Below average — CMS composite of the measures below.
A standard survey is most likely before 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 Legacy Park Health And Rehabilitation during CMS and state inspections, most recent first.
A resident with an indwelling urinary catheter had their drainage bag left uncovered and visible to the public on multiple occasions, despite facility policy requiring dignity and privacy. Observations and staff interviews confirmed the bag was not covered, and the DON acknowledged that catheter bags should be concealed with a dignity or privacy cover.
A resident with Bipolar Disorder and Major Depressive Disorder, identified as having a PASRR Level II outcome for serious mental illness, was not accurately coded for this condition in a significant change MDS assessment. The RN MDS Coordinator and DON confirmed the assessment did not reflect the resident's PASRR status, despite active diagnoses and supporting documentation.
A resident with serious mental illness and a PASRR Level II outcome did not have this outcome addressed in their comprehensive care plan, despite facility policy requiring such inclusion. Both the RN MDS Coordinator and DON confirmed the omission during record review and interviews.
Staff did not follow hand hygiene protocols while distributing and setting up meal trays for multiple residents, including those with significant cognitive and physical impairments. Despite facility policy requiring hand hygiene during tray pass, a CNA was observed assisting several residents with their meals without performing hand hygiene between each interaction. This lapse was confirmed by both the CNA and the DON.
A resident in a LTC facility suffered harm due to a significant medication error involving Morphine Sulfate. The medication was incorrectly transcribed and administered on a scheduled basis instead of as needed, leading to the resident becoming semi-comatose with labored respirations and hypotension. The error was not caught by the facility's verification processes, and communication with hospice providers was lacking.
The facility failed to maintain complete and accurate medical records for several residents with indwelling urinary catheters. Documentation of urine output and catheter changes was missing for multiple residents, and a required communication tool was not completed for a resident transferred to the ER. Interviews with the DON and ADON confirmed these documentation deficiencies.
A resident in hospice respite care with multiple diagnoses received Morphine Sulfate at an incorrect frequency due to a transcription error by an LPN. The medication was administered routinely instead of as needed, contrary to the physician's order.
A hospice resident's Morphine order was transcribed incorrectly in the MAR, leading to incorrect dosing. The pharmacist failed to identify the error during the Medication Regimen Review. The resident, with multiple diagnoses, was supposed to receive Morphine 100 mg per 5 ml, but the MAR documented it as 20 mg per 5 ml, resulting in a lower dose being administered.
A resident's Morphine orders were incorrectly transcribed and administered on a scheduled basis instead of as needed, due to the facility's QAPI committee failing to identify and address quality deficiencies. The error was discovered when the resident's daughter noticed her mother was unusually drowsy. The facility did not conduct a thorough investigation or root cause analysis, and failed to implement an effective action plan, including comprehensive staff education and coordination with hospice and agency staff.
The facility failed to provide written information about the right to formulate an advance directive to 22 residents, as confirmed by medical record reviews and staff interviews. This deficiency affected residents with various cognitive abilities and medical conditions, and was acknowledged by the Nurse Liaison, Social Worker, and DON.
The facility failed to accurately complete MDS assessments for two residents. One resident's MDS inaccurately recorded a diagnosis of Pneumonia, which was not documented in their medical record. Another resident's oral health status was not assessed or documented accurately, despite notes indicating dental issues. The DON and MDS Coordinator confirmed these deficiencies.
A facility failed to resubmit a PASRR for a resident after a new diagnosis of Psychosis was identified. The resident, admitted with Dementia, Anxiety, Panic Disorder, and Adult Failure to Thrive, was found to have severe cognitive impairment. Despite the new diagnosis being recorded, the PASRR was not updated as required. This was confirmed by the DON during an interview.
The facility failed to update care plans with new interventions after falls for two residents. One resident with severe cognitive impairment had an unwitnessed fall, and another with moderate impairment fell from a wheelchair. Despite interventions being applied, the care plans were not revised to include these changes.
A resident, who was cognitively intact but dependent on staff for personal hygiene, was observed with long, dirty fingernails over several days. Despite the resident's request for nail trimming, staff failed to provide the necessary grooming care. Interviews with a CNA and an LPN confirmed the issue, and the DON acknowledged that nail care should be part of daily care.
The facility failed to secure chemicals and medications for two residents, leading to safety deficiencies. A resident had unsecured nail polish remover and air freshener, while another had an unsecured bottle of multivitamins. Both residents were cognitively intact but had not been assessed for self-administration of medications. Staff confirmed that these items should have been secured according to facility policy.
A facility failed to document the fluid restriction and consumption for a resident requiring dialysis care on the MAR, despite policy requirements. The resident, with conditions including Edema and End Stage Renal Disease, was on a 960 ml/day fluid restriction. Staff interviews confirmed the oversight, and the DON acknowledged the documentation failure.
The facility failed to develop dementia care plans for two residents diagnosed with severe cognitive impairment. Despite having diagnoses of dementia and Alzheimer's Disease, their care plans did not address these conditions. The DON and MDS Coordinator confirmed the oversight, acknowledging that dementia care plans were expected for residents with such diagnoses.
A resident with severe cognitive impairment was prescribed PRN Ativan for anxiety without a stop date or documented evaluation for continued use, contrary to the facility's policy limiting PRN psychotropic medications to 14 days. Interviews with facility staff confirmed the lack of evaluation and rationale for the medication's continued use.
The facility failed to properly label and secure medications, as well as remove expired supplies. An insulin pen was found unlabeled on a medication cart, and an LPN left a cart unlocked while administering medications. Controlled substances were left unsecured in a medication room, and expired supplies were available for use. The DON and Pharmacy Director confirmed these deficiencies.
A resident admitted with multiple health conditions, including anemia and diabetes, did not receive dental care as per the facility's policy. Despite having missing and discolored teeth and expressing a desire to see a dentist, there was no documentation of dental assessment or care since admission. The DON confirmed the lack of dental care documentation.
The facility did not properly contain garbage in one of its dumpsters, as observed when dumpster #6 was found without a plug. This was confirmed by the Certified Dietary Manager, contrary to the facility's trash disposal policy.
The facility did not obtain informed consent for the Pneumococcal vaccine for two residents, despite policy requirements. One resident had COPD, Chronic Respiratory Failure, and a history of Pulmonary Embolism, while another had Intestinal Obstruction, Chronic Bronchitis, Shingles, and Polyosteoarthritis. The Infection Preventionist confirmed the lack of informed consent documentation.
A facility failed to accurately transcribe a physician's order for a resident with serious health conditions, leading to a discrepancy between the prescribed Humulin R insulin and the incorrectly listed Humulin N on the MAR. The error was not detected until the resident's endocrinologist inquired about the accuracy of the MAR. Despite the error, the resident continued to receive the correct medication.
Failure to Maintain Resident Dignity by Leaving Catheter Bag Uncovered
Penalty
Summary
A deficiency occurred when a resident's right to dignity was not maintained, as evidenced by the facility's failure to ensure that an indwelling urinary catheter drainage bag was covered and not visible to the public. The facility's policy on resident rights, revised in February 2021, requires all residents to be treated with dignity. The resident involved was admitted and later readmitted with diagnoses including colon cancer, hypertension, and dementia, and was assessed as cognitively intact. The resident had an indwelling urinary catheter, as documented in the medical record and care plan. On two separate occasions, observations revealed that the resident's catheter bag was left uncovered and visible from the hallway while the resident was lying in bed. During interviews, both an LPN and the Director of Nursing confirmed that the catheter bag was not covered and acknowledged that all indwelling urinary catheters should be covered with a dignity bag or privacy cover. These findings were based on policy review, medical record review, direct observation, and staff interviews.
Inaccurate MDS Assessment for Resident with PASRR Level II Outcome
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for one resident who was reviewed for MDS assessments. According to the MDS 3.0 Resident Assessment Instrument (RAI) Manual and the facility's own policy, assessments must accurately reflect a resident's status, including the identification of serious mental illness as determined by a Level II Pre-admission Screening and Resident Review (PASRR). Medical record review showed that a resident admitted with diagnoses of Bipolar Disorder and Major Depressive Disorder had a PASRR Level II outcome indicating a serious mental illness. However, the significant change MDS assessment did not code for the PASRR Level II condition, despite the resident having active diagnoses of Bipolar Disorder and Depression. Further review of the resident's records, including a psychiatric nurse practitioner's note, confirmed ongoing treatment for bipolar disorder and depression. During interviews, the RN MDS Coordinator acknowledged that the MDS assessment was inaccurate and did not reflect the PASRR Level II outcome. The DON also confirmed that the facility did not ensure the accuracy of the significant change MDS assessment for this resident, as required by facility policy and regulatory guidelines.
Failure to Address PASRR Level II Outcome in Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed all of a resident's needs, specifically omitting the required PASRR Level II outcome for a resident with serious mental illness. According to the facility's policy, the interdisciplinary team is responsible for creating a person-centered care plan that includes measurable objectives, timeframes, and addresses specialized services as recommended by PASRR. However, review of the medical record showed that the resident, who was admitted with diagnoses of Bipolar Disorder and Major Depressive Disorder and had a PASRR Level II outcome, did not have this outcome reflected in their care plan as of the most recent revision. During interviews, both the RN MDS Coordinator and the DON confirmed that the PASRR Level II outcome was not included in the resident's care plan, despite facility expectations and policy requirements. The omission was identified through policy review, medical record review, and staff interviews, confirming that the care plan did not comprehensively address the resident's mental health needs as required.
Failure to Perform Hand Hygiene During Meal Tray Distribution
Penalty
Summary
Facility staff failed to perform appropriate hand hygiene during the distribution and setup of meal trays for nine residents in one of three observed dining areas. According to the facility's own hand hygiene policy, staff are required to use proper hand hygiene during mealtimes, specifically when passing trays. Observations on a specified date revealed that a Certified Nursing Assistant (CNA) delivered and set up lunch trays for multiple residents without performing hand hygiene between each interaction. The residents involved had a range of medical conditions, including heart failure, dementia, chronic kidney disease, Parkinson's disease, diabetes, and other chronic illnesses. Their care plans indicated varying levels of cognitive impairment and physical dependency, with most requiring assistance or supervision with eating and personal hygiene. Despite these needs, the CNA did not follow hand hygiene protocols while assisting with meal setup, as confirmed by both direct observation and staff interviews. Interviews with the CNA and the Director of Nursing (DON) confirmed that hand hygiene was not performed as required during the meal service. The DON acknowledged that infection prevention and control practices were not maintained during the observed lunch service, specifically noting the failure to perform hand hygiene between serving each meal tray.
Significant Medication Error Leads to Resident Harm
Penalty
Summary
The facility failed to protect a resident's right to be free from significant medication errors, resulting in actual harm. A resident admitted for respite care with multiple diagnoses, including dementia and hospice status, was prescribed Morphine Sulfate to be administered as needed for shortness of breath. However, the medication order was transcribed incorrectly by nursing staff, leading to the resident receiving the medication on a scheduled basis instead of as needed. This error resulted in the resident receiving excessive doses of morphine over several days, leading to a semi-comatose state, constricted pupils, weak and irregular pulse, labored respirations, and hypotension. The transcription error occurred when the nursing staff entered the medication order into the electronic medical record (EMR) with the incorrect concentration and frequency. The order was supposed to be for Morphine Sulfate 100 mg per 5 ml, but it was entered as 20 mg per 5 ml, and the administration was scheduled every two hours instead of as needed. The error was not identified by the pharmacist during the medication regimen review, and the facility's process for double-checking medication orders failed to catch the mistake. The resident's daughter and sitter noticed changes in the resident's behavior and level of consciousness, prompting a hospice nurse to visit and identify the error. Interviews with facility staff revealed a lack of communication and verification processes. The LPN responsible for verifying the medication order assumed a supervisor would address the discrepancy but did not follow up. The facility's Director of Nursing confirmed the error and acknowledged that the facility's process for transcribing and verifying medication orders was not followed correctly. The hospice medical director and facility medical director both expressed concerns about the significant increase in morphine administration and the lack of communication with hospice providers regarding medication questions.
Incomplete Medical Records and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure that resident medical records were complete and accurate for five residents. The deficiencies were identified through a review of facility policies, medical records, and staff interviews. The facility's policy on emptying urinary collection bags required documentation of urine output, which was not recorded for several residents with indwelling urinary catheters. Additionally, the policy on changes in a resident's condition required detailed observations and communication with healthcare providers, which was not consistently followed. Resident #2 had an indwelling urinary catheter, but there was no documentation of urine output or a catheter change in the medical record from 11/21/2024 to 12/5/2024. Similarly, Residents #17, #18, and #19, who also had indwelling urinary catheters, lacked documentation of urine output in their medical records for specified periods. Resident #10 experienced extreme discomfort and requested to be transported to the ER, but the required SBAR communication tool was not completed. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed the lack of documentation for urine output and catheter changes, as well as the absence of the SBAR communication tool for Resident #10's transfer to the ER. These omissions indicate a failure to adhere to facility policies and ensure accurate and complete medical records for residents with indwelling urinary catheters.
Medication Administration Error in Hospice Respite Care
Penalty
Summary
The facility failed to administer medications according to physician orders for a resident receiving hospice respite care. The resident, who had multiple diagnoses including Normal Pressure Hydrocephalus, COPD, Chronic Kidney Disease, Dementia, and was under hospice care, was prescribed Morphine Concentrate 100 mg per 5 ml to be given 0.25 ml or 5 mg every 2 hours as needed for shortness of breath. However, the order was incorrectly transcribed by an LPN as Morphine Sulfate 20 mg per 5 ml, with a dosage of 0.25 ml or 1 mg to be administered every 2 hours routinely, rather than as needed. The error in transcription led to the resident receiving the correct concentration of Morphine Sulfate but at an incorrect frequency, as it was administered routinely instead of on a PRN basis as prescribed. The Director of Nursing confirmed the transcription error and the incorrect administration schedule, acknowledging that the resident received the medication every 2 hours routinely over several days, contrary to the physician's order.
Pharmacist Fails to Identify Transcription Error in Hospice Resident's Medication Order
Penalty
Summary
The facility failed to ensure that a licensed pharmacist accurately identified and corrected a transcription error in the medication administration record (MAR) for a hospice respite resident. The error involved the incorrect transcription of a physician's order for Morphine Concentrate, which was intended to be administered as needed (PRN) for shortness of breath. Instead, the order was transcribed with the wrong concentration and as a scheduled order, leading to the administration of incorrect doses. The resident involved was admitted for respite care with multiple diagnoses, including Normal Pressure Hydrocephalus, COPD, Chronic Kidney Disease, Dementia, and was under hospice care. The hospice physician's order specified Morphine Concentrate 100 mg per 5 ml, to be given 0.25 ml or 5 mg every 2 hours as needed. However, the MAR incorrectly documented the concentration as 20 mg per 5 ml, resulting in a 1 mg dose being administered instead of the intended 5 mg dose. This transcription error was not identified by the pharmacist during the Medication Regimen Review (MRR). Interviews revealed that the Director of Nursing acknowledged the transcription error made by a Licensed Practical Nurse, and the pharmacist admitted to missing the error during the MRR. The pharmacist explained that the process for hospice patients involves the pharmacy entering orders into a profile, which is then used by contracting pharmacists for the MRR. Despite receiving the correct concentration from the facility, the pharmacist did not catch the error in the MAR, as the facility's process did not include rechecking the MAR after receiving a signed prescription from the provider.
Medication Transcription Error Due to Inadequate QAPI Program
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) committee failed to ensure an effective program to identify and address quality deficiencies, specifically related to medication errors. The committee did not perform a root cause analysis or implement corrective systems to ensure appropriate care and safety in the transcription of medication orders. This failure was highlighted by a significant medication error involving a resident's Morphine orders, which were incorrectly transcribed and administered on a scheduled basis rather than as needed (PRN). The resident involved was admitted for respite care with hospice orders for Morphine Concentrate to be given as needed for shortness of breath. However, the orders were incorrectly transcribed by an LPN, resulting in the resident receiving multiple doses of Morphine on a scheduled basis over several days. This error was only identified when the resident's daughter noticed her mother was unusually drowsy and brought it to the attention of the facility's Director of Nursing (DON) and Assistant Director of Nursing (ADON). Despite identifying the error, the facility failed to conduct a thorough investigation or root cause analysis. The QAPI committee did not implement an effective action plan to correct the deficiencies, as they did not include all relevant staff in the education and corrective processes. The facility also failed to ensure clear communication and coordination with hospice and agency staff, which contributed to the transcription errors. The lack of documented audits and comprehensive staff education further exemplified the facility's inadequate response to the medication error.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to provide written information to residents and/or their representatives regarding the right to formulate an advance directive. This deficiency was identified through a review of facility documents, medical records, and interviews. Specifically, 22 out of 35 residents reviewed did not receive the necessary information about advance directives, which is a critical component of respecting residents' rights to make informed decisions about their care. The medical records of several residents, including those with severe cognitive impairments and those who were cognitively intact, lacked documentation of written information about advance directives. For instance, Resident #103, who had severe cognitive impairment, and Resident #34, who was cognitively intact, both did not have records indicating they were informed about their rights to formulate an advance directive. This pattern was consistent across multiple residents with varying cognitive abilities and medical conditions, such as hypertension, anxiety disorders, and chronic obstructive pulmonary disease. Interviews with facility staff, including the Nurse Liaison and the Social Worker, confirmed that the facility did not provide the required written information to residents or their representatives. The Nurse Liaison, responsible for completing admission paperwork, acknowledged the omission, and the Social Worker corroborated this failure. The Director of Nursing also confirmed the lack of provision of written information, highlighting a systemic issue in the facility's admission process and communication with residents and their families.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in the documentation of their health status. For one resident, the quarterly MDS assessment inaccurately recorded a diagnosis of Pneumonia, which was not documented in the resident's medical record. This resident had a history of severe cognitive impairment and multiple health conditions, including muscle weakness, stroke, and chronic respiratory issues. The MDS Coordinator confirmed the inaccuracy during an interview, acknowledging that the resident did not have a diagnosis of Pneumonia. For another resident, the facility failed to assess and document the resident's oral health status accurately. Despite nurse's notes indicating the resident had natural lower teeth and no upper teeth, the admission and annual MDS assessments reported no dental issues. Furthermore, there was no documentation of the resident being asked about or seen by a dentist since admission. The Director of Nursing and the MDS Coordinator both confirmed the lack of assessment and documentation regarding the resident's oral condition.
Failure to Resubmit PASRR After New Diagnosis
Penalty
Summary
The facility failed to resubmit a Pre-Admission Screening and Resident Review (PASRR) for a resident after a new mental health diagnosis was identified. The resident, who was admitted with diagnoses including Dementia, Anxiety, Panic Disorder, and Adult Failure to Thrive, was found to have severe cognitive impairment and a new diagnosis of Psychosis. Despite this new diagnosis being recorded on 6/12/2020, the facility did not resubmit the PASRR to the state-designated authority as required. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged that a new PASRR should have been submitted following the addition of the Psychosis diagnosis.
Failure to Update Care Plans After Falls
Penalty
Summary
The facility failed to revise comprehensive care plans with new interventions after falls for two residents. Resident #37, who has severe cognitive impairment and a history of falls, experienced an unwitnessed fall. Despite the fall being documented in a Falls Investigation Report and the resident being assessed with no injuries, the care plan was not updated with new interventions. The MDS Coordinator acknowledged that it was her responsibility to update the care plan but confirmed that no new interventions were added after the fall. Similarly, Resident #306, with moderate cognitive impairment and a history of falls, fell from a wheelchair. Although anti roll backs were applied to the wheelchair as an immediate intervention and were observed in place during subsequent observations, the comprehensive care plan was not updated to include this intervention. The Director of Nursing confirmed that the care plan should have been revised to reflect the new fall prevention intervention but was not.
Failure to Provide Adequate Nail Care for Resident
Penalty
Summary
The facility failed to provide adequate personal grooming for a resident who was unable to perform activities of daily living independently. The facility's policy on Activities of Daily Living (ADL) requires that residents receive appropriate care and services to maintain or improve their ability to carry out ADLs, including grooming and personal hygiene. Despite this policy, Resident #79, who was cognitively intact but dependent on staff for toileting, bathing, and required assistance with personal hygiene, was observed multiple times with long fingernails and brown debris under the nails. There was no documentation indicating that the resident had refused nail care. Observations over several days revealed that the resident's fingernails remained untrimmed and dirty, despite the resident expressing a desire to have them trimmed. Interviews with facility staff, including a Certified Nursing Assistant (CNA) and a Licensed Practical Nurse (LPN), confirmed the presence of brown debris under the resident's fingernails. The Director of Nursing stated that she expected nail care to be provided as part of daily care, especially when nails were long or dirty, indicating a failure to adhere to the facility's grooming policy for this resident.
Failure to Secure Chemicals and Medications for Residents
Penalty
Summary
The facility failed to ensure that chemicals and medications were secured for two residents, leading to deficiencies in safety and supervision. Resident #25, who was cognitively intact with a BIMS score of 14, had an unsecured bottle of nail polish remover and an aerosol can of Glade air freshener on her bedside dresser. Despite the resident's awareness of the need to secure these items and the absence of wandering residents in the hallway, the facility's policy required that such chemicals be stored securely. Interviews with staff, including an LPN and the DON, confirmed that these items should not have been left unsecured in the resident's room. Similarly, Resident #27, also cognitively intact with a BIMS score of 15, had an unsecured 200-count bottle of multivitamins on the sink counter in her room. The resident had not been assessed for self-administration of medications, as required by the facility's policy. Observations and interviews with staff, including an LPN and an RN, confirmed that the multivitamin bottle should not have been left unsecured and should have been taken to the nurses' station. The DON reiterated that medications are not supposed to be left unsecured in a resident's room.
Failure to Document Fluid Restriction for Dialysis Resident
Penalty
Summary
The facility failed to document the fluid restriction amount and the amount consumed by a resident requiring dialysis care on the Medication Administration Record (MAR). The facility's policy, revised on May 10, 2023, mandates that the fluid restriction amount and the amount consumed should be documented in the physician's order and on the MAR. However, for Resident #31, who was admitted with diagnoses including Edema, Acute Kidney Failure, and End Stage Renal Disease requiring dialysis, this documentation was not completed. The physician's orders indicated a fluid restriction of 960 ml per day, but the MAR from May 1 to May 31, 2024, lacked any record of the fluid restriction amount or the fluid consumed by the resident each shift. Interviews with staff and the resident confirmed the oversight. A Licensed Practical Nurse (LPN) acknowledged that the fluid consumed by the resident was not documented on the MAR, despite the resident being on a 960 ml/day fluid restriction. A Certified Nursing Assistant (CNA) and the resident herself confirmed that the resident did not have a water pitcher at her bedside, and fluids were provided by dietary and nursing staff. The Director of Nursing (DON) also confirmed the failure to document the fluid restriction and consumption on the MAR, highlighting a lapse in adherence to the facility's policy.
Failure to Develop Dementia Care Plans for Residents
Penalty
Summary
The facility failed to develop a dementia care plan for two residents diagnosed with dementia, as required by their policy. Resident #12 was admitted with diagnoses including Dementia with Psychotic Disturbance, Alzheimer's Disease, and Vascular Disorder of the Intestine. A quarterly Minimum Data Set (MDS) assessment indicated severe cognitive impairment, yet the comprehensive care plan did not address dementia. The Director of Nursing (DON) and the MDS Coordinator confirmed the absence of a dementia care plan, despite the expectation that residents with dementia should have person-centered interventions. Similarly, Resident #21, admitted with Chronic Obstructive Pulmonary Disease, Delusional Disorder, and Severe Vascular Dementia, also lacked a dementia care plan. The quarterly MDS assessment showed severe cognitive impairment, but the care plan did not reflect this diagnosis. Both the DON and the MDS Coordinator acknowledged the oversight, confirming that dementia should have been included in the care plan as per the facility's policy.
Deficiency in PRN Antianxiety Medication Management
Penalty
Summary
The facility failed to provide evaluation and rationale for the continued use of a PRN antianxiety medication for a resident with severe cognitive impairment. The facility's policy on psychotropic medication use, revised in July 2022, states that residents should not receive medications that are not clinically indicated to treat a specific condition and that PRN orders for psychotropic medications are limited to 14 days. However, the medical record review revealed that a resident was prescribed Ativan 0.5 mg every 6 hours as needed for anxiety, initially with a 14-day limit, but subsequently, the order was changed to 0.25 mg without a stop date, and no evaluation or rationale for continued use was documented. Interviews with facility staff, including a Nurse Practitioner and the Director of Nursing, confirmed that the PRN Ativan order for the resident did not have a stop date, and there was no documented evaluation for its continued use. Additionally, the Pharmacist Consultant confirmed that there were no pharmacy recommendations to discontinue the PRN Ativan. This lack of evaluation and documentation for the continued use of the PRN antianxiety medication constitutes a deficiency in the facility's adherence to its policy and regulatory requirements.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to proper medication labeling and storage protocols, as evidenced by several observations and interviews. An insulin pen was found on a medication cart without a pharmacy label, resident name, or open date, and a Licensed Practical Nurse (LPN) was about to use it without knowing when it was opened. Additionally, a medication cart was left unlocked and unattended while an LPN administered medications to a resident, which was confirmed by the LPN. The Director of Nursing (DON) acknowledged that insulin pens should be dated and labeled with resident information when opened. Further deficiencies were noted in the medication room, where the door was propped open and medications, including controlled substances like Hydrocodone and Oxycodone, were left unsecured. Expired medical supplies, such as syringes, needles, IV start kits, and transfer straw kits, were also found in the medication room and available for use. The Pharmacy Director and Pharmacist confirmed that the controlled substances should have been secured behind two locked areas, and the expired supplies should not have been available for use. The DON confirmed the medication cart should not have been left unsecured and acknowledged the presence of expired supplies.
Failure to Arrange Dental Care for a Resident
Penalty
Summary
The facility failed to arrange dental care for a resident, identified as Resident #34, who was admitted with diagnoses including anemia, diabetes mellitus, hypothyroidism, and generalized muscle weakness. The facility's policy on dental services, revised in December 2016, states that routine and 24-hour dental services are provided through various referral options. However, a review of Resident #34's medical records revealed no assessment of the resident's mouth by a nurse or dentist since admission. Observations and interviews conducted on May 28, 2024, noted that the resident had missing and discolored teeth and expressed a desire to see a dentist, yet had not been asked if they wanted dental care. The Director of Nursing confirmed the absence of documentation indicating that the resident had seen a dentist since admission.
Improper Garbage Containment
Penalty
Summary
The facility failed to ensure proper containment of garbage and refuse in one of its six dumpsters. According to the facility's policy on trash disposal, dated August 23, 2023, trash should be disposed of appropriately, and the dumpster area should be maintained for cleanliness and prevention of rodents, with a securely placed dumpster plug. On May 28, 2024, at 11:20 AM, an observation of the outside dumpster area revealed that dumpster #6 was missing a dumpster plug. This observation was confirmed during an interview with the Certified Dietary Manager at 11:25 AM on the same day.
Failure to Obtain Informed Consent for Pneumococcal Vaccination
Penalty
Summary
The facility failed to offer informed consent prior to administering the Pneumococcal vaccine to two residents, which was identified during a review of facility policies, medical records, and staff interviews. The facility's policy, revised on February 7, 2023, mandates that residents should be given the Pneumococcal Immunization upon admission unless medically contraindicated or refused, with documented evidence of acceptance or declination kept on file. Resident #21, admitted with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Chronic Respiratory Failure, and a history of Pulmonary Embolism, did not have documented informed consent for the vaccination. Similarly, Resident #38, admitted with diagnoses such as Intestinal Obstruction, Chronic Bronchitis, Shingles, and Polyosteoarthritis, also lacked informed consent documentation. The Infection Preventionist confirmed the absence of informed consent for these residents, which was against the facility's expectations.
Transcription Error in Physician's Order for Insulin
Penalty
Summary
The facility failed to accurately transcribe a physician's order for a resident with multiple serious health conditions, including End Stage Renal Disease, Type 1 Diabetes, and Congestive Heart Failure. The resident was prescribed Humulin R (short-acting insulin) to be administered according to a sliding scale protocol. However, the handwritten physician orders were incorrectly transcribed onto the Medication Administration Record (MAR) as Humulin N (intermediate-acting insulin). This transcription error occurred on 12/13/2023 and was not detected until 12/21/2023 when the resident's endocrinologist inquired about the accuracy of the MAR. The error was due to a nurse inadvertently selecting the wrong insulin name from an automated drop-down menu in the facility's electronic record system. Despite the error, the resident continued to receive the correct medication, Humulin R, as the incorrect order had not been sent to the pharmacy for fulfillment, and Humulin N was not available for use. The Director of Nursing (DON) confirmed that the facility launched an investigation upon receiving the endocrinologist's call. The investigation revealed that multiple nursing staff had administered Humulin R per the sliding scale protocol to the resident between 12/13/2023 and 12/21/2023 without detecting the transcription error. The DON acknowledged that the facility had failed to accurately transcribe the new orders onto the MAR, leading to confusion at the endocrinologist's office. The facility's failure to detect the transcription error at the time it was written resulted in a discrepancy between the prescribed medication and the medication listed on the MAR, although the resident did not receive the incorrect insulin due to the pharmacy not fulfilling the erroneous order.
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Illustrative
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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 Knoxville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wellpark Health And Rehabilitation | 0.1 mi | ★★★★★ | 2 | 0 |
| West Hills Health And Rehab | 0.8 mi | ★★★★★ | 0 | 0 |
| Lyonsview Health And Rehabilitation Center | 2.9 mi | ★★★★★ | 0 | 0 |
| Senator Ben Atchley State Veterans' Home | 4.6 mi | ★★★★★ | 2 | 0 |
| Nhc Healthcare, Ft Sanders | 5.8 mi | ★★★★★ | 7 | 0 |
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