale of 8-10 between January 16, 2025, and February 6, 2025. The Medication Administration Record (MAR) showed that staff administered Oxycodone 5 mg two tablets for a pain scale of 8-10 on several occasions when the resident's pain level was recorded as 0 or 4, which did not align with the prescribed pain scale. Additionally, Oxycodone 5 mg one tablet was administered for a pain scale of 4-7, but it was given when the resident's pain level was recorded as 8, 9, and 10, which exceeded the prescribed pain scale. For Resident 43, the facility also failed to adhere to the physician's order for pain management. The MAR indicated that staff administered Oxycodone 5 mg one-half tablet for a pain scale of 8-10 when the resident's pain level was recorded as 4, which was below the prescribed pain scale. These discrepancies in administering pain medication were reviewed with the Nursing Home Administrator and Director of Nursing, highlighting a failure in providing appropriate pain management as per physician orders.
Failure to Obtain Consent and Assess Entrapment Risks for Bed Rails
Penalty
Summary
The facility failed to review the risks and benefits of using bed rails with the residents or their representatives and did not obtain informed consent for their use. This deficiency was identified for four out of five residents reviewed for accident hazards. Specifically, Residents 33, 42, 70, and 109 had enabler bars installed on their beds without documented consent or education provided to them or their responsible parties about the potential risks associated with these devices. The facility only addressed these issues after the surveyor's intervention. Additionally, the facility did not properly assess all zones that pose a risk for entrapment from bed rails for two of the residents reviewed. For Residents 33 and 109, the facility's assessments did not include a review of zone six, which could potentially pose a risk for entrapment between the end of the enabler device and the side of the headboard. These oversights were confirmed through interviews with facility staff, including the Nursing Home Director, Director of Nursing, and a corporate regional director.
Failure to Conduct Annual Reviews and In-Service Training for Nurse Aides
Penalty
Summary
The facility failed to ensure that three nurse aides received an annual performance review and at least 12 hours of in-service education annually, as required by regulations. Employee 10, hired on September 12, 2023, did not have an annual performance review due in September 2024. Employee 11, hired on November 15, 2022, had a performance evaluation covering the period from November 15, 2022, to November 15, 2023, but lacked evidence of a subsequent evaluation. Employee 12, hired on May 30, 2023, along with Employees 10 and 11, did not receive the mandatory 12 hours of in-service training. The Nursing Home Administrator confirmed the absence of documentation for these requirements during interviews conducted in February 2025.
Missing Laboratory Reports in Clinical Records
Penalty
Summary
The facility failed to ensure that laboratory reports were included in the clinical records of three residents. For Resident 22, a physician's progress note indicated that several laboratory tests, including a CBC, BMP, BNP, and Troponin, were requested on January 13, 2025, with a stat turnaround time. However, there was no evidence of these tests in the resident's clinical record. Similarly, for Resident 92, a physician's progress note indicated that a CBC and BMP were to be repeated on January 13, 2025, and noted as completed, yet these results were not found in the clinical record. Resident 46's clinical record also lacked evidence of completed lab work, despite progress notes on February 7 and February 14, 2025, indicating that a CBC and BMP were completed. An interview with the Nursing Home Administrator, Director of Nursing, and a corporate consultant confirmed that the laboratory reports for these residents were not available for review. It was revealed that only the medical director and one other facility physician had access to view any resident's laboratory results in the system, which contributed to the unavailability of the lab results in the clinical records. This deficiency was identified during a review conducted on February 20, 2025.
Improper Food Storage in Kitchen
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety in the main kitchen. During an initial tour of the kitchen, it was observed that a tray of ground beef was thawing above a shelf containing eggs in the refrigerator. Additionally, there were three opened containers of beef base with a date of September 7, 2024, and a fourth container with no date. The refrigerator also contained a large container of lemon juice with a use-by date of January 18, 2025, a large container of salsa with a use-by date of January 25, 2025, a large container of mustard with a use-by date of April 8, 2024, and a large container of BBQ sauce with a use-by date of February 7, 2025. Employee 5, the director of dining services, confirmed these findings and discarded all the mentioned food items. It was revealed that dietary staff are expected to mark food items with received by, opened, and use-by dates.
Failure to Implement Infection Control Measures
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with chronic wounds or indwelling medical devices, as required by the Centers for Medicare and Medicaid Services (CMS) guidelines. Observations revealed that Resident 223, who had an indwelling urinary catheter, did not have EBP in place. Similarly, Resident 112, who had a central venous catheter for hemodialysis and open sores on his legs, also lacked EBP. Interviews with staff confirmed the absence of EBP for these residents, despite the facility's policy requiring such precautions. Additionally, the facility did not adhere to proper hand hygiene protocols. During medication administration, an LPN was observed turning off the faucet with clean hands after washing, contrary to the facility's policy of using a paper towel to maintain hand cleanliness. Furthermore, Resident 22, who was on contact precautions due to ESBL in her urine, had no care plan addressing these precautions, and staff were unaware of the reason for the precautions. The facility's failure to implement and maintain infection control measures was discussed with the Nursing Home Administrator and Director of Nursing.
Failure to Honor Advance Directive Choices
Penalty
Summary
The facility failed to honor the advance directive choices for Resident 53. A clinical record review revealed that the resident had a physician's order for Do Not Resuscitate (DNR) throughout their stay until February 20, 2025. However, on February 7, 2025, the facility contacted the resident's responsible party to complete a POLST form, which was completed on February 11, 2025, indicating that CPR should be performed if necessary. Despite this, there was no documentation that the facility recognized the change in the resident's wishes and discontinued the DNR order until it was identified by the surveyor. This oversight was discussed with the Director of Nursing and the Nursing Home Administrator during an interview on February 20, 2025.
Failure to Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an allegation of misappropriation of resident property involving a registered nurse, Employee 2, who was accused of stealing narcotics from Resident 118. The facility's policy on abuse, neglect, exploitation, or misappropriation requires that such allegations be reported immediately to the administrator and other relevant authorities, including state licensing agencies, the local/state ombudsman, adult protective services, law enforcement, the resident's representative, the attending physician, and the facility medical director. However, despite receiving emails from two nurses, Employee 6 and Employee 7, on January 21, 2025, alerting the Director of Nursing to the alleged theft, the facility did not notify the required agencies. The Department of Health received a complaint on January 24, 2025, regarding the alleged misappropriation, which was confirmed during an interview with the Director of Nursing and Employee 1 on February 21, 2025. The clinical record review of Resident 118 showed no documentation of the allegation, and the Director of Nursing and Employee 1 acknowledged that they were aware of the situation but failed to report it to the appropriate authorities. This oversight is a violation of the facility's policy and state regulations, specifically 28 Pa. Code 201.14(a)(c) and 28 Pa. Code 201.18(b)(1)(2)(e)(1).
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to ensure that assessments accurately reflected a resident's status, specifically for Resident 113. A clinical record review revealed that the admission MDS assessment for Resident 113 incorrectly indicated that he received five insulin injections during the previous seven days. However, an interview with Resident 113 confirmed that he had never received an insulin injection and did not have a diabetes diagnosis. This discrepancy was acknowledged by the Nursing Home Administrator, who confirmed that the MDS assessment was completed in error.
Failure to Provide Adequate Activity Program for Resident
Penalty
Summary
The facility failed to provide an ongoing program of activities designed to meet the individual needs and interests of a resident, identified as Resident 7. The resident's care plan indicated a dependency on staff for emotional, intellectual, physical, and social needs, with specific interventions to invite her to activities such as mass, musical programs, and craft activities. Observations over three consecutive days revealed that Resident 7 was consistently found sitting in a wheelchair at the nurses' station without her busy blanket, which she enjoys. The activity logs for January and February 2025 showed that Resident 7 attended only three activities in total, with no documentation of her refusing any activities. An interview with the activity director confirmed that Resident 7 had only been taken to three activities in the last two months. The facility employs two activity aides, one dedicated to the dementia unit and the other responsible for the remaining 87 residents. The deficiency was reviewed with the Administrator, highlighting the facility's failure to provide an ongoing program of activities to meet the needs of Resident 7, as required by resident rights regulations.
Failure to Maintain Resident's Range of Motion
Penalty
Summary
The facility failed to provide necessary services to maintain or improve a resident's range of motion (ROM). Resident 7, admitted on December 2, 2015, was assessed in a quarterly Minimum Data Set (MDS) on November 22, 2024, as having no impairments in upper or lower extremities. However, a subsequent MDS assessment indicated a limited ROM in both upper and lower extremities. Despite being discharged from physical therapy on December 26, 2024, and occupational therapy on November 15, 2024, the facility did not document any further assessment or intervention to address the decline in ROM. This lack of action was confirmed in an interview with the Nursing Home Administrator on February 20, 2025.
Failure to Address Bowel and Bladder Incontinence
Penalty
Summary
The facility failed to assess and implement individualized interventions to promote bowel and bladder continence for a resident identified as frequently incontinent. The resident was admitted on January 20, 2025, and the admission MDS assessment indicated frequent incontinence of bowel and bladder with no attempts at a toileting program. The resident was assessed as dependent on staff for toileting hygiene due to impaired balance and required extensive assistance from one staff member for toileting needs. The care plan initiated on January 21, 2025, noted the resident's self-care performance deficit related to impaired balance but did not include any assessment or treatment interventions to address the incontinence. An interview with the Nursing Home Administrator and Director of Nursing confirmed the lack of evidence for further assessment or implementation of interventions to promote continence. This failure to appropriately identify, assess, and provide treatment and services to maintain bowel and bladder function was noted as a deficiency.
Inadequate Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide appropriate respiratory care and services for three residents. Resident 22 was observed multiple times with a nasal cannula delivering oxygen at 4 liters per minute, despite having no physician's order for oxygen therapy. The resident's care plan noted a risk for ineffective breathing patterns related to oxygen use, yet there was no documentation supporting the necessity or authorization for the oxygen being administered. Resident 6 had a physician's order for oxygen at 2 liters per minute via nasal cannula and BiPAP at bedtime, but observations revealed discrepancies in the oxygen concentrator settings and improper storage of respiratory equipment. The BiPAP mask was found unbagged and hanging off the bedside stand, and the nasal cannula was lying on the floor. Resident 70 had orders for CPAP using room air, but observations showed an oxygen concentrator set to 4 liters per minute connected to a CPAP machine, with improperly stored and undated equipment. These findings were confirmed by the Director of Nursing and the Nursing Home Administrator.
Failure to Implement Dialysis Access Site Care
Penalty
Summary
The facility failed to implement appropriate care to prevent potential complications from a dialysis access site for a resident requiring dialysis. The resident, who needed dialysis treatments three times a week through a central venous catheter (CVC) in the right upper chest, reported being unaware of any equipment in his room to address complications from the dialysis access site. During an observation, there were no signs indicating right arm use restrictions, such as warnings for phlebotomists not to use the right arm for blood draws. The clinical record review revealed physician orders to avoid taking blood pressures on the resident's right arm and to monitor the catheter site for complications. However, there was no order restricting blood draws from the right arm or requiring an emergency kit in the resident's room. The facility's plan of care incorrectly referenced a graft in the arm, which the resident did not have. An LPN confirmed the absence of signage and emergency kit materials in the resident's room, despite believing there was a protocol for such measures. A physician's order to implement an emergency dialysis kit was only added after the surveyor's questioning.
Lack of Staff Competency in Managing Medical Devices
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary competencies and skill sets for the care and assessment of residents with specific medical devices. This deficiency was identified for three employees, including a registered nurse and two licensed practical nurses, who lacked documented competencies related to the management of indwelling urinary catheters, cardiac pacemaker devices, and central venous catheters. The surveyor's review of facility documentation and interviews with the Nursing Home Administrator and other staff confirmed the absence of evidence for these competencies. The deficiency affected residents with complex medical needs, including those with indwelling catheters, a Life Vest for cardiac monitoring, and central venous catheters. For instance, Resident 114 had orders for the use of a Life Vest and PICC line care, while Resident 112 had an IJ catheter requiring specific care instructions. Despite these needs, the facility could not provide evidence that the involved staff had the necessary knowledge and confirmed competencies to manage these devices, as required by physician orders and regulatory standards.
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 186 citations issued within 25 miles in the last 12 months — 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 Montoursville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Valley View Rehab And Nursing Center | 1.6 mi | ★★★★★ | 16 | 0 |
| Edenbrook North | 1.6 mi | ★★★★★ | 21 | 0 |
| Edenbrook South | 1.6 mi | ★★★★★ | 28 | 0 |
| Williamsport Home, The | 3.8 mi | ★★★★★ | 19 | 0 |
| Rose View Rehab And Care Center | 4.2 mi | ★★★★★ | 1 | 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.