Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 The Heritage At Lowman Rehab And Healthcare during CMS and state inspections, most recent first.
Surveyors found that nourishment room refrigerators on multiple units were not maintained within the facility’s required temperature range and that temperature logs were frequently incomplete or missing. In several units, recorded refrigerator temperatures were consistently above 40°F, and multiple days had no temperature documentation at all. One refrigerator lacked an internal thermometer. During interviews, leadership reported that kitchen staff are responsible for checking nourishment rooms, a supervisor aide reviews for expired items and logs, and the staff member currently assigned to these checks is new, while the Administrator stated that kitchen and nursing staff are expected to monitor temperatures and stocking with training provided during orientation and annually.
Surveyors found that nursing staff did not consistently follow the facility’s medication storage policy, resulting in expired and improperly stored medications on multiple medication carts. On one cart, an opened Insulin Aspart vial remained available for use past its expiration, and Promethegan suppositories labeled for refrigeration were stored at room temperature. On another cart, several Insulin Aspart FlexPens and a Liraglutide injection pen lacked required open dates or usable dating, and on a third cart, expired Alprazolam tablets remained in the drawer despite having been administered previously. These issues showed that outdated medications and undated insulin and injectable products were stored with medications in active use.
A resident with intact cognition and multiple medical conditions, including chronic respiratory failure and generalized muscle weakness, had a care plan directing staff to provide a daily shower/tub/bed bath and PRN, but facility records showed long periods with no documented baths or offers of bathing, particularly on weekends. The resident reported not receiving needed assistance, stated that a shower was expected on a specific day each week, and that no alternative baths were offered when that did not occur, nor were baths or showers offered on certain other days. Documentation did not show daily refusals, and the care plan did not address any refusal pattern. The Administrator and a CNA described expectations that residents be offered regular baths and that refusals be documented, highlighting that the resident’s bathing preferences and care plan were not consistently followed or recorded.
Surveyors found the facility’s medication error rate at 8%, exceeding the 5% threshold, due to improper insulin pen administration techniques by nursing staff. Policy and manufacturer instructions required priming insulin pens by dialing 2 units and holding the pen with the needle pointing upward until a drop of insulin appeared. Instead, an LPN primed a pen with the needle pointed downward into a trash can, and an RN primed a pen horizontally with the needle cap left on, without observing insulin at the needle tip. These deviations from required priming procedures contributed to the elevated medication error rate.
The facility failed to identify specific behaviors for antipsychotic use in a resident with dementia and did not ensure end dates for psychotropic medications for three residents. Interviews confirmed the lack of specific behavior monitoring and missing end dates for as-needed medications.
The facility failed to remove discontinued medications from medication carts, as observed during a survey. Medications for three residents were found in the carts without current physician orders. The facility's policy requires discontinued medications to be returned or destroyed, but they remained in the carts, confirmed by nursing staff. The Pharmacy Consultant and DON acknowledged the medications should have been removed and disposed of properly.
The facility failed to administer pneumonia vaccinations to three residents, despite its policy requiring all residents to be offered vaccines unless contraindicated or previously vaccinated. One resident had no documentation of consent or refusal for an updated vaccine, another consented but was not administered the vaccine, and a third had no further vaccinations documented after receiving PCV13 in 2015. The DON confirmed the lapse in vaccination administration.
A resident, who was cognitively intact, expressed a preference for regular dining ware instead of Styrofoam and plastic utensils during a COVID-19 outbreak. Despite not having COVID-19, the resident was subjected to the same restrictions as those in isolation, contrary to the facility's policy. The decision to use Styrofoam for all residents was made by the DON and Administrator, without considering individual preferences.
A resident was not involved in the care planning process as required by facility policy. Despite being cognitively intact, the resident was unaware of care plan meetings, with the last documented meeting occurring over a year ago. The Social Services Director acknowledged a review took place but failed to conduct a full meeting or document it in the EMR, leading to a deficiency.
A resident with dementia, congestive heart failure, and asthma was found with medications at their bedside without an assessment for self-administration. The facility's policy requires an interdisciplinary team assessment for self-administration, which was not conducted. The resident was cognitively intact, but the medications were not ordered to be kept at the bedside, leading to potential risks.
The facility failed to ensure that the SNF-ABN was accurate and complete for two residents prior to their discharge from Medicare Part A skilled services. For one resident with Parkinson's disease and another with dementia, the section for selecting options regarding payment responsibility was left blank, leaving them uninformed about their choices and financial responsibilities. The Social Services Director admitted to being unaware of the requirement to document the estimated cost per day and acknowledged that the options box should have been checked.
The facility failed to create comprehensive care plans for behavioral symptoms for three residents, leading to unmet care needs. One resident exhibited disruptive behavior without a care plan addressing it, despite being prescribed medications. Another resident's care plan only addressed medication side effects, not the behaviors leading to prescriptions. A third resident exhibited various disruptive behaviors, but the care plan lacked interventions for these symptoms. Staff interviews revealed unclear responsibilities for care planning.
A resident's care plan inaccurately included diabetic interventions, despite the resident not having diabetes. The resident, who had severe cognitive impairment and was receiving hospice care, was at risk of unmet care needs due to this error. The Registered Dietician confirmed the inaccuracy and was unsure why these interventions were included.
A resident with a history of pressure ulcers did not have their heels elevated as ordered, despite being at risk for skin integrity issues. Observations showed the resident's feet were not elevated, and staff interviews revealed a lack of awareness about the care plan requirements.
A facility failed to implement orders for a splint/palm protector for a resident with limited ROM, leading to potential further decrease of ROM and/or pain. The resident, with severe cognitive impairment and multiple diagnoses, was observed without the prescribed device. Staff interviews revealed confusion and inconsistency regarding the device's application, and the Treatment Administration Record showed no documentation of its use.
A facility failed to properly store oxygen tanks, creating potential hazards. An oxygen tank was found free-standing in a resident's room, despite the presence of a holder. Additionally, a tank was improperly stored in a storage room. Staff interviews confirmed the facility's policy required secure storage of oxygen tanks, which was not followed.
The facility failed to maintain proper nutritional care for three residents, leading to significant weight changes and inadequate meal monitoring. One resident experienced substantial weight loss without proper intervention, while another faced inconsistent meal documentation and weight fluctuations. A third resident's weight was inaccurately monitored, contributing to the deficiency. The Registered Dietitian acknowledged issues with weight accuracy and incomplete meal records, impacting nutritional assessments.
A facility failed to monitor the prophylactic use of an antibiotic for a resident with a history of UTIs, leading to a deficiency in antibiotic stewardship. The resident was on Nitrofurantoin daily, but the care plan did not address its use, and there was no documentation of symptom monitoring. Despite a letter from the Pharmacy Consultant, the physician continued the regimen without providing a rationale, placing the resident at risk.
A resident fell and sustained multiple injuries, including fractures and hematomas, when staff providing incontinent care walked away, leaving the resident unsupported. The resident had a significant medical history and was dependent on staff for all activities of daily living.
Failure to Maintain Safe Temperatures and Monitoring in Nourishment Room Refrigerators
Penalty
Summary
The deficiency involves the facility’s failure to maintain safe refrigerator temperatures and complete temperature monitoring in all four nourishment room refrigerators, contrary to its own policy titled "Refrigerators and Freezers" revised December 2022. The policy requires refrigerator temperatures to be maintained between 35°F and 40°F, freezers at less than 0°F, and mandates monthly tracking sheets for all refrigerators and freezers with documentation of corrective actions when temperatures are out of range. Review of the December 2025 temperature log for the Damascus unit nourishment room refrigerator showed that all six recorded temperatures were above 40°F, and no data was recorded for days 7 through 9. In addition, an observation of the Damascus unit nourishment room refrigerator revealed there was no thermometer present to measure the internal temperature. Similar issues were identified in the nourishment room refrigerators on the Bethal and two other named units. For the Bethal unit, the September 2025 temperature log had no data recorded for days 28 through 30, and the December 2025 log showed two of four recorded temperatures above 40°F with no data recorded for days 5 through 9. For one unit, the September 2025 log had no data for days 26 through 30, and the December 2025 log showed three of four recorded temperatures above 40°F with no data for days 5 through 9. For another unit, the September 2025 log had no data for days 19 through 20 and 23 through 30, and the December 2025 log showed four of four recorded temperatures above 40°F with no data for days 5 through 9. During interviews, the Culinary Manager and Registered Dietician stated that kitchen staff are responsible for checking nourishment rooms on each unit, and a supervisor aide checks behind them for expired items and temperature logs, noting that the person currently assigned to check the nourishment areas is new. The Administrator stated her expectation that kitchen staff assist with monitoring nourishment room temperatures and stocking, with nursing staff helping, and that training is provided during orientation, annually, and as needed.
Expired and Improperly Stored Medications on Multiple Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were stored and labeled according to policy and professional standards, including removal of outdated/expired medications and proper storage conditions. The facility policy required all drugs and biologicals to be stored in a safe, secure, and orderly manner, with nursing staff responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner, and for refrigerating unopened insulin vials/pens until use and dating them once opened. During an observation of Medication Cart A on one wing, surveyors found an Insulin Aspart Injection vial that had been opened on 11/04/25 and was expired as of 12/02/25, yet remained on the cart. They also found a ten-count package of Promethegan 25 mg suppositories labeled to be refrigerated, stored in the top drawer of the cart and not cool to the touch. Further observations of Medication Cart A on another wing revealed multiple insulin and injectable medications without required open dates or clear usable dating. An Insulin Aspart FlexPen had a manufacturer expiration date of 10/08/25 but no open date documented. A Liraglutide Injection pen and another Insulin Aspart FlexPen were also present without any open dates or expiration dates noted on them. On Medication Cart B, surveyors identified Alprazolam 0.25 mg tablets with an expiration date of 07/2025 still stored on the cart, with four tablets remaining, and documentation showing the medication was last administered on 11/21/25. These findings showed that expired medications and medications lacking required dating were stored on active medication carts alongside medications in current use, contrary to the facility’s own storage policy.
Failure to Honor Resident Bathing Preferences and Provide Daily Bathing as Care Planned
Penalty
Summary
The deficiency involves the facility’s failure to honor a cognitively intact resident’s stated bathing preferences and to provide or offer daily bathing assistance as care planned. Facility policy on Resident Shower and Bathing requires that residents receive assistance for bathing and showering in accordance with their care plans, with personal hygiene needs met and preferences honored. The resident was admitted with multiple diagnoses including pulmonary edema, chronic respiratory failure with hypoxia, lack of coordination, central corneal ulcer, and generalized muscle weakness. A recent MDS showed a BIMS score of 15/15, indicating intact decision-making ability. The resident’s comprehensive care plan identified a self-care deficit related to osteoporosis, unsteadiness, generalized muscle weakness, gait abnormalities, and pre-glaucoma, with a goal that the resident would be neat, clean, and dressed daily, and an intervention directing staff to complete a shower/tub/bed bath daily and PRN. The care plan did not document any pattern of bathing refusals. Despite this, review of shower and bath documentation showed that the resident was not offered and did not receive any type of bath on Fridays, Saturdays, and Sundays in August and September, had only two days of documented baths or offers in October, and only six days of any type of bath documented in November. There was no documentation that the resident refused daily baths or showers. The resident reported not receiving needed assistance to bathe, stated that Fridays were her preferred shower day and that if she did not get a shower on Fridays no other type of bath was offered, and that she was told she was not on the list when she requested bathing on Saturdays, with no baths or showers offered on Sundays. She also stated that most days she was not offered any type of bath and that it depended on which staff were working. The Administrator acknowledged that refusals were marked on the report but that many of the notations reflected that the resident had already received a bath that day, and the surveyor noted concern about days with no documentation of an offer or provision of bathing. A CNA stated that residents are supposed to receive bed baths seven days a week and showers two days a week, and that refusals must be offered and documented, underscoring that the expected practice was not consistently followed for this resident.
Improper Insulin Pen Priming Leading to Elevated Medication Error Rate
Penalty
Summary
The facility failed to maintain a medication administration error rate below 5%, resulting in an 8% error rate based on 2 errors out of 25 opportunities. Facility policy on insulin pens required staff to follow proper infection control, storage, administration, and documentation practices, including specific steps for priming the pen: dialing 2 units, holding the pen with the needle pointing upward, tapping to move air bubbles to the top, and pressing the injection button until insulin appeared at the tip, with instructions to discard the pen and notify the nurse/pharmacy if insulin did not appear after 3–4 attempts. The manufacturer’s recommendations similarly directed staff to wipe the pen tip with alcohol, attach the needle, remove both caps, dial 2 units, hold the pen with the needle pointing upwards, and press the button until at least one drop of insulin appeared, repeating as needed before dialing the ordered dose. During one observed insulin administration, an LPN primed an insulin pen while holding it with the needle pointed downward into a trash can, contrary to both facility policy and manufacturer instructions that required the needle to be pointed upward. In a separate observation, an RN attempted to prime an insulin pen while holding it horizontally and leaving the cap on the needle, then dialed 2 units and pushed the dosage button without seeing insulin escape the needle. The RN confirmed priming the pen horizontally with the needle capped and stated this was her usual practice. These observed practices deviated from the required priming procedures and contributed to the calculated medication error rate of 8%.
Deficiency in Psychotropic Medication Management
Penalty
Summary
The facility failed to identify specific trigger behaviors for the use of antipsychotic medication in one resident, who was admitted with Parkinson's disease and dementia. This resident was severely cognitively impaired and was administered antipsychotic medication daily without documented specific behaviors being monitored. Interviews with the LPN, DON, and SSD confirmed that while behavior monitoring was noted, no specific behaviors were identified or documented for this resident. Additionally, the facility did not ensure that psychotropic medications had an end date for three residents. These residents were prescribed medications such as Lorazepam and Clonazepam for conditions like anxiety disorder, altered mental status, and dementia, but the orders lacked specified end dates. The Pharmacy Consultant and DON confirmed the necessity of having end dates for as-needed psychotropic medications, which were missing in these cases.
Failure to Remove Discontinued Medications from Carts
Penalty
Summary
The facility failed to ensure that discontinued medications were removed from medication carts, as observed during a survey. Specifically, medications for three residents were found in the medication carts without current physician orders. For one resident, dronabinol and oxycodone were found in the narcotic drawer of the medication cart, despite the orders for these medications having ended on specific dates in August. Another resident had alprazolam in the medication cart, with the order having ended in February. A third resident had hydrocodone-acetaminophen and tramadol in the cart, with orders that ended in May and June, respectively. The facility's policy requires that discontinued, outdated, or deteriorated medications be returned or destroyed as per the dispensing pharmacy's instructions. However, the medications remained in the carts, which was confirmed by the nursing staff during observations. The Pharmacy Consultant and the Director of Nursing acknowledged that the medications should have been removed and disposed of properly once the orders ended. The process outlined by the Director of Nursing involves notifying the unit manager, who, along with the nurse, would log and secure the medications until disposal by the pharmacy.
Failure to Administer Pneumonia Vaccinations
Penalty
Summary
The facility failed to ensure pneumonia vaccinations were offered and/or provided to three of five residents reviewed for immunizations. The facility's policy, dated April 2023, mandates that all residents be offered vaccines to prevent infectious diseases unless contraindicated or previously vaccinated. However, the review revealed that Resident 25, who was admitted on an unspecified date and had received PCV 13 in 2016 and PPSV 23 in 2005, had no documentation of an up-to-date pneumonia vaccine consent or refusal as of June 2024. Similarly, Resident 43, admitted on an unspecified date, had received PPSV 23 in 2022 but had not been administered the updated pneumonia vaccine despite consenting in May 2023. Resident 100, admitted on an unspecified date, had received the PCV13 vaccine in 2015, with no further documentation of pneumonia vaccinations. The admission Vaccination Consent Form for Resident 100, dated December 2023, did not indicate whether the resident consented to or refused the pneumonia vaccine. During an interview, the DON, who had been in the position for three weeks, confirmed that the pneumonia vaccines were not administered, highlighting a lapse in the facility's adherence to its vaccination policy.
Failure to Honor Resident's Dining Preferences During COVID-19 Outbreak
Penalty
Summary
The facility failed to honor a resident's right to make choices regarding the use of regular dining ware during a COVID-19 outbreak. Resident 108, who was cognitively intact with a BIMS score of 15 out of 15, expressed a preference for regular plates and utensils instead of the Styrofoam containers and plastic utensils provided. Despite not being affected by COVID-19, the resident was subjected to the same dining restrictions as those in isolation, which was against the facility's policy that allowed for reusable dishes and utensils for residents on isolation. The decision to use Styrofoam and plastic utensils for all residents on the unit was made by the Director of Nursing and the Administrator, based on a policy from Lutheran. This decision was implemented without considering individual resident preferences or the facility's own policy on isolation precautions. Interviews with staff, including a CNA and the Registered Dietician, confirmed that the use of Styrofoam was a blanket policy for the unit, regardless of individual resident COVID-19 status or preferences. The Vice President of Clinical Operations was unaware of the resident's expressed desire for regular dining ware, indicating a communication gap in addressing resident preferences.
Resident Not Involved in Care Planning Process
Penalty
Summary
The facility failed to ensure that a resident, identified as R95, was afforded the right to participate in the development and implementation of his person-centered care plan. The facility's policy mandates that residents, along with their families or legal representatives, are encouraged to participate in care plan meetings, which should be scheduled at convenient times. However, R95, who was cognitively intact with a BIMS score of 15, was unaware of his care planning meetings. The last documented care plan meeting for R95 was on January 13, 2022, despite the requirement for such meetings to occur every 90 days. During interviews, the Social Services Director (SSD) confirmed responsibility for the care plan meetings and acknowledged that a review with R95 occurred on July 18, 2024, but it was not a full care plan meeting. Furthermore, the SSD could not provide documentation for this meeting, which is required to be recorded in the electronic medical record (EMR). This lack of documentation and failure to conduct a comprehensive care plan meeting within the stipulated timeframe led to the deficiency, placing R95 at risk of not being informed about the goals and outcomes of his care.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident was assessed for self-administration of medications before medications were left at the bedside. Resident 114, who was readmitted with diagnoses of dementia, congestive heart failure, and asthma, was observed with an inhaler and a tube of clotrimazole-betamethasone cream on their bed. The resident had a BIMS score indicating they were cognitively intact, yet there was no assessment conducted to determine if they could safely self-administer these medications. The physician orders did not include instructions for these medications to be kept at the bedside. During observations and interviews, it was confirmed by LPN7 and the Director of Nursing that Resident 114 had not been assessed for self-administration of the medications found at the bedside. The facility's policy stated that residents have the right to self-administer medications if deemed clinically appropriate and safe by the interdisciplinary team, which had not been done in this case. This oversight had the potential for the resident to over-medicate or for the medications to be accessed by other residents.
Incomplete SNF-ABN Notices for Two Residents
Penalty
Summary
The facility failed to ensure that the CMS-10055 Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) was accurate and complete for two residents prior to their discharge from Medicare Part A skilled services. For one resident with Parkinson's disease, the ABN notice indicated that skilled care was no longer required, but the section for selecting options regarding payment responsibility was left blank. This omission meant that the resident or their representative was not fully informed about their options and potential financial liability. Similarly, for another resident with dementia, the ABN notice also failed to have the options section completed, leaving the resident or their representative uninformed about their choices and financial responsibilities. During an interview, the Social Services Director admitted to being unaware of the requirement to document the estimated cost per day and acknowledged that the options box should have been checked. This oversight placed the residents and their representatives at risk of not being fully informed about their Medicare coverage and potential liability for services not covered.
Failure to Develop Comprehensive Care Plans for Behavioral Symptoms
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for behavioral symptoms for three residents, leading to unmet care needs. Resident 115, with intact cognition, exhibited disruptive behavior by yelling out continuously, which disturbed other residents. Despite being prescribed medications like Lorazepam and Sertraline, there was no care plan addressing these behavioral symptoms. Interviews with staff revealed that the resident's behavior was linked to a desire for companionship, yet no interventions were documented in the care plan. Resident 120, with severely impaired cognition, was prescribed psychotropic medications for anxiety and restlessness. However, the care plan only addressed potential side effects of these medications and did not include any interventions for the behaviors that warranted the prescriptions. The clinical notes did not document any behavioral symptoms, indicating a lack of comprehensive assessment and planning for the resident's needs. Resident 25, with moderately impaired cognition, was also prescribed multiple medications for anxiety but lacked a care plan addressing the specific behaviors leading to these prescriptions. The resident exhibited various disruptive behaviors, including yelling and hallucinations, which were noted in the medication administration record. Interviews with staff indicated that the responsibility for care planning was unclear, with the Social Service Director and MDS Coordinator providing conflicting information about who was responsible for developing and updating care plans for behavioral symptoms.
Inaccurate Care Plan for Resident
Penalty
Summary
The facility failed to ensure the accuracy of the Comprehensive Care Plan for a resident, identified as R40, who was part of a sample of 30 residents reviewed for care plans. The facility's policy requires a comprehensive, person-centered care plan to be developed and implemented for each resident, addressing their physical, psychosocial, and functional needs. However, the care plan for R40 included interventions related to diabetes, despite the resident not having a diagnosis of diabetes. This discrepancy was identified during a review of the resident's Nutrition Care Plan, which was dated several months prior to the survey. R40 was admitted to the facility with diagnoses of Parkinson's disease and dementia and was receiving hospice care. The resident's cognitive impairment was severe, as indicated by a Brief Interview for Mental Status (BIMS) score of zero out of 15. During an interview, the Registered Dietician (RD) responsible for the development of the Comprehensive Nutritional Care Plan confirmed that R40 was not diabetic and expressed uncertainty as to why diabetic interventions were included in the care plan. This inaccuracy in the care plan placed the resident at risk of unmet care needs.
Failure to Elevate Resident's Heels as Ordered
Penalty
Summary
The facility failed to ensure that a resident's heels were elevated as ordered, which was necessary to prevent the recurrence of a deep tissue injury. The resident, identified as R94, had a history of hemiplegia or hemiparesis, anxiety, depression, and was at risk for pressure ulcers. The care plan for R94 included interventions for skin integrity issues and specifically ordered that the resident's heels be floated on a device while in bed. However, during multiple observations, it was noted that R94's feet were not elevated, and no positioning device was in place. Interviews with staff revealed a lack of awareness and adherence to the care plan. LPN6 confirmed that R94's feet were not elevated and acknowledged the resident's past skin issues. CNA3 was unaware of the requirement to elevate R94's feet and confirmed that they were not elevated during observation. LPN5, who was interviewed later, stated that R94's wounds were healed and was unaware of the need for heel elevation. This lack of compliance with the care plan and staff awareness contributed to the deficiency identified in the report.
Failure to Implement Splint/Palm Protector Orders
Penalty
Summary
The facility failed to carry out orders for a splint/palm protector for a resident with limited range of motion (ROM), potentially causing further decrease of ROM and/or pain. The resident, who had severe cognitive impairment and diagnoses including hemiplegia, anxiety, and depression, was observed multiple times without the prescribed splint or palm protector in place. The resident's care plan did not address the contracture or the use of the splint/palm protector, despite orders indicating its necessity for positioning and contracture management. Interviews with staff revealed confusion and inconsistency regarding the application of the splint/palm protector. A Licensed Practical Nurse confirmed the absence of the device, and the Director of Therapy noted a contradiction between continuous and PRN orders. The Occupational Therapist mentioned a system limitation in documenting the palm protector and acknowledged the order's inconsistency. The Director of Nursing was unaware of documentation for the device's application, and the Treatment Administration Record showed no evidence of the splint/palm protector being applied.
Improper Storage of Oxygen Tanks
Penalty
Summary
The facility failed to properly store an oxygen tank in a resident's room and in a storage room, creating a potential hazard. In the case of the resident, identified as R100, who was admitted with acute and chronic respiratory failure, COPD, and other viral pneumonia, an oxygen tank was observed free-standing on the floor without being secured in a holder. This observation was made during a survey, and it was noted that the oxygen tank holder was available but not used. A Licensed Practical Nurse (LPN) acknowledged the improper storage and secured the tank in the holder. Additionally, in one of the storage rooms, an oxygen tank was found free-standing on the floor instead of being stored in the designated storage bin. The LPN confirmed that the tank should have been placed in the storage bin. Interviews with the Unit Manager and the Director of Nursing revealed that the facility's policy required oxygen tanks to be stored in racks with chains, sturdy portable carts, or approved stands, and never left free-standing. The facility's failure to adhere to this policy was identified as a deficiency.
Inadequate Nutritional Monitoring and Care
Penalty
Summary
The facility failed to maintain acceptable nutritional parameters for three residents, leading to potential health risks. For one resident, R120, the facility did not accurately monitor weight changes or meal intake. Despite being on a regular diet with thin liquids, R120 experienced significant weight loss over a short period. Observations revealed that R120 often did not consume the meals provided, and staff failed to encourage eating or offer alternatives when the resident expressed dissatisfaction with the food. The Registered Dietitian (RD) acknowledged inaccuracies in weight records and incomplete meal documentation, which hindered proper nutritional assessment. Another resident, R115, also faced issues with nutritional management. Despite being on a mechanically altered diet, R115 experienced significant weight fluctuations. The facility did not consistently document meal consumption, and there were instances where R115 did not receive a meal tray. The RD noted discrepancies in weight records and relied on incomplete data for assessments. The lack of accurate and consistent monitoring of R115's nutritional intake and weight contributed to the deficiency. For resident R68, the facility failed to provide consistent and accurate weight monitoring. R68 experienced significant weight loss since admission, but the RD suspected inaccuracies in the initial weight records. The RD requested reweights but noted ongoing issues with weight accuracy throughout the facility. The absence of regular nutrition risk meetings and reliance on morning meetings for reweight requests further contributed to the deficiency. These failures in monitoring and documentation led to inadequate nutritional care for the residents involved.
Failure to Monitor Prophylactic Antibiotic Use
Penalty
Summary
The facility failed to monitor the prophylactic use of an antibiotic for a resident, identified as R16, who was part of a sample of 30 residents reviewed for antibiotic stewardship. R16 was admitted with diagnoses including congestive heart failure and dementia and was cognitively intact with a BIMS score of 14 out of 15. The resident had been on a daily antibiotic, Nitrofurantoin, for a personal history of urinary tract infections. However, the comprehensive care plan did not address the prophylactic use of this antibiotic, and there was no documentation of symptom monitoring or rationale for its continued use. Interviews with facility staff revealed that while infection control meetings were held monthly, they did not specifically address the long-term use of prophylactic antibiotics. The Pharmacy Consultant had sent a letter to the physician regarding the antibiotic use, but no further follow-up was conducted. The physician disagreed with discontinuing the antibiotic, citing stability on the current regimen, yet failed to provide documentation or rationale for this decision. This lack of monitoring and documentation placed the resident at risk of unmet care needs related to prolonged antibiotic use.
Failure to Maintain Resident Safety During Incontinent Care
Penalty
Summary
The facility failed to maintain resident safety from harm for one resident. Specifically, while providing incontinent care to a resident, staff walked away, resulting in the resident falling to the floor and suffering multiple injuries, including a hematoma of the scalp, a skin tear and hematoma over the right elbow/forearm, and an acute closed fracture of the tibia and fibula. The incident occurred when two CNAs were providing care, and one turned away to dispose of soiled items, leaving the resident unsupported, leading to the fall. The resident involved had a significant medical history, including bed confinement status, encephalopathy, muscle weakness, unsteadiness on feet, abnormalities of gait and mobility, and major depressive disorder. The resident was severely cognitively impaired and dependent on staff for all activities of daily living, including personal hygiene and toileting. The resident's care plan indicated a potential for falls and injuries related to imbalance and muscle weakness, with specific interventions requiring two staff members for transfers, toileting, dressing, bathing, and providing care. On the day of the incident, the resident was being turned on her left side for incontinence care by two CNAs. One CNA turned away to dispose of soiled items, and the resident fell to the floor face down. The CNAs and the nurse assessed the resident, who was then transferred to a local hospital. The resident's representative expressed concerns about the incident, stating that the facility staff dropped the resident during care. The facility's Director of Nursing and Administrator confirmed the incident and the resident's injuries.
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What surveyors actually found near you
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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.
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Nursing homes near White Rock
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| L.m.c.- Extended Care | 9.2 mi | ★★★★★ | 0 | 0 |
| St Andrews Operator, Llc | 10 mi | ★★★★★ | 0 | 0 |
| Retreat At Wellmore Of Lexington | 10.4 mi | ★★★★★ | 0 | 0 |
| Presbyterian Home Of South Carolina-columbia | 11.5 mi | ★★★★★ | 0 | 0 |
| Nhc Healthcare - Lexington | 12.6 mi | ★★★★★ | 1 | 0 |
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