Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Eaton Creek Post Acute during CMS and state inspections, most recent first.
A CNA transferred a dependent, non-English speaking resident with multiple medical conditions from a shower bed to a regular bed without the required second staff member and failed to lock all shower bed wheels, causing the resident to fall between the beds and sustain a left humeral neck fracture and multiple bruises. The incident was not reported or documented at the time, and the resident's pain and injuries went unrecognized for several days until discovered by another CNA, resulting in delayed medical intervention.
A LTC facility failed to protect residents from abuse and neglect, resulting in Immediate Jeopardy. A cognitively impaired resident was found in a compromising position with another resident due to inadequate supervision. Another resident alleged sexual assault by a fellow resident, causing psychosocial harm. The facility also failed to address a resident's substance abuse history, leading to an overdose, and did not intervene when a resident with an intellectual disability was physically abused by a family member. Additionally, a staff member verbally abused a resident.
The facility administration failed to manage operations effectively, leading to abuse, neglect, and significant weight loss among residents. Incidents included unaddressed abuse, delayed reporting of allegations, and inadequate nutritional support. The administration also failed to follow up on a resident's drug history, resulting in an overdose. The QAPI plan was not maintained, and the governing body did not provide necessary oversight.
The facility's Governing Body failed to provide adequate oversight for the QAPI Program, resulting in a lack of effective plans to address and investigate allegations of abuse and neglect, as well as nutritional needs. This led to significant weight loss among residents and an Immediate Jeopardy situation. The facility did not establish or implement interventions to address these concerns, and interviews confirmed the Governing Body's responsibility for the QAPI program.
The QAPI Committee at the facility failed to effectively identify, report, and address incidents of abuse and significant weight loss among residents. Multiple incidents of abuse were not properly intervened or documented, and systemic failures in monitoring nutritional status led to severe weight loss in several residents. The facility's administration and Governing Body did not provide adequate oversight, resulting in significant deficiencies in the quality of care.
The facility failed to report allegations of abuse and neglect within the required timeframe, resulting in Immediate Jeopardy. A resident reported a sexual assault by another resident, which was not reported to the State Survey Agency within 2 hours. Additionally, a resident's cocaine overdose was reported a day late, and another incident of sexual abuse was reported over three hours late. These delays in reporting violated the facility's policies and resulted in a citation for substandard quality of care.
The facility failed to conduct thorough investigations into multiple allegations of abuse and neglect involving several residents. In one case, a cognitively impaired resident was allegedly involved in a sexual abuse incident with another resident, but the investigation was inadequate and did not include all relevant witness statements or consider the police report. Another incident involved a resident who alleged sexual assault, resulting in psychosocial harm and delayed incontinence care, but the investigation was insufficient and lacked comprehensive documentation. Additionally, the facility did not adequately investigate a resident's cocaine overdose, leading to an Immediate Jeopardy situation and substandard quality of care.
The facility failed to assess and address the nutritional needs of several residents, leading to significant weight loss. Systemic failures included inadequate monitoring and documentation of meal intake, and insufficient assistance during meals. Residents experienced severe weight loss, with many meal intakes undocumented. Staff interviews revealed a lack of awareness and communication regarding residents' dietary needs, resulting in Immediate Jeopardy.
A resident with a history of elopement and multiple diagnoses, including dementia, managed to exit a facility through a window, remaining unnoticed for over 8 hours. Despite having a wander guard and a care plan, inadequate supervision and monitoring led to the resident being found 3 miles away. Staff failed to conduct required rounds, and the resident's room was not properly identified, contributing to the oversight.
A resident's Hydrocodone medication was misappropriated in an LTC facility. The facility's investigation was incomplete, failing to determine responsibility for the missing medication. An agency nurse, who was on duty during the discrepancy, refused drug testing and did not return to the facility. The resident, with chronic pain, did not receive documented doses of the medication as per the physician's order.
The facility failed to ensure proper documentation and communication during resident transfers, as evidenced by incomplete transfer forms and missing physician orders for six residents. For instance, a resident was transferred without a completed form, and the family was not notified. Other residents were transferred without documented orders or completed forms, leading to inadequate communication with receiving hospitals.
The facility failed to provide bed-hold notices to residents or their representatives during transfers to hospitals or therapeutic leave, as required by policy. This deficiency affected five residents, including those with severe cognitive impairments and acute medical conditions. The DON acknowledged the lack of documentation for bed-hold forms in each case.
Two residents with head lice were not provided with updated care plans reflecting necessary isolation precautions. Despite orders for lice-killing shampoo, the care plans lacked interventions for the lice condition. Interviews with staff confirmed the oversight, highlighting a deficiency in the facility's care planning process.
A resident dependent on staff for personal hygiene did not receive adequate bathing services as per the facility's policy. Over several months, the resident received significantly fewer bed baths than scheduled and no showers, despite being dependent on staff for ADLs. Interviews revealed staffing issues and heavy workloads contributed to the deficiency.
The facility failed to document physician orders for medication administration for two residents. One resident was given Haldol without a documented order after becoming combative, and another was administered simethicone following a verbal order without proper documentation. The DON and ADON acknowledged the absence of required orders, indicating a lapse in following the facility's policies for medication administration.
The facility failed to prevent and adequately care for pressure ulcers in two residents, resulting in the development of a Stage IV ulcer in one resident. Despite being at risk for impaired skin integrity, the resident's ulcer was not discovered until it had progressed significantly, indicating a lapse in weekly skin audits and communication among nursing staff.
The facility failed to maintain adequate nursing staff, impacting resident safety and well-being. The facility assessment indicated a staffing plan, but actual staffing levels were insufficient, particularly on weekends and nights. Interviews revealed high reliance on agency staff, unmet resident needs, and high staff turnover, with key positions remaining unfilled.
The facility did not maintain the required RN coverage for 8 consecutive hours on two days in June 2024. This deficiency was confirmed through a review of the facility's assessment, licensure checklist, and employee time sheets. The Administrator acknowledged the staffing shortage and the absence of an RN on those days.
Failure to Provide Adequate Supervision and Safe Transfer Resulting in Resident Harm
Penalty
Summary
A certified nursing assistant (CNA) attempted to transfer a resident with significant physical and cognitive impairments from a shower bed to the resident's bed without the required assistance of a second staff member. The resident was dependent on staff for all activities of daily living, required two-person assistance for transfers, and had a history of multiple complex medical conditions, including heart failure, diabetes, muscle weakness, and moderate cognitive impairment. The CNA did not lock all the wheels on the shower bed, specifically forgetting to secure the bottom wheels, which resulted in the shower bed shifting during the transfer. This caused the resident's legs to fall between the beds and the upper body to become stuck, leading to an acute, mildly displaced fracture of the left humeral neck, as well as multiple bruises and soft tissue swelling. The incident was not reported at the time it occurred. The CNA did not notify the charge nurse or any supervisory staff, as required by facility policy, and did not document the event. Over the following days, the resident exhibited signs of pain, including moaning and non-verbal cues, but there was no documentation of pain assessments or administration of pain medication. The resident's condition, including swelling and bruising, was only discovered several days later by another CNA during routine care, who then notified the nurse on duty. Subsequent medical evaluation confirmed the fracture and additional injuries, and the resident was transferred to the hospital for further assessment and treatment. Facility policies required immediate reporting of accidents, completion of event notes, provider notification, and implementation of new interventions following incidents. The policies also specified that residents requiring two-person assistance for transfers must not be moved by a single staff member. In this case, the CNA acted alone, failed to follow safety protocols, and did not report the incident, resulting in a delay in the identification and treatment of the resident's injuries. The resident, who was non-English speaking and had difficulty communicating, was dependent on staff for all care and unable to advocate for herself, further contributing to the delay in appropriate response.
Failure to Prevent Abuse and Neglect in LTC Facility
Penalty
Summary
The facility failed to provide an environment free from abuse for several residents, resulting in Immediate Jeopardy. A cognitively impaired resident with wandering tendencies was found in a compromising position with another resident, indicating a lack of supervision and intervention by staff. The facility's failure to supervise and intervene placed both residents at risk of sexual abuse. Additionally, the facility did not adequately address the wandering behavior of the cognitively impaired resident, which had been documented multiple times prior to the incident. Another incident involved a resident who alleged that a fellow resident entered her room, naked from the waist down, and attempted to sexually assault her. This incident caused psychosocial harm to both the victim and her roommate. The facility's failure to prevent this incident and to provide adequate supervision and intervention contributed to the Immediate Jeopardy situation. The facility also failed to recognize and address a resident's history of substance abuse, resulting in an overdose and hospitalization. Furthermore, a resident with an intellectual disability was physically abused by a family member, and staff failed to intervene effectively. Additionally, a staff member verbally abused a resident, although this did not rise to the level of Immediate Jeopardy. These incidents highlight the facility's failure to protect residents from various forms of abuse and neglect, leading to a citation for substandard quality of care.
Facility Administration Fails to Prevent Abuse and Neglect
Penalty
Summary
The facility administration failed to effectively manage and oversee the operations, leading to multiple instances of abuse, neglect, and significant weight loss among residents. The administration did not provide adequate oversight of clinical staff, resulting in a lack of intervention in cases of observed abuse and delayed reporting of allegations. Specific incidents included a resident being found in a compromising position with another resident, and staff failing to intervene immediately. Another resident reported a sexual assault, but the allegation was not reported until the following day, and the administration did not thoroughly investigate the incident. The administration also failed to address the nutritional needs of residents, resulting in significant weight loss for several individuals. The facility did not monitor meal consumption or provide necessary assistance to residents during meals, contributing to their declining nutritional status. Additionally, the administration did not implement a process to follow up on a resident's history of illicit drug use, leading to an overdose within the facility. The lack of communication and documentation regarding the resident's drug history and the absence of a system to address such issues further exemplified the administration's failures. The facility's Quality Assurance Performance Improvement (QAPI) plan was not effectively maintained, and the administration did not ensure that all allegations of abuse and neglect were reported and investigated thoroughly. The governing body failed to provide oversight over the QAPI program, resulting in a lack of timely reporting and investigation of abuse and neglect incidents. The administration's inability to maintain effective communication and oversight contributed to the ongoing Immediate Jeopardy situation, highlighting systemic failures in the facility's management and operations.
Governing Body's Oversight Failure Leads to Immediate Jeopardy
Penalty
Summary
The facility's Governing Body, which includes the Administrator, Senior President of Operations, Regional Director of Operations, Assistant President of Clinical Operations, Regional Nurse Manager, Assistant Director of Nursing, and the Director of Nursing, failed to provide adequate oversight for the Quality Assurance Performance Improvement (QAPI) Program. This failure resulted in the lack of an effective QAPI plan to address, report, and investigate allegations of sexual abuse, physical abuse, and neglect. Additionally, the Governing Body did not implement effective interventions to address the nutritional needs of vulnerable residents, leading to significant weight loss. These deficiencies led to an Immediate Jeopardy situation, indicating that the noncompliance was likely to cause serious harm to residents. The review of the facility's policies and QAPI meeting minutes from June, July, and August 2024 revealed that the facility did not establish or implement interventions to address concerns related to resident abuse, neglect, and nutritional status decline. The facility failed to provide an environment free from abuse and neglect for several residents and did not timely report or thoroughly investigate allegations of abuse and neglect. Furthermore, the facility did not monitor or address residents' nutritional status, resulting in significant weight loss for multiple residents. Interviews with the Administrator and Regional Director of Operations confirmed the Governing Body's responsibility for the QAPI program, yet they were unable to provide documentation showing that the QAPI plan addressed these critical issues.
QAPI Committee's Failure in Addressing Abuse and Nutritional Deficiencies
Penalty
Summary
The Quality Assurance and Performance Improvement (QAPI) Committee at the facility failed to ensure an effective program that systematically identified, reported, tracked, investigated, analyzed, and used data related to abuse and nutritional status. This failure resulted in Immediate Jeopardy when staff did not intervene in multiple incidents of abuse, including a situation where a resident was observed in a compromising position with another resident, and another incident where a resident reported sexual assault by another resident. Additionally, staff failed to intervene when a family member physically abused a resident, and no interventions were implemented for a resident with a history of cocaine abuse, leading to an overdose. The QAPI Committee also failed to address significant and severe weight loss among residents. Several residents experienced substantial weight loss, with meal percentages not being documented consistently. The committee did not identify or monitor systemic failures related to nutrition, which contributed to the weight loss. The facility's documentation was inadequate, with missing QAPI meeting minutes and sign-in sheets, and there was no evidence of root cause analyses being conducted for the incidents. The facility's administration, including the Administrator and Director of Nursing, did not provide adequate oversight for the QAPI program. There was a lack of documentation and follow-up on significant events, and the facility was unable to demonstrate that QAPI meetings were conducted regularly. The Governing Body also failed to ensure the QAPI program was effectively implemented to address and investigate allegations of abuse and neglect, as well as nutritional needs, resulting in significant deficiencies in the quality of care provided to residents.
Failure to Timely Report Abuse and Neglect
Penalty
Summary
The facility failed to timely report allegations of abuse and neglect for several residents, resulting in an Immediate Jeopardy situation. Resident #2 reported an alleged sexual assault by Resident #3, which was not reported to the State Survey Agency within the required 2-hour timeframe. The incident occurred on the night of 5/8/2024, but the report was not made until the following morning. The facility's staff, including a Registered Nurse, failed to act on the allegation immediately, with the nurse dismissing the resident's claims as fabrications. This inaction allowed Resident #3, who was cognitively impaired and known to wander, to continue roaming the facility naked, posing a risk to other residents. In another incident, Resident #19 experienced a cocaine overdose on 11/8/2023, which was not reported to the State Survey Agency within the mandated 2-hour period. The resident was found unresponsive after a visit from an unidentified individual and was treated with Narcan before being transported to the hospital. The overdose was only reported the following day, despite the facility's policy requiring immediate reporting of such incidents. The delay in reporting was acknowledged by the facility's Administrator and Director of Nursing, who confirmed the failure to adhere to the reporting timeline. Additionally, the facility failed to report an allegation of sexual abuse involving Residents #4 and #5 within the required timeframe. The incident was reported to the State Agency over three hours after it occurred, exceeding the 2-hour limit. The Administrator, who was responsible for reporting abuse allegations, admitted to the delay in reporting. These failures to report timely and adequately resulted in a citation for substandard quality of care and highlighted significant lapses in the facility's adherence to its abuse reporting policies.
Inadequate Investigations into Abuse Allegations
Penalty
Summary
The facility failed to conduct thorough investigations into multiple allegations of abuse and neglect involving several residents. In one instance, a cognitively impaired resident with dementia was allegedly involved in a sexual abuse incident with another resident. The facility's investigation was inadequate as it did not include all relevant witness statements or consider the police report, which contained additional allegations of prior sexual contact between the residents. The facility concluded there was no evidence of sexual abuse, despite conflicting accounts and evidence suggesting otherwise. Another incident involved a resident who alleged sexual assault by another resident, resulting in psychosocial harm and delayed incontinence care. The facility's investigation was insufficient, as it did not thoroughly explore the allegations or gather necessary evidence, such as the soiled sheet used by the alleged perpetrator. The facility also failed to retain video surveillance footage that could have provided crucial information about the incident. Staff interviews were conducted, but the investigation lacked comprehensive documentation and failed to address why the victim was left in a soiled state for an extended period. Additionally, the facility did not adequately investigate a resident's cocaine overdose, which was part of the broader pattern of insufficient investigations. The facility's failure to perform thorough investigations and take appropriate corrective actions resulted in an Immediate Jeopardy situation, posing a risk of serious harm to the residents involved. The facility's policies on abuse prevention and investigation were not effectively implemented, leading to substandard quality of care.
Systemic Failures in Nutritional Care Lead to Significant Weight Loss
Penalty
Summary
The facility failed to adequately assess and address the nutritional needs of several residents, leading to significant and severe weight loss. The report highlights systemic failures in monitoring and documenting meal intake, as well as providing necessary assistance during meals. For instance, Resident #67 experienced a 9% weight loss over two months, with more than half of their meal intakes undocumented. Similarly, Resident #65 lost 8.5% of their body weight in one month, with a significant portion of meal intakes not recorded, and was observed struggling to eat without assistance. Resident #63 suffered a 10.19% weight loss over 3.5 months, with a high percentage of meal intakes undocumented. The facility's failure to follow care plans and document meal consumption contributed to this decline. Resident #45 experienced a 5% weight loss over 1.6 months, with a history of dehydration and missed meals due to inadequate assistance. Interviews with staff and family members revealed a lack of awareness and communication regarding residents' needs for meal assistance and documentation. Resident #46 lost 13.5% of their body weight over 1.5 months, with a significant number of meals undocumented. The facility did not hold an interdisciplinary team meeting to address the weight loss or implement interventions. Observations and interviews indicated that residents were not consistently offered assistance or alternatives during meals, and staff were not adequately informed about residents' dietary needs. These failures resulted in Immediate Jeopardy, as the facility's noncompliance posed a risk of serious harm to the residents.
Resident Elopement Due to Inadequate Supervision and Monitoring
Penalty
Summary
The facility failed to ensure a safe and secure environment for a vulnerable and high-risk resident with wandering behaviors, leading to an Immediate Jeopardy situation. The resident, who had a history of elopement and was identified as an elopement risk, managed to exit the facility through a window in his room. The resident was found by his sister approximately 3 miles away from the facility, after being missing for about 8 and a half hours. The facility staff were unaware of the resident's absence during this time. The resident had been admitted with multiple diagnoses, including dementia, schizoaffective disorder, and a history of elopement. Despite having a wander guard bracelet and a care plan addressing his elopement risk, the resident was able to leave the facility unnoticed. Interviews with staff revealed that rounds were not conducted as required, and the resident's room was not properly monitored. Additionally, the resident's name was not placed outside his room, leading to confusion among staff about his presence in the facility. The facility's policy on elopement and wandering patients was not effectively implemented, as evidenced by the lack of adequate supervision and monitoring of the resident. Staff interviews indicated that rounds were supposed to be conducted every two hours, but this was not consistently done. The resident's habit of sleeping in the bathroom on the floor was not documented in his care plan, which contributed to the oversight. The facility's failure to monitor the resident and secure the environment resulted in the resident's unauthorized exit and subsequent Immediate Jeopardy citation.
Misappropriation of Resident's Narcotic Medication
Penalty
Summary
The facility failed to protect a resident from misappropriation of property, specifically involving the narcotic medication Hydrocodone. The facility's policy on abuse prohibition and narcotic control was not adhered to, as evidenced by the missing medication that was not accounted for. The investigation summary revealed that the medication was delivered but could not be found, and there was a lack of documentation regarding the removal of a narcotic card from the cart. The facility's investigation was incomplete, and there was insufficient evidence to determine how the narcotic card was not accounted for. The resident involved, who was admitted with diagnoses including cerebrovascular disease, hemiplegia, and chronic pain, had a physician's order for Lortab, a narcotic pain medication, to be administered three times a day. However, the Medication Administration Record (MAR) showed that the medication was not documented as administered on specific dates. Additionally, the Controlled Drug Receipt/Record/Disposition Form indicated that a nurse signed out the medication but did not document its administration, leading to a discrepancy that was not resolved. The investigation noted that all nurses were drug tested except for an agency nurse who refused to return to the facility for testing. This nurse, who was on duty during the time of the discrepancy, did not work at the facility following the incident. The facility's Director of Nursing confirmed that the investigation did not determine who was responsible for the misappropriation, and there was uncertainty about whether the staffing agency was notified of the nurse's refusal to undergo a drug screen.
Inadequate Transfer Documentation and Communication
Penalty
Summary
The facility failed to ensure proper documentation and communication during the transfer or discharge of residents, as evidenced by the lack of completed transfer forms and physician orders for six residents. The facility's policy requires that a Transfer to Hospital Form be completed and sent with the resident, including details such as current diagnosis, medications, and contact information. However, for all six residents reviewed, these forms were either incomplete or not sent, and physician orders for transfers were not consistently documented. Resident #44, for instance, was transferred to the hospital without a completed transfer form, and the family was not notified of the transfer. The clinical notes indicated that the resident exhibited severe behavioral disturbances, leading to the decision to transfer him for a psychological evaluation. Despite the urgency, the necessary documentation was not completed, and the family member reported not being informed about the transfer, highlighting a communication breakdown. Similarly, other residents, such as Resident #43 and Resident #52, were transferred without documented physician orders or completed transfer forms. In some cases, the receiving hospitals were not informed of the residents' medical conditions or the reasons for their transfers, as seen with Resident #52, who was disoriented upon arrival at the emergency department. The facility's failure to adhere to its transfer and discharge policy resulted in inadequate communication and documentation, compromising the safe and effective transition of care for these residents.
Failure to Provide Bed-Hold Notices During Resident Transfers
Penalty
Summary
The facility failed to provide a bed-hold notice to residents or their representatives at the time of transfer to a hospital or therapeutic leave for five out of six residents reviewed for discharge. The facility's policy, revised on 7/31/2023, mandates that written information regarding bed-hold policies be provided to residents and/or their representatives prior to transferring a resident. However, this policy was not adhered to in the cases reviewed. Resident #43, who was admitted with diagnoses including unspecified dementia and chronic kidney disease, was transferred twice to a psychiatric hospital without documentation of a bed-hold form. The resident's Power of Attorney confirmed that no bed-hold policy was communicated during these transfers. Similarly, Resident #52, admitted with acute kidney failure, was transferred to a hospital for a blood transfusion without a bed-hold form being initiated. The Director of Nursing (DON) acknowledged the absence of documentation for these transfers. Additional cases include Resident #53, who was transferred due to worsening health conditions, Resident #54, who was sent to the ER for further evaluation after being found lethargic, and Resident #51, who was transferred to a hospital for evaluation after a decline in condition. In each instance, the medical records lacked documentation of a bed-hold form, and the DON confirmed the facility's failure to provide the required bed-hold policy to residents or their representatives at the time of transfer.
Failure to Update Care Plans for Residents with Head Lice
Penalty
Summary
The facility failed to update the care plans for two residents who were found to have head lice, which required isolation precautions. Resident #45, diagnosed with Alzheimer's disease, Nutritional Deficiency, and GERD, was noted to have a roommate with lice, and a lice-killing shampoo was ordered. However, the care plan for Resident #45 did not include any interventions for the lice condition or isolation precautions. Similarly, Resident #56, with diagnoses including Sepsis, Acute Respiratory Failure, and Encephalopathy, was observed to have lice during a shower, and a lice-killing shampoo was ordered. Despite this, the care plan for Resident #56 also lacked any mention of the lice condition or necessary isolation precautions. Interviews with the MDS Coordinator and the Director of Nursing confirmed that the care plans for both residents were not updated to reflect the need for isolation precautions due to head lice. The MDS Coordinator acknowledged the absence of care plans for the lice condition, and the Director of Nursing stated that residents with head lice should be placed on contact isolation and that their care plans should reflect this. The failure to update the care plans for these residents represents a deficiency in the facility's adherence to its policy of developing comprehensive, person-centered care plans.
Failure to Provide Adequate Personal Hygiene Care
Penalty
Summary
The facility failed to provide necessary services for maintaining personal hygiene for a resident who was unable to perform activities of daily living (ADL) independently. The facility's policy required that care and services be provided for activities such as bathing, dressing, and grooming. However, the review of the ADL Verification Worksheets revealed that the resident received significantly fewer bed baths than scheduled and did not receive any showers over several months. The resident was dependent on staff for personal hygiene and transfers, as indicated in the medical records and care plan. Interviews with family members and staff highlighted the deficiency in care. A family member reported that the resident smelled sour and did not receive proper nail care or showers. The Director of Nursing confirmed that the resident's ADL documentation was incomplete and that the facility had the capability to shower residents with tracheostomies. A CNA reported that due to staffing issues and heavy workloads, residents often did not receive their baths, especially on weekends, and that there was a high turnover of staff due to the demanding conditions.
Failure to Document Physician Orders for Medication Administration
Penalty
Summary
The facility failed to provide a physician order for medication administration for two residents, leading to a deficiency in following proper procedures for medication orders. Resident #43, who was admitted with diagnoses including Unspecified Dementia, Type 2 Diabetes, Anxiety Disorder, and Chronic Kidney Disease, was administered Haldol 5mg IM after becoming combative. However, there was no documented physician order for this medication in the resident's medical record for February 2024. The Director of Nursing acknowledged the absence of the order during a review of the medical record. Similarly, Resident #8, admitted with conditions such as Atrial Fibrillation, Hemiplegia, and Altered Mental Status, was given simethicone following a verbal order from a Nurse Practitioner after the resident began vomiting. The Physician Order Sheet for September 2024 did not contain an order for simethicone. The Assistant Director of Nursing confirmed that all medications administered must have a corresponding doctor's order, and the Director of Nursing acknowledged the lack of documentation for the simethicone order. These incidents highlight the facility's failure to adhere to its policies regarding verbal and telephone orders, as well as medication administration.
Failure in Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for two residents, leading to the development and progression of pressure ulcers. Resident #31, who was admitted with conditions including Acute Diastolic Heart Failure, Morbid Obesity, and Protein Calorie Malnutrition, developed a facility-acquired Stage IV pressure ulcer on the coccyx. The resident's care plan indicated a risk for impaired skin integrity and required weekly skin audits, but the ulcer was not discovered until it had progressed to Stage IV. The Wound Care Nurse acknowledged that the wound should have been identified before reaching such an advanced stage, suggesting that weekly skin audits were not effectively conducted. Interviews with facility staff revealed a lack of adherence to established protocols for skin assessments. The Director of Nursing stated that her expectations were for nursing staff to complete full body skin audits weekly and for CNAs to perform skin checks during showers. However, the process for identifying and reporting new or worsening skin conditions was not followed, as evidenced by the failure to detect the pressure ulcer in a timely manner. This deficiency highlights a breakdown in communication and protocol adherence among the nursing staff, leading to inadequate wound care and prevention measures for the residents involved.
Inadequate Staffing and RN Coverage
Penalty
Summary
The facility failed to maintain sufficient nursing staff to ensure resident safety and well-being, as evidenced by a review of the facility assessment, employee time sheets, and interviews. The facility assessment indicated a staffing plan based on resident needs, but the actual staffing levels were inadequate, particularly on weekends and nights. The review of employee time sheets revealed that the facility relied heavily on agency staff, with 81 different agency staff working from April to June 2024. On several occasions, the facility did not meet the required 8 hours of RN coverage, and the Per Patient Day (PPD) staffing hours were consistently low, indicating insufficient staffing to meet resident needs. Interviews with staff and residents highlighted the impact of inadequate staffing. A CNA reported being understaffed and having to care for 18 residents alone, leading to dissatisfaction and eventual resignation. The Ombudsman noted resident complaints about unmet needs, such as not being changed and unanswered call lights. The Administrator acknowledged the staffing issues, citing a high reliance on agency staff and a lack of consistent staffing management. The Activities Director, who was temporarily handling staffing, admitted to not attending Quality Assurance Performance Improvement meetings and being unfamiliar with the Payroll Based Journal (PBJ) requirements. The facility's staffing challenges were compounded by high turnover and a lack of permanent staff in key positions. The Activities Director mentioned open positions for Unit Managers, charge nurses, and CNAs, indicating a significant staffing gap. Interviews with former staff members revealed that the heavy workload and inadequate support contributed to the high turnover. The Administrator and other staff members acknowledged the ongoing staffing difficulties, with staffing being managed by a patchwork of different managers and lacking a dedicated staffing coordinator.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure Registered Nurse (RN) coverage for 8 consecutive hours a day, 7 days a week, as required by federal regulations. Specifically, on two days in June 2024, the facility did not have the mandated RN coverage. This deficiency was identified through a review of the facility's assessment, nursing home licensure checklist, and employee time sheets, which confirmed the absence of RN coverage for the required duration on June 15 and June 23, 2024. During an interview, the Administrator acknowledged the staffing shortage and the lack of RN presence on those days.
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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 Nashville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Whites Creek Wellness And Rehabilitation Center | 4 mi | ★★★★★ | 3 | 0 |
| Advanced Health Care Of Nashville | 4.5 mi | — | 0 | 0 |
| The Health Center At Richland Place | 6 mi | ★★★★★ | 8 | 0 |
| Nashville Center For Rehabilitation And Healing Ll | 6.6 mi | ★★★★★ | 0 | 0 |
| Green Hills Center For Rehabilitation And Healing | 7.4 mi | ★★★★★ | 0 | 0 |
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