Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 Heritage Hills Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that two residents receiving chemotherapy via PICC lines did not receive care in accordance with physician orders, facility policy, and professional standards. For one resident, a PICC with a baseline external length of 0 cm had a dressing change documented, but the required external length measurement was left blank; during an observed dressing change, an LPN measured the external length as 1 cm and acknowledged it had not been previously documented. For the second resident, the PICC dressing was not changed on admission and was delayed for nine days, and there was no documentation that the external catheter length was measured as ordered. The NP stated she expected timely dressing changes and external length measurements, and the DON could not provide evidence that these tasks were completed and documented until surveyors raised the concern.
A resident with severe cognitive impairment and a history of Alzheimer’s disease and major depressive disorder was in a day room when another resident with a known history of sexually inappropriate behavior was observed touching the cognitively impaired resident’s lower private area. The incident occurred despite prior documented episodes of inappropriate touching by the same resident toward others, including earlier incidents involving the same victim, and despite a care plan addressing this behavior. Facility records also showed a discrepancy between the documented location of the resident on observation sheets and the actual location where the incident occurred, and leadership could not demonstrate that the involved residents were kept free from abuse.
A resident with dementia and major depressive disorder had physician orders for Seroquel twice daily and at bedtime, along with an order for re-evaluation of these medications. An LPN documented that the re-evaluation with the provider occurred, but later admitted it had not been done, and the orders had been entered for only 14 days. As a result, the Seroquel orders dropped off the MAR and were not re-entered for several days, during which the resident did not receive the prescribed Seroquel doses. The DON later confirmed that the orders had initially been time-limited and had lapsed before being reordered.
A resident with dementia and neuromuscular dysfunction experienced a witnessed fall from bed while one staff member was assisting with turning. Record review showed the resident was dependent for rolling in bed, and the ADL care plan for impaired mobility contained conflicting bed mobility interventions: one entry required two staff and a sheet for turning and repositioning, while a later entry required only one staff and a sheet. The earlier intervention was not removed, leaving the care plan incomplete and unclear about the resident’s actual assistance needs. During interview, the Regional Clinical Director and DON acknowledged the discrepancy and were unable to show that the care plan accurately reflected the resident’s needs.
Failure to supervise a resident at risk for elopement: A resident with dementia, severely impaired cognition, and wheelchair use was identified as a wander/elopement risk and had an order for a wander bracelet on the wheelchair. The resident was observed self-propelling in the parking lot without staff supervision and without the wander guard attached, and a NA later left the resident outside unsupervised after finding him/her in the parking lot. The DON acknowledged the resident should not have been outside unsupervised.
Failure to provide ordered honey thickened fluids for two residents. One resident with aspiration pneumonia, stroke, severe cognitive impairment, and swallowing difficulty was observed coughing after drinking a liquid that staff could not identify as the ordered consistency, and a nurse later documented nectar liquids at lunch. Another resident with dysphagia and aspiration pneumonia was observed with a drink that poured freely and did not appear honey thickened. Staff reported preparing drinks at bedside and using inconsistent amounts of thickener, including a half packet for one resident, despite physician orders and manufacturer instructions for honey-like consistency.
Unsafe and Unclean Environment with Urine Odors and Soiled Linens: Surveyors noted a strong urine odor in the main building and on all three nursing units, with multiple resident rooms smelling of urine. On one unit, a resident was observed in bed with saturated clothing and bedding, brownish discoloration and dried stains on linens, and food particles scattered on the comforter and bed linens. An LPN acknowledged the observations, a resident reported that the unit smelled like pee, and the Administrator could not provide evidence that the environment was maintained as safe and clean.
A resident whose primary language was [NAME] was given a newsletter in English even though he or she said it could not be read and wanted it in the primary language. In addition, four residents were observed with soiled or saturated bed linens, urine odor, and delayed or incomplete ADL care; one resident reported waiting over an hour for personal care, another refused care and was not reattempted for hours, and an NA documented care as completed when it was not.
Failure to provide scheduled showers and personal hygiene assistance for multiple residents was identified. Residents with varying cognitive and physical needs, including dependence for ADLs, reported missed showers, lack of morning care, urine-soiled bedding, and staff not offering bathing services. Records did not show evidence that showers were provided or refused on scheduled days, and the DON stated that missed showers should be reattempted and documented, but could not provide evidence for the affected residents.
Insufficient staffing on the South Unit resulted in delayed response to call lights, missed personal care, and incomplete showers. A resident with intact cognition was found waiting over an hour for care and sitting in urine, while another resident reported no personal care during the shift and no showers were completed because only 3 NAs were scheduled. A resident at risk for elopement was also observed outside unsupervised without a wander guard.
Staff competency failures affected residents needing specialized care. A resident ordered honey-thick fluids was given a drink that was not correctly identified, and another resident with dysphagia also received a beverage that did not appear properly thickened; a NA reported using inconsistent amounts of thickener and not knowing the cup volume. A CMT also had a resident drink Biotene mouthwash despite the label warning not to swallow, mismeasured liquid haloperidol, and a Life Enrichment Director assisted with feeding without documented feeding-assistance training or competency.
Facility failed to use its facility assessment to match staffing to resident acuity, census, and care needs. Residents reported long waits for call lights, missed showers and care, and a urine odor in the building; surveyors observed residents in urine-soaked bedding and unkempt with food on bedding. Staffing records showed limited NAs on units with high care needs, staff confirmed short staffing, and a resident at risk for elopement was observed outside unsupervised.
Failure to Maintain an Effective QAPI Program: The facility did not maintain an effective, comprehensive, data-driven QAPI program focused on outcomes of care and quality of life. Surveyor concerns included a resident found saturated in urine in the morning, four instances of delayed morning care until well after 12-2 PM, and call bells not being answered timely. The 2025 QAPI binder did not show that the QAPI committee discussed these concerns, and the Administrator could not provide evidence of a good faith attempt to address the cited nursing care issues.
Failure to Follow PICC Line and Wound Care Standards: An LPN flushed a resident’s PICC line and infused an antibiotic without aspirating for blood return as required by facility policy. In a separate event, an LPN and the ADON provided wound care to another resident but applied bordered gauze so the adhesive contacted excoriated skin, and the LPN acknowledged she should not have done so.
Medication Administration Errors Exceeded 5% Error Rate: Surveyors observed two medication administration errors during 26 opportunities, resulting in a 7.69% error rate for a resident with dementia and intellectual disabilities. A CMT gave Biotene mouthwash with a straw so the resident swallowed it, despite the label warning not to swallow and an LPN stating it should have been given with a mouth swab. The same resident's ordered haloperidol dose was also mismeasured when staff used an inaccurate dropper instead of an appropriately sized syringe.
An untrained Life Enrichment Director assisted a resident with dysphagia and a pureed diet during breakfast even though the resident’s care plan identified aspiration risk, a prior choking episode, and pocketing food. Interviews and record review showed the staff member had not completed a state-approved paid feeding assistant program, had no feeding-assistance competency, and had no documented training for feeding assistance.
Failure to Explain Binding Arbitration Agreements: The facility did not explain the ADR agreement in a way the residents or their representatives could understand for two residents. Both residents had intact cognition, one with a hx of stroke and the other with legal blindness, yet each signed an arbitration agreement even though the admission packet documented that the facility rep had not presented and explained it. In interview, both residents said they did not recall any explanation and were unaware they had agreed to binding arbitration.
Infection control failures involved a resident on contact precautions for C. Diff and another resident with a suprapubic catheter. Staff did not follow posted enteric precautions when an RN failed to wash with soap and water after exiting the room and the DON entered without gown or gloves during wound care. The catheter drainage bag was repeatedly observed on the floor instead of being hung off the bed frame, and staff acknowledged the improper placement.
Call Light System Not Functioning on One Unit: The facility failed to ensure that residents on the [NAME] Unit had a working call system that relayed alerts directly to staff or a centralized staff work area. Residents reported long waits for call light responses, and surveyors observed two powered-off monitors at the Nursing Station. An LPN stated staff did not use equipment that communicated alerts directly to staff, the ADON said the monitors were broken, and the Maintenance Director said the issue needed repair and he was unaware of it until the surveyor raised it.
Two residents at risk for falls did not receive adequate supervision or required safety interventions. One resident with paraplegia fell from bed after being left unattended and without the assistance of two staff as required, while another resident with quadriplegia was found in bed with only one of two ordered floor mats in place. Staff and the DON confirmed that established safety protocols were not followed.
Three residents with pressure ulcers did not receive timely or complete wound care, including missing documentation of wound characteristics and failure to implement or transcribe physician-recommended treatments such as peri-wound skin prep. Orders were not entered into the medical record, resulting in necessary interventions not being provided, as confirmed by staff interviews.
A resident with a history of urine retention was not provided a urology consult as ordered by a physician after a failed trial void. The order was changed to 'as needed' by a nurse, leading to it not being documented for daily follow-up. The resident was later hospitalized with a fever and infection, and the facility administrator acknowledged the failure to schedule the consult.
A resident with Parkinson's disease and moderately impaired cognition missed two medical appointments due to the facility's failure to provide transportation and maintain proper communication. The facility lacked a clear record-keeping system for appointments, leading to missed neurology and dental visits. Staff interviews revealed a lack of awareness and communication regarding the resident's scheduled appointments.
A resident whose primary language is Spanish was given important documents in English, which they could not read, violating their rights. The resident signed financial and admission documents, including a health insurance non-coverage notice, without understanding them. Staff communicated in Portuguese, not Spanish, and the facility failed to provide evidence of documents in the resident's preferred language.
The facility failed to follow physician orders for a resident's urine collection, using a straight catheter without an order, and did not communicate in the resident's native language, causing distress. Another resident's weight was not monitored as ordered, with no evidence of physician notification. The DON could not provide evidence of compliance.
The facility failed to maintain an effective infection prevention and control program, with deficiencies in scabies management, Enhanced Barrier Precautions (EBP), and wound care practices. Staff did not follow protocols for bagging and removing belongings of residents with suspected scabies, and failed to wear appropriate PPE during high-contact care activities. Additionally, the laundry room lacked gowns for handling soiled linens, indicating significant lapses in infection control measures.
The facility failed to implement an effective antibiotic stewardship program, as evidenced by the lack of antibiotic review processes and monitoring for two residents prescribed antibiotics. The Infection Preventionist, new to the role, had not been trained to conduct antibiotic timeouts, and the Regional Nurse acknowledged the need for improvement in this area.
The facility failed to manage a Freestyle Libre sensor for a diabetic resident, lacking documentation and physician orders. Additionally, daily weights and wound care orders for another resident were not consistently followed, and wound care documentation for two residents was incomplete. Staff interviews confirmed these deficiencies.
The facility failed to ensure residents received necessary specialist appointments, impacting three residents with conditions requiring follow-up care. One resident with a traumatic brain injury did not have a neurology appointment scheduled, another with mouth pain did not see a dentist, and a third with a diabetic foot infection did not have a podiatrist appointment. Staff interviews confirmed these oversights.
The facility failed to provide adequate pressure ulcer care for two residents. One resident had no physician's order for an ankle wound, and staff were unsure how to prepare the correct Dakin's solution. Another resident's wound care did not match updated recommendations, and a float nurse was unaware of the treatments. The DON could not provide evidence of proper care, indicating a failure to meet professional standards.
The facility failed to provide sufficient nursing staff, resulting in delayed responses to call lights and inadequate care for residents. A resident was observed self-toileting due to lack of assistance, while another remained soiled before a wound dressing change. Staff shortages were reported, with fewer nursing assistants than required, leading to delays in morning care. The Director of Nursing Services could not justify the staffing inadequacies.
The facility failed to ensure nursing staff had the necessary competencies for wound care and hypodermoclysis. An LPN provided wound care without a physician's order and used unclean equipment, while another LPN did not clean scissors before use. An RN did not assess the drip rate for hypodermoclysis, leading to incorrect infusion rates. Competency assessments were incomplete or missing, and staff interviews revealed a lack of proper training.
The facility failed to address pharmacy recommendations for three residents, leading to deficiencies in medication management. A resident's medication orders lacked diagnoses, another's liquid concentrate orders were not updated with both milligrams and milliliters, and a third resident's anticoagulant monitoring and scheduling were not adjusted as recommended. The DNS and Regional Nurse acknowledged these issues.
The facility experienced a medication error rate of 56%, involving several residents. Errors included late administration of medications, incorrect administration of Tums, improper infusion rate of D5 solution, and failure to check apical pulse before administering Metoprolol Tartrate. Additionally, Prevacid was crushed against instructions. Staff acknowledged these errors, and the facility could not demonstrate adherence to its medication administration policy.
A resident with moderate cognitive impairment and medical conditions requested an external catheter at night for comfort, which was agreed upon by a nurse practitioner. However, the catheter was not consistently provided, as evidenced by treatment records and staff interviews. The facility failed to adhere to the resident's care plan, impacting their wellbeing.
A resident on hospice care was found with an empty oxygen tank, and staff were unable to promptly replace it due to a lack of knowledge about oxygen supply locations and prioritization of other tasks. The resident's oxygen level dropped significantly before the DNS intervened to replace the tank.
A resident with severe cognitive impairment and multiple pressure ulcers experienced inadequate pain management during wound care. Despite repeated complaints of pain, the LPN continued treatment without notifying a provider or using non-pharmacological interventions. The resident had only received Tylenol earlier in the day, and the Director of Nursing could not provide evidence of effective pain management.
A facility failed to maintain accurate medical records for a resident with vascular wounds. The resident, admitted with type II diabetes mellitus and heart failure, had a physician's order for an Unna Boot treatment, which was later changed to clobetasol and a tubi grip. Despite this change, the treatment records inaccurately documented the completion of the Unna Boot treatment. Observations confirmed the absence of the Unna Boot, and staff interviews revealed a lack of explanation for the inaccurate documentation.
A facility failed to follow physician's orders for daily wound dressing changes for a resident with hemiplegia, hemiparesis, and type 2 diabetes. The resident's dressing was not changed as ordered, and staff interviews confirmed the oversight. The Regional Director expected compliance with the orders, but an LPN admitted to inaccurately documenting the dressing change.
A resident with hemiplegia and hemiparesis fell in the shower while unsupervised by a licensed NA, resulting in bruises and a scratch. The resident required substantial assistance for showers, but was left alone with a nursing student when the NA stepped out. The facility failed to provide evidence of adequate supervision, as required by their agreement with the nursing school.
A resident with COVID-19 was not properly isolated due to staff failing to wear required PPE. Despite signage indicating necessary precautions, a Nursing Assistant and a Physical Therapy Assistant entered the room without full PPE, including missing gowns and eye protection. Both staff members acknowledged their oversight, and the facility's leadership confirmed the breach in infection control protocols.
A resident with a UTI and DVT did not receive medications as ordered, with several medications administered late and one not given at all. The DON acknowledged the failure to follow physician's orders, which included specific times for medication administration.
A facility failed to securely store tramadol, a Schedule IV controlled substance, leading to 22 missing pills for a resident with dementia and pain. The medication was not logged or stored properly, resulting in a breach of professional principles for medication security.
A resident with cognitive impairments and identified as an elopement risk was transported to a medical appointment unaccompanied by facility staff, leading to the resident's successful elopement. The resident's wander bracelet was removed, and the resident's whereabouts became unknown after the appointment was canceled. The resident was found by facility staff on a main road approximately 8 miles from the facility. The facility failed to implement its policy on wandering and elopement, resulting in inadequate supervision and significant risk to the resident's safety.
A medication administration error occurred when a nurse in training, under inadequate supervision, administered the wrong medications to a resident. The preceptor prepared the medications and handed them off to the trainee, who misheard the room number and administered them to the wrong resident. The facility's policy on medication administration was not followed, and the trainee's competency had not been demonstrated.
A resident with multiple health conditions was administered incorrect medications by a nurse in training, leading to dizziness and a significant drop in blood pressure. The error was identified promptly, and the resident was monitored closely, but the facility failed to ensure adherence to its medication administration policy.
Failure to Follow PICC Line Dressing and Measurement Orders for Two Chemotherapy Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide PICC line care and dressing changes according to physician orders, facility policy, and professional standards of practice for two residents receiving chemotherapy via PICC lines. For Resident ID #1, hospital documentation showed a PICC was inserted in the left arm with a baseline external catheter length of 0 cm, and the resident was to receive chemotherapy through this line. The January 2026 MAR contained a physician’s order to change the central line dressing every 7 days and to measure the external catheter length with each dressing change. The dressing change was signed as completed on 1/31/2026, but the documentation field for the catheter length was left blank. During a surveyor-observed dressing change on 2/6/2026, an LPN measured the external catheter length as 1 cm and acknowledged that the external length had not been documented previously in the resident’s record. For Resident ID #2, hospital records indicated a PICC was inserted in the right arm with a baseline external catheter length of 0 cm, and this resident was also to receive chemotherapy via the PICC. The January 2026 MAR showed a physician’s order to change the central line dressing every 7 days and to measure the external catheter length, but the order was marked incomplete due to the resident being absent from the facility. The PICC dressing was not changed on admission and was not completed until 2/6/2026, nine days later, and there was no evidence in the record that the external catheter length was measured as required by facility policy and the physician’s order. During interviews, the Nurse Practitioner stated she expected PICC dressings to be changed as ordered and the external length measured and reported if different from baseline, and the Director of Nursing Services was unable to provide evidence that the PICC dressing and external length measurements had been completed and documented for either resident until the surveyor brought the issue to the facility’s attention.
Failure to Prevent Repeated Sexual Abuse Between Residents
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse when another resident with a known history of sexually inappropriate behavior inappropriately touched the resident’s lower private area in a unit day room. On the date of the incident, an Activities Aide walking by the South Unit day room observed one resident in a wheelchair positioned beside another resident’s chair and touching the other resident’s lower private area. The staff member immediately intervened, separated the residents, and notified the nurse. Both residents were assessed and found without injuries. The resident who was touched had been admitted with diagnoses including Alzheimer’s disease and major depressive disorder, and a recent MDS assessment documented severe cognitive impairment. Record review showed that the resident who engaged in the touching had an existing care plan, initiated months earlier, addressing a history of sexually inappropriate behavior and inappropriate touching of other residents and staff. The care plan documented multiple prior incidents of inappropriate touching involving other residents, including two earlier incidents with the same cognitively impaired resident. Despite these prior events and care plan focus, the resident continued to engage in inappropriate touching. Documentation also showed a discrepancy between the location recorded on a 15‑minute observation sheet, which indicated the resident was at the nurse’s station on a different unit at the time of the incident, and the actual location of the incident in the South Unit day room. During interview, the Administrator acknowledged the prior inappropriate touching incidents involving these residents and the implementation of interventions but could not provide evidence that the affected residents were kept free from abuse by the resident with sexually inappropriate behavior.
Failure to Follow Physician Orders for Seroquel Resulting in Missed Doses
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services met professional standards of quality by not properly following physician orders for Seroquel for one resident. The resident was admitted with dementia with behavioral disturbances and major depressive disorder and had physician orders for Seroquel 50 mg by mouth twice daily starting 12/20/2025 and Seroquel 25 mg by mouth at bedtime starting 12/19/2025. There was also a physician order to re-evaluate the Seroquel orders with the provider on 1/2/2026. The January 2026 MAR showed that this re-evaluation order was signed off as completed by an LPN, indicating the medications were re-evaluated with the provider, but progress notes contained no evidence that such a re-evaluation occurred. During an interview, the LPN stated she had signed that she re-evaluated the Seroquel order with the provider but acknowledged that she had not done so. She also revealed that when the Seroquel orders were initially entered, they were entered for only 14 days. The January 2026 MAR showed that the last administration of the twice-daily Seroquel was on 1/2/2026 at 1:00 PM and the last administration of the bedtime Seroquel was on 1/1/2026, after which both orders were no longer in place. The same Seroquel orders were not re-entered until 1/10/2026 and 1/11/2026, resulting in the resident not receiving Seroquel as ordered for a total of 8 days. The DON acknowledged that the Seroquel orders had initially been entered for only 14 days and that, upon later review, the orders were found to be no longer in place.
Inaccurate Care Plan Documentation for Bed Mobility Assistance
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurately documented medical records for a resident with dementia and neuromuscular dysfunction who was admitted in April 2023. A community complaint reported to the state health department raised concerns about safety and care practices surrounding the resident’s fall on 1/12/2026. Nursing progress notes documented that the resident experienced a witnessed fall in his/her room while care was being provided, when one staff member was assisting with turning in bed and the resident fell out of bed onto the floor. A Quarterly MDS assessment indicated the resident was dependent for rolling in bed from back to side and returning to back. Review of the resident’s ADL care plan, initiated 4/14/2023 for physical limitations related to impaired mobility, showed conflicting interventions for bed mobility. One intervention, dated 6/7/2024, stated the resident required the assist of two staff and a sheet for turning and repositioning, while a later intervention, dated 12/23/2025, stated the resident required the assist of one staff and a sheet for turning and repositioning. The care plan did not clearly indicate which level of assistance was current, resulting in an incomplete and inaccurate description of the resident’s needs for turning and repositioning in bed. During an interview, the Regional Clinical Director, with the DON present, acknowledged that the earlier two-person assist intervention should have been removed when the one-person assist intervention was implemented and could not provide evidence that the care plan accurately reflected the resident’s needs.
Failure to Supervise Resident at Risk for Elopement
Penalty
Summary
The facility failed to ensure adequate supervision for a resident who was at risk for wandering and elopement and who was able to leave the facility unsupervised. The resident was admitted with diagnoses including mild neurocognitive disorder, dementia, and anxiety, and the MDS showed a BIMS score of 5 out of 15, indicating severely impaired cognition. The resident also required a wheelchair for ambulation. A progress note documented that the resident was found wheeling in the parking lot and was returned to the unit, and an Interim Elopement/Wandering Risk Evaluation identified the resident as at risk for wander/elopement. The care plan included an intervention to apply a wander guard device, and a physician order directed staff to check placement of the wander bracelet on the wheelchair every shift. During observation, the resident was seen self-propelling in the parking lot away from the front door with no staff supervising and no wander guard located on the wheelchair. A NA later stated the resident had been in the dining room, then went outside to look for the resident and found him/her in the parking lot. The NA introduced the surveyor to the resident and returned inside, leaving the resident outside without supervision. The NA stated she was unaware of the wander bracelet order and that the resident should not have been outside without supervision. The TAR showed the wander bracelet placement check was documented as completed by an LPN on the same shift, but the DON acknowledged the resident did not have a wander guard on the wheelchair and should not have been outside unsupervised.
Failure to Provide Ordered Honey Thickened Fluids
Penalty
Summary
The facility failed to provide and prepare food in a form designed to meet individual needs for 2 residents who had physician orders for honey thickened fluids. Resident ID #49 was admitted with diagnoses including aspiration pneumonia and stroke, had a BIMS score of 3, and was documented as coughing or choking during meals with complaints of swallowing difficulty. The care plan identified a nutritional problem related to swallowing that required honey thickened fluids, and a physician order dated 4/19/2025 specified honey thickened fluids. During observation, Resident ID #49 was seen eating lunch and picked up an 8-ounce mug of liquid that spilled over the top along with a dry white powdery substance. After taking a drink, the resident immediately started coughing. Staff A was unable to identify the liquid consistency and asked the nurse, and Staff B stated it was maybe nectar. A nursing progress note documented that the resident was observed coughing with nectar liquids at lunch, that liquids were downgraded to pudding thickness, and that a speech evaluation was requested. Another note stated a chest x-ray was being ordered to rule out aspiration pneumonia. Resident ID #19 had diagnoses including dysphagia, acute respiratory failure, and aspiration pneumonia, with a BIMS score of 9. The care plan called for a therapeutic diet as ordered, including the prescribed fluid consistency, and a hospice recommendation approved by the physician requested honey thick fluids for recurring aspiration pneumonia. A physician order dated 6/9/2025 specified honey thickened fluids. During observation, the resident had an 8-ounce cup with a lid and tea bag inside, and when the liquid was poured out it flowed freely and did not appear honey thickened. Staff C stated the drink appeared thickened at the bottom but not on top and that NAs prepare and thicken drinks at bedside. Staff D stated she mixed 1 packet of Thick & Easy into Resident ID #49's apple juice and used only a half packet for Resident ID #19, while also stating she did not know the number of fluid ounces in the cups supplied by the facility. The thickener instructions provided by the facility stated that 1 packet should be added to 4 fluid ounces of liquid for honey-like consistency.
Unsafe and Unclean Environment with Urine Odors and Soiled Linens
Penalty
Summary
The facility failed to maintain a safe and clean environment in the main building and on all three nursing units observed. During the initial tour, surveyors noted a noticeable foul odor that smelled distinctly of urine upon entering the main building. Additional observations on the South, East, and West Units found strong, unpleasant urine odors in resident rooms, including multiple rooms on the West Unit where residents were observed in beds with saturated bed comforters and clothing, brownish discoloration on white bed linens, dried tan/yellow stains, and food particles resembling scrambled eggs scattered on the comforter and linens while the resident remained in bed. Staff interviews confirmed the observations. An LPN acknowledged the odors and conditions noted on the unit. During a resident group interview, one resident stated that the unit smelled like pee. Surveyors continued to note strong and unpleasant odors throughout the survey process in the main building and all three nursing units. When interviewed, the Administrator was unable to provide evidence that the facility maintained a safe and clean environment relative to the main building and the three nursing units.
Failure to Provide Communication in Resident’s Primary Language and Timely ADL Care
Penalty
Summary
The facility failed to ensure that a resident whose primary language is [NAME] received communication in a language he or she could understand to support a dignified existence. Resident ID #86 was admitted in December 2021 with a diagnosis including depression. The care plan identified the resident’s primary language as [NAME], and the MDS indicated that books, newspapers, and magazines were very important to the resident. During observation, the resident was seen with a copy of THE DAILY CHRONICLE on the bedside table, but it was written in English. The resident indicated that he or she speaks some English but could not read the newsletter and wanted to receive it in the primary language. Staff later observed the resident receiving the newsletter again in English, and the Life Enrichment Director stated the resident would be expected to receive it in the primary language. The DNS was unable to provide evidence that the resident received the newsletter in a language he or she could understand. The facility also failed to ensure dignified existence for residents observed with soiled bed linens and delayed or incomplete ADL care. Resident ID #30, admitted in October 2023 with osteoarthritis and adult failure to thrive, had an admission MDS showing a BIMS score of 15 and dependence on staff for ADLs. During observation, the resident was lying in bed and stated he or she had been waiting for personal care for over an hour and was sitting in urine; the bed linens had a tan/yellow stain and a strong urine odor. Resident ID #37, admitted in March 2024 with alcohol abuse and major depressive disorder, was dependent on staff for ADLs and had a care plan addressing refusal of care. The resident was observed in bed with saturated clothing and linens, an overpowering urine odor, and brown discoloration on the sheet. Staff reported the resident refused care earlier in the morning and that ADL care was not reattempted until approximately three and a half hours later. Resident ID #12, admitted in February 2024 with morbid obesity and cognitive communication deficit, was observed lying in bed with dried tan/yellow discolorations on the linens and food particles resembling scrambled eggs scattered on the comforter and bed linens. Resident ID #26, admitted in July 2024 with dementia, was observed lying in bed with dried tan/yellow discolorations on the linens and a strong urine odor. Although documentation showed care had been recorded as completed for Resident ID #26 shortly before the observation, the assigned NA acknowledged that the care was not actually completed and that the documentation was inaccurate. The DNS stated that staff should reattempt care every 5-10 minutes when a resident refuses if that is what the care plan indicates, but was unable to provide evidence that Residents ID #12, 26, 30, and 37 received timely assistance with ADL care and clean bed linens.
Failure to Provide Scheduled Showers and Personal Hygiene Assistance
Penalty
Summary
The facility failed to provide necessary assistance with bathing and personal hygiene for six residents who were unable to complete ADLs independently. Resident #30, admitted with osteoarthritis and adult failure to thrive, was dependent on staff for ADLs and told the surveyor that he/she had been waiting over an hour for personal care and was sitting in urine. The resident’s bedding was observed with dried and wet tan/yellow stains and a strong urine odor, and the resident also reported not knowing when the last shower occurred and that staff only provided in-bed personal care and dry shampoo. The resident was scheduled for showers twice weekly, but the record did not show that a shower was provided on the scheduled shower day or that showers were offered, received, or refused on scheduled days. Resident #34, admitted with legal blindness and intact cognition, reported receiving only two showers since admission and stated that staff did not offer showers, providing only basic hygiene in the room. The resident was scheduled for weekly showers, but the record did not show a shower on the scheduled day or evidence that the shower was offered, received, or refused. Resident #41, admitted with anxiety and requiring substantial assistance with ADLs, was observed in bed wearing a johnny and stated that he/she could not remember the last shower and that staff had not provided personal care during the shift. The resident was scheduled for twice-weekly showers, but the record did not show a shower on the scheduled day or evidence of an offer, receipt, or refusal. Resident #69, admitted with osteoarthritis and requiring substantial assistance with ADLs, stated that he/she had not received a shower since admission and that staff had not provided personal care during the shift. Resident #73, admitted with osteoarthritis and needing assistance with ADLs, stated that staff changed the brief but did not wash him/her during morning care. Resident #75, admitted with Alzheimer’s and severely impaired cognition, was also scheduled for weekly showers, but the record did not show that showers were offered, received, or refused. The DON stated that residents should receive showers on scheduled days, that missed showers or refusals should be reattempted and documented, and that staff should accommodate residents who missed showers or requested additional showers; however, she was unable to provide evidence that the six residents were offered, received, or refused showers on their scheduled shower days.
Insufficient South Unit Staffing Led to Missed Care and Unsupervised Resident
Penalty
Summary
The facility failed to provide sufficient nursing staff on the South Unit to meet resident needs and to ensure a licensed nurse was in charge on each shift, as reflected in the staffing review, resident observations, and staff interviews. The facility assessment stated that staffing should be based on resident care needs, acuity, census, and changes in resident volume or unit needs, but the nursing schedule from 9/15/2025 to 9/17/2025 showed only 3 NAs scheduled for the South Unit with a census of 30 residents. The South Unit assignment sheet identified 14 residents who required Hoyer lifts and noted that 2 assists are needed when using a mechanical lift, and another facility document showed 6 residents required assistance with meals. The Staffing Coordinator stated that 3 NAs was the base staffing for the South Unit. During the resident council task, multiple residents reported waiting 30 minutes to 1 hour for staff to respond to call lights, and one resident reported waits of up to 2 hours. Resident #30, who had diagnoses including osteoarthritis and adult failure to thrive and had a BIMS score of 15, was observed on 9/15/2025 waiting over an hour for personal care and sitting in a puddle of urine, with a sheet showing dried and wet tan/yellow stains and a strong urine odor. The resident stated that showers were scheduled for Tuesdays on the day shift and that staff were providing personal care in bed and using dry shampoo for hair washing. On 9/16/2025, the resident was observed ungroomed with greasy hair and a strong urine odor and stated that a scheduled shower had not been received; the record did not show evidence that the shower was provided or that showers were offered, received, or refused on scheduled shower days. Resident #73, who had osteoarthritis and a BIMS score of 15, stated on 9/17/2025 that personal care had not been provided during the shift and that staff had changed the brief in the morning but had not washed the resident. The resident’s shower schedule called for showers twice weekly, but the record did not show evidence that showers were offered, received, or refused on scheduled shower days. Staff J stated she was still trying to complete morning care and had not completed any showers on the South Unit because only 3 NAs were scheduled and there would not be time. Resident #15, who had mild neurocognitive disorder, dementia, anxiety, and was at risk for elopement, was observed self-propelling in the parking lot without supervision, and the DON acknowledged the resident did not have a wander guard on the wheelchair and should not have been outside unsupervised.
Staff Competency Failures in Thickened Liquids, Medication Administration, and Feeding Assistance
Penalty
Summary
The facility failed to ensure that nursing staff and other staff assisting residents had the appropriate competencies and skill sets to provide safe care for residents with specific diet and medication needs. For a resident with diagnoses including aspiration pneumonia and stroke, a physician ordered honey-thick fluids. During observation, the resident was given a drink that spilled over the mug, was not identified correctly by staff, and caused immediate coughing after the resident drank it. A nursing assistant could not identify the liquid consistency, and an LPN stated she was not sure and thought it might be nectar thick. A second resident with dysphagia, acute respiratory failure, and aspiration pneumonia also had a physician order for honey-thick fluids. During observation, the resident had a cup with tea that poured freely and did not appear thickened. Staff later stated the drink appeared thickened at the bottom but not on top, and that nursing assistants prepared and thickened drinks at bedside. A nursing assistant reported using one packet of thickener for one resident’s beverage and only half a packet for the other resident’s honey-thick liquids, while also stating she did not know the fluid ounces in the facility cups or how much thickener was needed to achieve the ordered consistency. For another resident, a CMT administered Biotene mouthwash by placing a straw in the cup and allowing the resident to drink and swallow it, despite the product label warning not to swallow and the order being for comfort measures/dry mouth. The same CMT also mismeasured liquid haloperidol, initially drawing up 2.5 ml instead of the ordered 0.25 ml, and an LPN was observed using an inaccurate dropper before obtaining a smaller syringe to measure the ordered dose. In addition, a Life Enrichment Director assisted a resident with a pureed meal despite not having completed feeding-assistance training or a competency, and the facility could not provide evidence of state-approved training for that staff member.
Facility Assessment Not Used to Match Staffing to Resident Needs
Penalty
Summary
The facility failed to implement and use its facility-wide assessment to determine the resources needed to care for residents competently during day-to-day operations and emergencies. The undated facility assessment stated that staffing patterns were based on resident care needs, acuity, census, and other factors such as communicable disease outbreaks and admission or discharge volume, but survey findings showed the staffing pattern was not being adjusted to match resident needs. During resident council, multiple residents reported waiting 30 minutes to 1 hour for call light response, with one resident stating waits could be up to two hours, and residents also complained about missed showers, missed care, and a urine odor in the building. Record review showed the South Unit had 3 NAs for 30 residents and the [NAME] Unit had 4 NAs for 40 residents, while the South Unit assignment included 14 residents who required Hoyer lifts, including 7 residents on one assignment, and 6 residents who required assistance with meals. Survey observations found residents in urine-saturated sheets with dried amber stains and several residents appearing unkempt with food on their bedding. Staff interviews confirmed staffing concerns, including an LPN stating no residents on the [NAME] Unit received showers because there were only 3 NAs, and an NA stating the facility was short staffed. A resident at risk for elopement was also observed outside unsupervised in the parking lot without a wander guard on the wheelchair, and the DON acknowledged the resident should not have been outside unsupervised.
Failure to Maintain an Effective QAPI Program
Penalty
Summary
The facility failed to implement and maintain an effective, comprehensive, data-driven QAPI program focused on outcomes of care and quality of life. Review of the facility’s QAPI policy showed that the program was expected to identify and prioritize quality deficiencies, develop and implement corrective action or performance improvement activities, and monitor the effectiveness of those activities. However, review of the 2025 QAPI binder did not show evidence that the QAPI committee discussed the concerns identified during the January 2025 QAPI meeting. A QAPI action plan initiated on 9/16/2024 identified surveyor concerns involving one resident found saturated in urine in the morning, four instances of residents not receiving morning care until well after 12-2 PM, and call bells not being answered timely. During interview on 9/18/2025, the Administrator was unable to provide evidence of a good faith attempt to correct the concerns from the 2024 annual recertification survey and was unable to provide evidence of a comprehensive QAPI program that addressed monitoring of nursing services and care concerns.
Failure to Follow PICC Line and Wound Care Standards
Penalty
Summary
The facility failed to provide care that met professional standards for a resident with a PICC line and for a resident receiving wound care. For the resident admitted in August 2025 with diagnoses including sepsis and peripheral vascular disease, a facility policy titled Central Venous Catheter Flushing and Locking required flushing the catheter and aspirating for blood return prior to each infusion. During observation, an LPN flushed both PICC line lumens with normal saline but did not aspirate for blood return before infusing an antibiotic. In interview immediately afterward, the LPN acknowledged that she did not aspirate for blood return and was unaware if it was the facility's policy. The DON stated she would expect aspiration for blood return prior to medication administration per facility policy. For the resident readmitted in February 2025 with diagnoses including multiple sclerosis and anxiety, a physician ordered cleansing of the coccyx with normal saline, patting dry, applying zinc, and covering the excoriation on the buttocks with bordered gauze. During wound care observation, an LPN and the ADON cleansed the wound, applied zinc, and then covered it with bordered gauze, but the bordered gauze did not cover the excoriation and the adhesive was applied directly to the excoriated skin. The LPN acknowledged that she applied the bordered gauze to the excoriated skin and that she should not have. The wound physician later evaluated the resident and changed the order to omit the dressing, and the DON was unable to provide evidence that care met professional standards relative to the wound care.
Medication Administration Errors Exceeded 5% Error Rate
Penalty
Summary
The facility failed to ensure that each resident's medication regimen was free from a medication error rate of 5% or greater. During surveyor observation of 26 medication administration opportunities, two errors were identified, resulting in an error rate of 7.69% for Resident ID #4. The facility policy stated that medications are to be administered in a safe and timely manner and as prescribed. Resident ID #4 was admitted in April 2024 with diagnoses including dementia and intellectual disabilities. A physician ordered Biotene Dry Mouth/Throat Liquid, 15 mL three times daily for comfort measures/dry mouth, and the product label stated, "Do not swallow." During observation, a CMT placed a straw into the medicine cup containing the mouthwash and the resident swallowed it. The CMT stated the mouthwash was given to drink because the resident could not swish and spit, while an LPN later stated the mouthwash should have been administered using a mouth swab. The resident also had an order for Haloperidol Lactate Concentrate 2 mg/mL, 0.25 mL twice daily. During observation, the CMT used the dropper and measured two full droppers, then adjusted the amount to 2.5 mL, or 5 mg, before acknowledging it was not the ordered 0.25 mL. A later observation showed the LPN using the dropper and being unable to accurately measure 0.5 mg, then obtaining a smaller syringe to draw up the ordered 0.25 mL. The DON acknowledged the resident should not have been given a straw to drink the mouthwash and that staff should have used the appropriate size syringe to measure the liquid medication.
Untrained Staff Assisted Resident With Dysphagia During Meals
Penalty
Summary
The facility failed to ensure that Resident ID #46, who was readmitted in February 2025 with dysphagia and required a pureed diet, was assisted with meals by a qualified staff member. The resident’s care plan dated 6/9/2023 identified a risk for aspiration due to dysphagia and a prior choking episode during breakfast, and also noted that the resident had been observed pocketing food. During observation on 9/17/2025 at 8:19 AM, the Life Enrichment Director was seen assisting the resident with breakfast. During interview, the Life Enrichment Director stated that she had not been in a role that would have trained her to provide feeding assistance and had not completed a state-approved paid feeding assistant program. The Staff Development Coordinator stated that the Life Enrichment Director had not completed a competency for feeding assistance, and review of her online training did not show evidence of feeding-assistance training. The DNS was unable to provide evidence that the Life Enrichment Director had received state-approved training for feeding assistance and stated that staff would be expected to receive specialized training before assisting residents with meals.
Failure to Explain Binding Arbitration Agreements
Penalty
Summary
The facility failed to explain the binding arbitration agreement to residents and/or their representatives in a form and manner they could understand, including in a language they understood, for 2 of 12 residents reviewed. The facility policy stated that binding arbitration agreements are voluntary, not required for admission or care, and must be explained in a way that takes into account the resident’s or representative’s language, literacy, and stated learning preference. Resident ID #20 was admitted with a diagnosis including stroke and had a BIMS score of 15 out of 15, indicating intact cognition. The admission packet showed the resident signed an Alternative Dispute Resolution Agreement on 8/29/2025, but the form documented that the facility representative had not presented and explained the ADR to the resident and/or legal representative. During interview, the resident could not recall anyone explaining the agreement and stated s/he was unaware of signing it and would not have agreed to it. Resident ID #42 was admitted with a diagnosis including legal blindness and also had a BIMS score of 15 out of 15. The admission packet showed the resident signed the ADR agreement on 7/29/2025, but the form likewise documented that the facility representative had not presented and explained it. The resident also could not recall an explanation, was unaware of agreeing to binding arbitration, and stated s/he would not have agreed to it. The Admissions Director acknowledged the forms documented that the agreements were not explained and could not provide evidence that the facility had explained them before the residents entered into the agreements.
Infection Control Failures With Contact Precautions and Catheter Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for a resident on contact precautions for C. Diff. The resident was readmitted in August 2025 with a diagnosis including C. Diff, and a physician order dated 8/19/2025 directed contact precautions. Surveyor observations from 9/15/2025 through 9/18/2025 showed signage outside the room instructing staff to use sanitizer when entering, gown and glove at the door, and wash hands with soap and water when leaving. During an observation on 9/16/2025, an RN exited the room after care and did not wash hands with soap and water as directed by the signage. During another observation on 9/17/2025, the DON entered the room during wound care and closed the privacy curtain without putting on a gown or gloves before entering or before contact with the resident's environment. The RN and DON both acknowledged the actions when interviewed, and the Infection Preventionist stated staff should follow the posted signage. The facility also failed to maintain proper catheter care for a resident with a suprapubic catheter. The resident was readmitted in March 2024 with diagnoses including spastic quadriplegic cerebral palsy and neuromuscular dysfunction of the bladder, and had a suprapubic catheter. Surveyor observations on 9/15/2025 found the catheter drainage bag on the floor at 11:04 AM, 2:17 PM, and 2:26 PM. After the 2:26 PM observation, an LPN acknowledged the bag was on the floor and stated it should be hung on the resident's bed. The drainage bag was again observed on the floor on 9/17/2025 after the concern had been brought to the facility's attention. The Infection Preventionist and DON both stated they expected the drainage bag to be hung on the bed frame and not resting on the floor.
Call Light System Not Functioning on One Unit
Penalty
Summary
The facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system that relays the call directly to a staff member or to a centralized staff work area for 1 of 3 units observed, the [NAME] Unit. Review of the facility policy titled, "Answering the Call Light," last revised 9/2022, stated that the purpose of the procedure is to ensure timely responses to residents' requests and needs. During the resident council task on 9/16/2025, multiple residents reported waiting long periods for staff to respond to call lights, with average wait times between 30 minutes and 1 hour, and one resident stating it could take up to two hours. On 9/17/2025, surveyor observation of the [NAME] Unit found two monitors at the Nursing Station that were powered off. An LPN stated that staff did not use equipment that communicates a resident's call light alert directly to staff, and acknowledged that the call lights did not call directly to a staff member or centralized staff work area. The ADON acknowledged the monitors were powered off and said they were broken, while the Maintenance Director stated the monitors needed repair and he had not been aware of the issue until it was brought to his attention by the surveyor. The Administrator was unable to provide evidence that the call lights on the [NAME] Unit communicated directly to staff or to a centralized staff work area, per the regulation.
Failure to Provide Adequate Supervision and Accident Prevention for Residents at Risk for Falls
Penalty
Summary
The facility failed to provide adequate supervision and care to prevent accidents for two residents identified as being at risk for falls. One resident with paraplegia, who was cognitively intact and dependent on two staff members for bed mobility, was left unattended at the bedside during care. The nursing assistant elevated the bed to waist height and did not return it to the lowest position. While the resident was positioned on their side for wound treatment, the staff member stepped away to call for a nurse, during which time the resident fell from the bed and required hospital evaluation and admission. Documentation indicated that the resident required two staff for repositioning and use of a turning sheet, but this protocol was not followed at the time of the incident. Another resident with spastic quadriplegia, who had a physician's order and care plan interventions for the bed to be kept in a low position with floor mats on both sides, was observed to have only one floor mat in place while in bed. Staff confirmed that a floor mat was missing from one side and acknowledged that both should have been present according to the care plan and physician's order. The DON was unable to provide evidence that the required safety interventions were in place for this resident at the time of observation.
Failure to Provide Timely and Complete Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services for residents with pressure ulcers, as required by professional standards of practice. Three residents with existing pressure injuries did not receive timely or complete wound care interventions. For one resident admitted with a coccyx pressure injury, there was no documentation of the wound's stage, description, or characteristics upon admission, and no treatment order was implemented for two days. Recommendations from the wound physician, including the application of skin prep to the peri-wound area, were not transcribed into the medical record, resulting in the treatment not being administered. Another resident admitted with multiple wounds, including stage III pressure injuries to both heels, also did not receive recommended peri-wound skin prep. Although the wound physician made specific recommendations during wound rounds, these were not transcribed into the medical record, and there was no evidence that the treatments were provided. The care plan for this resident included administering treatments as ordered, but the necessary interventions were not carried out. A third resident with a stage IV pressure ulcer of the right lateral ankle and a wound to the right knee similarly did not receive the recommended skin prep treatment. The wound nurse communicated the physician's recommendations to the provider, who approved them, but failed to transcribe the orders, resulting in the treatments not being given. Interviews with staff confirmed that the recommended treatments were not implemented for all three residents, and there was no documentation to show that the required wound care was provided.
Failure to Schedule Urology Consult as Ordered
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice by not following a physician's order for a urology consult. The resident, admitted in November 2024 with a diagnosis including retention of urine, had a physician's order dated 12/9/2024 to obtain a urologist consult if a trial void failed every shift. This order was later changed by a nurse to an 'as needed' order on 12/21/2024, which resulted in the order not appearing on the Treatment Administration Record for daily sign-off by staff. The resident experienced a failed trial void on 12/10/2024, as documented in the progress notes, and a urology consult was ordered by the nurse practitioner. However, the facility did not schedule the urology consult as required. The resident was later taken to the hospital with a fever and infection, where it was discovered that the catheter was extremely dirty, likely causing a urinary tract infection. The administrator acknowledged during a surveyor interview that the urology consult appointment was not scheduled, confirming the facility's failure to adhere to the physician's order.
Resident Misses Multiple Medical Appointments Due to Facility Oversight
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, as evidenced by the resident missing two out of three scheduled medical appointments. The resident, who was admitted with a diagnosis of Parkinson's disease and had moderately impaired cognition, missed a neurology appointment on January 7, 2025, and two dental appointments on November 21, 2024, and December 16, 2024. The facility did not provide transportation for the neurology appointment, and there was no communication from the facility regarding the missed appointment. Additionally, there was no evidence of follow-up documentation or continuity of care documents in the resident's medical record for these appointments. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's scheduled appointments. A registered nurse recalled a family member inquiring about an upcoming appointment but could not provide details about the conversation. The Assistant Director of Nursing Services indicated that multiple staff members were responsible for scheduling appointments, but there was no clear record-keeping system for past appointments. The Regional Director of Clinical Services and the ADNS acknowledged the absence of continuity of care documents and confirmed that the resident did not attend the scheduled neurology or dental appointments.
Failure to Provide Documents in Resident's Preferred Language
Penalty
Summary
The facility failed to ensure that a resident received important documents in a language they understand, which is a violation of their rights. The resident, whose primary language is Spanish, was given financial and admission documents in English, which they could not read. This included a notice of health insurance non-coverage and an admission packet, both of which were signed by the resident despite not being in their preferred language. The resident's Quarterly Minimum Data Set (MDS) assessment confirmed that their preferred language is not English. Interviews conducted during the survey revealed further issues. The resident's representative, who translated for the resident, reported that a staff member instructed the resident to sign the documents or face the possibility of having to leave the facility. Additionally, the staff member communicated in Portuguese, not Spanish, further complicating the resident's understanding. The Admissions Coordinator and the Administrator both acknowledged that the documents were not provided in Spanish, and the Administrator could not provide evidence that the documents were available in the resident's preferred language.
Failure to Follow Physician Orders for Urine Collection and Weight Monitoring
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice. For one resident, a urine sample was collected via a straight catheter without a physician's order, despite the resident being able to provide a sample through urination. The resident, who does not speak English, was not adequately informed about the procedure in their native language, Spanish, leading to distress and fear during the process. The nurse involved could not provide evidence of an order for the catheterization, and the nurse practitioner confirmed that no such order was given. The physician also indicated that a clean urine catch is the standard method unless otherwise specified in an order. Another resident experienced a significant weight loss, and the facility failed to obtain the resident's weight as ordered by the physician. The resident's weight was supposed to be recorded weekly for four weeks and then monthly, but records showed that the weights were not obtained on the specified dates. Additionally, there was no evidence that the physician or provider was notified about the missed weight recordings. The Director of Nursing Services was unable to provide evidence that the weights were obtained or that the physician was informed of the oversight.
Infection Control Deficiencies in Scabies Management and PPE Use
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during the survey. Two residents with suspected scabies did not have their belongings bagged and removed from their rooms as per the facility's policy and physician's orders. Despite being informed of the potential scabies cases, staff did not follow the required procedures, and the Director of Housekeeping did not ensure the removal and storage of the contaminated items. This lack of adherence to protocol was confirmed through staff interviews and observations, where no black bags were found in the designated storage area. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) for residents requiring such measures. Staff failed to wear the appropriate personal protective equipment (PPE) during high-contact care activities, such as administering medication through a feeding tube and providing wound care. Observations revealed that staff did not don gowns as required, and in one case, a resident was not even placed on EBP until after the surveyor's intervention. This oversight was acknowledged by the staff and the Director of Nursing Services, indicating a gap in the facility's infection control practices. The facility also demonstrated deficiencies in wound care practices. Staff did not adhere to the no-touch technique, as evidenced by the use of unclean scissors and improper glove use during wound dressing changes. Furthermore, the laundry room lacked gowns for handling soiled linens, and staff admitted to not wearing gowns while sorting contaminated laundry. These observations highlight significant lapses in the facility's infection control measures, as staff failed to follow established protocols and policies, potentially compromising resident safety.
Failure in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to establish an effective Infection Prevention and Control Program (IPCP) that includes an antibiotic stewardship program with protocols and a system to monitor antibiotic use. This deficiency was identified for two residents, both of whom were prescribed antibiotics without evidence of an antibiotic review process or formal tracking and monitoring of their antibiotic use. Resident ID #78 was readmitted with diagnoses including dementia and type II diabetes mellitus and was prescribed Keflex for a foot infection. However, there was no evidence of an antibiotic timeout to assess the continued need for the antibiotic. Similarly, Resident ID #194, readmitted with type II diabetes mellitus, was prescribed Augmentin for a bacterial infection, but again, there was no evidence of an antibiotic review process. During interviews, the Infection Preventionist (IP), who had recently assumed the role, admitted to not completing antibiotic timeouts or maintaining line listings of residents on antibiotics due to a lack of training. The Regional Nurse confirmed that the facility should conduct antibiotic timeout assessments and acknowledged that the facility could improve in this area. The facility was unable to provide evidence of a system to monitor antibiotic use, which is necessary to ensure residents are prescribed the appropriate antibiotics.
Deficiencies in Sensor Management, Weight Monitoring, and Wound Care Documentation
Penalty
Summary
The facility failed to meet professional standards of quality in the management of a Freestyle Libre sensor for a resident with diabetes. The resident, who was admitted with diagnoses including diabetes and acute kidney failure, had a Freestyle Libre sensor that was not documented in the medical records, and there was no physician's order for its use or replacement. Interviews with staff, including an LPN and the Director of Nursing Services (DNS), confirmed the lack of documentation and orders, despite the sensor being used to monitor the resident's blood glucose levels. The facility also failed to adhere to physician's orders for daily weights and wound care for another resident with a prosthetic heart valve and heart failure. The resident's hospital discharge summary included an order for daily weights, which was not consistently followed, resulting in missed opportunities to monitor the resident's weight changes. Additionally, the facility did not perform daily dressing changes on surgical wounds as ordered, with evidence showing that dressings were not changed on the specified dates. Furthermore, the facility did not document wound care assessments for residents with non-pressure wounds according to policy and standard practice. One resident with a vascular wound lacked documentation of wound characteristics from June to September, and the facility could not provide wound care notes from an outside provider. Another resident with a diabetic foot infection had incomplete documentation of wound characteristics upon admission, and there was no initial wound evaluation recorded. Interviews with staff, including a float nurse and the DNS, revealed gaps in wound care documentation and evaluation.
Failure to Schedule Specialist Appointments for Residents
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and their comprehensive care plans. This deficiency was identified for three residents who required specialist appointments. One resident, admitted with traumatic brain injury and subarachnoid hemorrhage, was prescribed Keppra for seizure activity and required a follow-up appointment with neurology. However, there was no evidence of the appointment being made until it was brought to the facility's attention by a surveyor. Another resident, admitted with skin cancer and hypertension, complained of mouth pain and was prescribed Tylenol with a follow-up appointment with a dentist. The facility failed to make the dental appointment. Additionally, a third resident, admitted with type II diabetes mellitus and orthopedic aftercare following surgical amputation, required a follow-up with a podiatrist for a diabetic foot infection. The facility did not make this appointment either. Interviews with staff, including an RN, LPNs, and the Director of Nursing Services, confirmed the lack of appointments for these residents.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services for residents with pressure ulcers, as observed in two cases. Resident ID #5 was admitted with pressure ulcers and a care plan indicating the need for wound care. However, there was no physician's order for treating the right ankle wound, and the LPN was observed using an incorrect concentration of Dakin's solution due to a lack of knowledge on how to prepare the correct dilution. The wound physician and other staff members were also unsure about the correct preparation of the solution, and there was no order in place for the ankle wound treatment. Resident ID #62 was admitted with pressure ulcers and was under the care of an in-house wound physician. Despite recommendations to discontinue certain treatments, the physician's orders still included them, leading to a mismatch between the wound care provided and the recommendations. A float nurse was unaware of the resident's wound treatments and did not perform them, indicating a lack of communication and adherence to updated wound care protocols. The Director of Nursing Services was unable to provide evidence that both residents received appropriate pressure ulcer care to promote healing and prevent infection. The discrepancies in treatment orders and the lack of proper wound care highlight the facility's failure to ensure that residents with pressure ulcers receive care consistent with professional standards of practice.
Insufficient Nursing Staff Leads to Delayed Care and Resident Neglect
Penalty
Summary
The facility was found to have insufficient nursing staff to meet the needs of residents, impacting their safety and well-being. During the survey, it was observed that the facility did not utilize contracted nursing staff despite staffing challenges. Residents reported long wait times for staff response to call lights, particularly during the night and evening shifts. Specific instances included a resident on the East Unit experiencing delays during the 11:00 PM to 7:00 AM shift, and another resident on the South Unit not receiving assistance to get out of bed until the afternoon. Nursing assistants reported being short-staffed, with fewer staff members than required, leading to delays in providing morning care. One resident, admitted with difficulty in walking, was observed self-toileting due to a lack of staff assistance, despite having triggered the call light. Staff members were seen walking by without providing help, and the call light was turned off without assistance being rendered. The Regional Nurse expected staff to respond to call lights within 2 to 5 minutes, which was not adhered to in this case. Another resident, admitted with pressure ulcers and urinary incontinence, was found saturated in urine prior to a scheduled wound dressing change. The staff member conducting the wound care did not provide incontinence care beforehand, and the resident remained soiled for over 30 minutes. The nursing assistant responsible for the resident was unsure when the last incontinence care was provided. The Director of Nursing Services could not explain the lack of care or provide evidence of sufficient staffing to ensure resident safety and well-being.
Deficiencies in Nursing Competencies and Procedures
Penalty
Summary
The facility was found to have deficiencies in ensuring that nursing staff possessed the appropriate competencies and skills to provide safe and effective care to residents. Specifically, the facility failed to ensure that staff followed proper procedures for wound care and hypodermoclysis. In one instance, a Licensed Practical Nurse (LPN), identified as Staff E, provided wound care to a resident's ankle without a physician's order and used an unclean wash basin to mix wound care solution. This was despite the facility's policy requiring a physician's order for wound care procedures and the competency assessment for Staff E, which emphasized the need for such an order and proper preparation techniques. Another deficiency was observed with a different LPN, identified as Staff A, who failed to clean scissors before using them to cut a sterile wound dressing for a resident. The competency assessment for Staff A was incomplete, missing pages and signatures, indicating a lack of proper training verification. Additionally, the facility's policy on hypodermoclysis was not adhered to by Registered Nurse (RN) Staff B, who did not assess the drip rate of a hypodermoclysis infusion as required. The RN set up the infusion but failed to ensure the correct flow rate, resulting in the solution infusing at a slower rate than ordered. The facility's failure to provide adequate training and competency assessments for its nursing staff was further highlighted by the lack of evidence that staff were competent in performing hypodermoclysis and wound care. Interviews with staff and the Regional Nurse revealed that staff were not calculating drip rates for hypodermoclysis and were performing wound dressings without physician orders. The Director of Nursing Services and the Regional Nurse could not provide evidence of staff competencies, underscoring the facility's deficiency in maintaining the highest practicable well-being of its residents.
Failure to Address Pharmacy Recommendations
Penalty
Summary
The facility failed to address pharmacy recommendations in a timely manner for three residents, leading to deficiencies in medication management. For Resident ID #15, the facility did not complete the diagnoses for use on medication orders lacking reasons, despite repeated recommendations from the consultant pharmacist in June, July, and August 2024. The medications involved included Divalproex Sodium, Risperidone, Atorvastatin, Flomax, Levothyroxine, Vitamin B1, and Trazodone. The Director of Nursing Services acknowledged that these recommendations had not been addressed. For Resident ID #58, the facility did not update liquid concentrate orders to include both milligrams and milliliters, as recommended by the pharmacist in July and August 2024. This omission involved medications such as Lorazepam Intensol and Morphine Sulfate Concentrate. Additionally, for Resident ID #63, the facility failed to document regular monitoring for signs of bleeding for a resident on Eliquis and did not adjust the medication schedule to every 12 hours as recommended. The Director of Nursing Services and the Regional Nurse acknowledged these deficiencies during a surveyor interview.
Medication Administration Errors Exceeding 5% Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported rate of 56% based on 25 observed opportunities for error. This deficiency involved multiple residents and was identified through surveyor observations, record reviews, and staff interviews. For Resident ID #241, medications were administered 3 to 4 hours late, and the LPN acknowledged the frequent lateness of medication administration. Resident ID #83 also received medications 3 to 4 hours late, and Tums were administered incorrectly after meals instead of before. Resident ID #191's D5 solution infusion was set at an incorrect drip rate, and the RN failed to assess the drip rate as required. Additionally, Resident ID #74's Metoprolol Tartrate was administered without checking the apical pulse, and Prevacid was crushed contrary to instructions. Staff interviews confirmed these errors, and the Regional Nurse, along with the Director of Nursing Services, could not provide evidence that the facility ensured a medication error rate below 5%. The facility's policy on administering medications emphasizes timely and accurate administration, which was not adhered to in these instances.
Failure to Provide Ordered External Catheter
Penalty
Summary
The facility failed to provide services to attain and maintain the highest practicable physical, mental, and psychosocial wellbeing for a resident who was reviewed for the use of an external catheter. The resident, who was admitted with diagnoses including type II diabetes mellitus and heart failure, had a moderate cognitive impairment. A progress note indicated that the resident requested an external catheter at night to improve quality of life, and the nurse practitioner agreed to this request. However, the resident reported to the surveyor that the external catheter was only provided on one occasion and not consistently thereafter, despite the order being in place. The September 2024 Treatment Administration Record showed that the external catheter was not used for 5 out of 10 opportunities. During interviews, a Licensed Practical Nurse confirmed the catheter was not signed off as in use for these opportunities and could not explain the discrepancy. The Director of Nursing Services stated that if the resident refused the catheter, there should be a progress note, but no such evidence was provided. This indicates a failure to adhere to the resident's care plan and preferences, impacting their wellbeing.
Failure to Provide Timely Oxygen Therapy
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for a resident who was on oxygen therapy. The resident, who had been admitted to hospice care, was observed by a surveyor to have an empty oxygen tank. Despite the presence of staff, including a Certified Medication Technician (CMT) and a Licensed Practical Nurse (LPN), there was a delay in addressing the empty oxygen tank. The CMT was unable to locate a replacement tank and the LPN prioritized other tasks over the resident's immediate need for oxygen. The situation was further complicated by the lack of knowledge among staff about the location of oxygen supplies and the absence of oxygen concentrators in the facility. The Director of Nursing Services (DNS) eventually intervened to replace the oxygen tank, but by that time, the resident's oxygen level had dropped to 78%, which is below the normal range. The report highlights the facility's failure to ensure that oxygen therapy was administered promptly and effectively, as required by professional standards.
Inadequate Pain Management During Wound Care
Penalty
Summary
The facility failed to provide adequate pain management for a resident with severe cognitive impairment and multiple pressure ulcers. The resident, admitted in August 2023, had a history of pressure ulcers and was noted to have a severely impaired cognition score. The care plan indicated the need for monitoring and treating pain, as well as assessing and anticipating the resident's needs for comfort and body positioning. However, during a surveyor observation, the resident was found to be in significant pain during wound care, yelling and attempting to retract their leg, without receiving appropriate pain management. The Licensed Practical Nurse (LPN) administering the wound care confirmed that the resident had only received Tylenol at 6:00 AM and had no other pain medication available. Despite the resident's repeated complaints of pain, the LPN continued the treatment without notifying a provider or using non-pharmacological interventions as outlined in the care plan. The Director of Nursing Services was unable to provide evidence that the resident was kept free from pain, highlighting a deficiency in the facility's pain management practices.
Inaccurate Medical Record Documentation for Resident with Vascular Wounds
Penalty
Summary
The facility failed to maintain accurate medical records for a resident with vascular wounds, as determined by surveyor observation, record review, and staff interviews. The resident, who was admitted in June 2024 with diagnoses including type II diabetes mellitus and heart failure, had a physician's order for an Unna Boot treatment to be applied twice weekly. However, a progress note from August 2024 indicated that the treatment was changed to clobetasol and a tubi grip following a wound clinic visit. Despite this change, the September 2024 Treatment Administration Record inaccurately documented that the Unna Boot treatment was completed on specific dates. Surveyor observations in mid-September 2024 confirmed that the resident did not have an Unna Boot in place, contradicting the treatment records. Interviews with a registered nurse and the Director of Nursing Services revealed that the Unna Boot order should have been discontinued, and they were unable to explain why the treatment was still being signed off as completed. This discrepancy highlights a failure in maintaining accurate medical records in accordance with professional standards and practices.
Failure to Follow Physician's Orders for Wound Care
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice and did not follow physician's orders for daily wound dressing changes for a resident. The resident, who was admitted with conditions including hemiplegia, hemiparesis, and type 2 diabetes, had a physician's order for a daily dressing change on a wound on the right arm. However, the treatment administration record showed that the dressing was last changed as ordered on August 14, 2024, by an LPN. During a surveyor interview, the resident could not recall if the dressing had been changed, and an observation revealed that the dressing was last labeled on August 13, 2024. Interviews with staff confirmed the deficiency. An LPN acknowledged that the dressing was not changed as ordered on August 14, 2024, and the Regional Director of Clinical Services stated that she expected the dressing to be changed per the physician's orders. Another LPN admitted to documenting the dressing change as completed on August 14, 2024, despite not having performed the task. This failure to adhere to the physician's orders and maintain accurate records led to the deficiency identified by the surveyors.
Inadequate Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident who was at high risk for falls. The resident, who had a history of hemiplegia and hemiparesis following a stroke, required substantial assistance for showers. On the day of the incident, a nursing assistant (NA) was working with a nursing student to provide care to the resident. The NA left the resident alone with the nursing student in the shower room to retrieve an item from the linen cart. During this time, the resident fell out of the shower chair, resulting in bruises to the right buttock and posterior thigh, as well as a scratch on the right ankle. The incident was reported to the Rhode Island Department of Health, and a subsequent investigation revealed that the nursing student was unsupervised by a licensed NA at the time of the fall. The facility's agreement with the Rhode Island College School of Nursing indicated that the facility was responsible for client care and the supervision of nursing students. However, the facility was unable to provide evidence that the resident was kept free from accidents, highlighting a lapse in supervision and adherence to the care plan designed to mitigate the resident's fall risk.
Inadequate Infection Control Practices for COVID-19 Positive Resident
Penalty
Summary
The facility failed to maintain appropriate infection control practices for a resident who was on isolation precautions due to a positive COVID-19 diagnosis. The resident, who was admitted in July 2024, had diagnoses including urinary tract infection, septicemia, and dementia. During a surveyor observation, it was noted that the resident's room had signage indicating it was an isolation room, requiring staff and visitors to wear specific personal protective equipment (PPE) such as a gown, N95 mask, eye protection, and gloves before entering. However, the surveyor observed that Nursing Assistant (NA), Staff E, was in the resident's room without the required PPE, specifically missing a gown and eye protection. Physical Therapy Assistant, Staff F, was also present in the room without wearing the necessary eye protection. Both staff members acknowledged their failure to adhere to the required infection control practices. The Assistant Director of Nursing Services and the Regional Director of Clinical Services confirmed that the staff did not follow the expected infection control protocols.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice by not following physician's orders. A complaint was submitted to the Rhode Island Department of Health alleging that a resident did not receive some medications and others were administered late. The resident, who was admitted in July 2024 with diagnoses including urinary tract infection (UTI) and deep vein thrombosis (DVT), had specific physician's orders for medications to be administered at designated times. On July 26, 2024, the Medication Administration Record (MAR) showed that several medications, including Ferrous Sulfate, Eliquis, Mucinex, Clopidogrel Bisulfate, Aspirin, Atorvastatin Calcium, Metoprolol Tartrate, Mometasone Furoate inhaler, Anoro Ellipta inhaler, and Bumex, were administered at 12:30 PM instead of the ordered time of 9:00 AM. Additionally, Cephalexin, ordered for administration every six hours, was not given at 12:00 AM as required. The Director of Nursing Service acknowledged during an interview that the Cephalexin was not administered as ordered and that the 9:00 AM medications were given late.
Failure to Securely Store Controlled Substances
Penalty
Summary
The facility failed to store medications in accordance with accepted professional principles, specifically regarding the secure storage of controlled substances. This deficiency was identified during a review of records and staff interviews, which revealed that 22 pills of tramadol, a Schedule IV controlled substance, were missing for a resident with dementia, anxiety disorder, and right hip pain. The resident had a physician's order for tramadol 25 mg to be administered twice daily for pain. The facility's policy required controlled substances to be counted upon delivery and documented in a narcotic log book, but this procedure was not followed. Staff interviews indicated that the tramadol was delivered to the facility and signed for by an LPN, who then allegedly handed it over to an RN. However, the RN denied receiving the medication, and the subsequent shift LPN was unaware of the delivery, as the medication was not logged. The missing tramadol was later found mixed with non-narcotic medications in a medication cart, indicating a failure to limit access and maintain secure storage, as required for controlled substances.
Failure to Provide Adequate Supervision for Elopement Risk Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as an elopement risk, received adequate supervision, leading to the resident successfully eloping from the facility. The resident, who had diagnoses including mild cognitive impairment and schizoaffective disorder, was admitted with a care plan indicating a risk for elopement. Despite this, the resident was transported to a medical appointment unaccompanied by facility staff, and the wander bracelet was removed prior to the appointment. The resident's whereabouts became unknown after the appointment was canceled, and the resident took several buses to multiple locations before being found by facility staff on a main road approximately 8 miles from the facility. This incident occurred despite previous elopement attempts and recommendations for close supervision due to cognitive impairments and functional decline. The facility's policy on wandering and elopement was not effectively implemented, and there was no evidence of a policy for escorting residents to medical appointments. Interviews with staff and the resident confirmed that the resident was left unsupervised, and the Assistant Director of Nursing admitted to removing the wander bracelet to prevent loss in case of hospital admission. The Medical Director was unaware of the resident's unsupervised appointment and subsequent elopement. The facility's failure to provide adequate supervision resulted in the resident being unsupervised in the community, posing a significant risk to the resident's safety.
Medication Administration Error Due to Inadequate Supervision and Competency
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies and skill sets to provide safe and effective care, as evidenced by a medication administration error involving a resident. The incident occurred when a nurse in training, under the supervision of a preceptor, administered the wrong medications to a resident. The preceptor prepared the medications and handed them off to the trainee, who then misheard the room number and administered the medications to the wrong resident. This error was later realized when the preceptor attempted to give the correct medications to the resident, only to find out that the trainee had already administered the wrong ones. The resident involved in the incident had been readmitted to the facility with multiple diagnoses, including hypertension, acute kidney failure, acute pyelonephritis, and chronic obstructive pulmonary disease. The medications administered in error included Aspirin, Duloxetine, Linezolid, Oxycontin ER, Flomax, and Metoprolol Succinate ER. The facility's policy on medication administration, which requires verification of the resident's identity and adherence to the 'five rights' of medication administration, was not followed. The preceptor's decision to allow the trainee to administer medications unsupervised contributed to the error. Interviews with facility staff, including the Unit Supervisor and the Director of Nursing Services (DNS), confirmed that the preceptor should have been present with the trainee during medication administration. The DNS acknowledged that the preceptor should not have been pouring medications for the trainee to administer and that the nurse who prepares the medication should be the one to administer it. Additionally, there was no evidence that the trainee had demonstrated competency in medication administration at the time of the error.
Significant Medication Error Due to Nurse in Training
Penalty
Summary
The facility failed to ensure that residents are free from significant medication errors, as evidenced by the case of a resident who was administered incorrect medications. The resident, who had diagnoses including hypertension, acute kidney failure, acute pyelonephritis, and chronic obstructive pulmonary disease, was given medications that were not prescribed to them. These medications included Aspirin, Duloxetine, Linezolid, Oxycontin ER, and Metoprolol Succinate ER, along with an incorrect dosage of Flomax. This error occurred due to a nurse in training administering another resident's medications to the affected resident. The incident was reported to the Rhode Island Department of Health, and it was noted that the resident experienced dizziness and a significant drop in blood pressure following the medication error. The resident's blood pressure readings fluctuated throughout the day, and the resident also reported abdominal discomfort and a lack of appetite. Despite these symptoms, the resident remained alert and oriented, and the Nurse Practitioner recommended hospital evaluation, which was declined by the resident and their family. Interviews with facility staff, including the Unit Supervisor and the Director of Nursing Services, confirmed that the medication error was identified promptly, and the Nurse Practitioner was contacted immediately. The nurse who administered the incorrect medications stayed with the resident for the rest of the shift to monitor their condition. However, the facility failed to provide evidence that the resident was free from significant medication errors or that the facility's medication administration policy was followed correctly.
What surveyors are citing around you — mapped
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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 605 citations issued within 25 miles in the last 12 months — including the 19 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Smithfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lincolnwood Rehabilitation And Healthcare Center | 0.8 mi | ★★★★★ | 9 | 0 |
| Golden Crest Nursing Centre | 1.8 mi | ★★★★★ | 8 | 0 |
| Cherry Hill Manor | 2.8 mi | ★★★★★ | 7 | 0 |
| Berkshire Place | 3.2 mi | ★★★★★ | 17 | 0 |
| Elmhurst Rehabilitation And Healthcare Center | 3.3 mi | ★★★★★ | 10 | 1 |
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.