Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Midtown Center For Health And Rehabilitation during CMS and state inspections, most recent first.
Inaccurate smoking assessments were found for two residents. One resident with COPD, nicotine dependence, and a care plan for smoking, and another resident with diabetes and emphysema, were both on the smoking list and observed smoking in the designated area, but their MDS assessments did not capture tobacco use despite BIMs scores of 9.
A resident with multiple diagnoses, including CHF, HTN, seizures, and a cognitive communication deficit, was observed in bed with oxygen via binasal cannula connected to an unsecured oxygen cylinder at the bedside. The LPN confirmed the tank should be secured and stated it was hazardous if it fell over.
Soiled enteral feeding equipment was observed for several residents with severe cognitive impairment and dependence on staff for ADLs and tube feeding. Feeding pumps and poles had dried tan or brown substances, and some poles appeared rusted. The DON and Administrator confirmed the equipment was dirty and, in one case, that a pole should be replaced.
A medication administration error occurred when an LPN administered Albuterol Sulfate instead of the prescribed Arformoterol to a resident with severe cognitive impairment and multiple diagnoses. The facility's policy requires verification of medications with the MAR, which was not followed, leading to the error confirmed by nursing staff.
The facility failed to ensure proper infection control practices during medication administration. Three LPNs did not perform hand hygiene as required by facility policy. LPN B did not wash hands after cleaning a blood pressure cuff and before or after administering medications. LPN A failed to perform hand hygiene before donning and after doffing PPE. LPN C also did not perform hand hygiene before donning PPE. The DON confirmed the necessity of hand hygiene before and after glove use.
The facility failed to provide adequate pressure ulcer care and prevention, resulting in Immediate Jeopardy for several residents. A resident developed a pressure ulcer on the palm due to long fingernails and a stage 3 ulcer on the buttock, with no signed physician orders for treatment. Observations showed missing hand rolls and poor hygiene. Other residents also suffered from inadequate ulcer care, with inconsistent staging and treatment. Staff interviews revealed confusion and non-compliance with care plans and policies.
A resident in an LTC facility experienced pain due to long toenails, with one toenail adhering to the skin, as the facility failed to provide necessary nail care. Despite a physician's order for a podiatry consultation, the resident did not receive podiatry services until months later, after the issue was highlighted by a surveyor. The facility's policy required regular nail assessments, but staff failed to notice the resident's nail condition, resulting in actual harm.
The facility failed to educate 33 out of 34 residents on advance directives, as required by their policy. Despite varying cognitive abilities among residents, the facility did not ensure that all were informed about their rights to refuse treatment and formulate an advance directive. The Administrator confirmed that this should occur at admission, but documentation was lacking.
The facility failed to report allegations of abuse involving four residents in a timely manner, as required by their policy. A cognitively intact resident reported feeling upset due to a CNA's comments, but the incident was not reported to the state. Additionally, two moderately cognitively impaired residents alleged verbal and physical aggression from another resident, with delays in reporting these incidents to the state agency.
The facility failed to investigate alleged resident-to-resident abuse thoroughly and did not submit timely 5-day follow-up reports for two residents. Incidents involved residents with varying cognitive impairments, and the facility delayed obtaining statements and implementing interventions. The Administrator acknowledged the oversight in reporting, indicating non-compliance with required protocols.
The facility failed to ensure LPNs had the necessary competencies for wound care, leading to inadequate treatment of pressure ulcers for several residents. Competency forms for two LPNs were incomplete, and multiple residents developed facility-acquired pressure ulcers that were not documented or treated according to physician orders. The DON acknowledged awareness of the issue, and the facility had prior issues with pressure ulcers.
The facility failed to ensure proper medication storage and supervision, as medications were left unattended by nursing staff during administration. An RN and two LPNs left medications out of sight while washing hands, and a medication cart was found unlocked with an unlabeled medication. Staff interviews confirmed these actions were against facility policy.
The facility failed to properly store food in the nourishment refrigerators on the 200 and 400 halls, with multiple items found unlabeled and undated. Staff interviews confirmed that these refrigerators are for resident use only and should contain labeled and dated items, as per facility policy. Despite this, the deficiency was noted during the survey, highlighting a lapse in policy adherence.
The facility's QAPI committee failed to address issues related to pressure ulcers and nail care, resulting in deficiencies in care. Several residents developed Stage 3 pressure wounds due to inadequate assessments and monitoring. The Administrator and DON were not fully informed about the severity of the wounds, and the Medical Director was unaware of the situation. Additionally, a resident experienced harm due to inadequate nail care. These incidents highlight a lack of proper communication, oversight, and adherence to professional standards of practice.
The facility failed to follow infection control protocols during medication administration, with several nurses neglecting hand hygiene and one LPN not cleaning an insulin pen's rubber seal before use. Additionally, reusable equipment was not cleaned between residents. These actions were confirmed by staff and the DON, indicating a breach in infection prevention practices.
Two residents experienced deficiencies in wound care management. One resident had a delay in antibiotic treatment for an infected wound, while another had a diabetic ulcer that was not identified until it was necrotic. Staff interviews revealed issues with timely reporting and assessment, partly due to staffing shortages.
The facility failed to provide appropriate catheter care for two residents with indwelling catheters. One resident did not have their catheter bag changed as ordered, leading to complications and hospital intervention. Another resident lacked documented physician orders for catheter use and care, with observations showing improper catheter bag positioning. Interviews confirmed that physician orders were not consistently followed, resulting in inadequate care and increased risk of complications.
A facility failed to provide appropriate care for a resident with a PEG tube, as required by their policy. Despite the resident's severe cognitive impairment and multiple medical conditions, there was no documentation of PEG site care in the Treatment Administration Record for June and July. Observations showed ongoing PEG tube feeding, but no evidence of site care, indicating a failure to adhere to the facility's policy.
Inaccurate Smoking Assessments
Penalty
Summary
Ensure each resident receives an accurate assessment was not met when the facility failed to accurately assess smoking status for 2 of 2 sampled residents, Resident #15 and Resident #62. The facility policy stated residents are assessed using a comprehensive assessment process to identify care needs. Resident #15 was admitted with diagnoses including encephalopathy, atrial fibrillation, bronchopneumonia, COPD, hypertension, wheezing, dyspnea, and nicotine dependence, and was care planned for smoking, but the admission MDS with a BIMs score of 9 did not code tobacco use. Resident #62 was admitted with diagnoses including diabetes and emphysema, and the annual MDS with a BIMs score of 9 did not assess tobacco use. Both residents were listed on the facility smoking list, and both were observed smoking in the designated smoking area. The MDS Director confirmed that tobacco use should have been captured on Resident #15's admission MDS and Resident #62's annual MDS.
Unsecured Oxygen Cylinder at Bedside
Penalty
Summary
The facility failed to ensure Resident #15 was free from accident hazards when the resident’s oxygen cylinder was left unsecured at the bedside. Resident #15 was admitted with diagnoses including atrial fibrillation, cerebrovascular disease, cognitive communication deficit, bronchopneumonia, congestive heart failure, hypertension, and seizures. A quarterly MDS indicated a BIMS score of 13, showing the resident was cognitively intact, dependent on staff for ADLs, and using oxygen therapy. A physician order dated 3/5/2025 directed oxygen at 2 liters per minute via binasal cannula. During observation on 9/3/2025 at 8:13 AM, the resident was in bed with the cannula in place and connected to an unsecured oxygen tank cylinder sitting at the bedside. The cylinder was not secured to prevent it from falling. During interview on 9/3/2025 at 8:19 AM, an LPN confirmed the oxygen tank should be secured to prevent injury or harm and stated it was hazardous if it fell over.
Soiled enteral feeding equipment
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment for residents receiving enteral tube feeding. Facility policy required reusable resident-care equipment, including feeding tube pumps, to be cleaned and disinfected, and used or dirty durable medical equipment such as feeding pumps to be stored in the soiled utility room. During review of records, observation, and interview, surveyors found multiple residents with enteral feeding pumps and poles that were visibly soiled with dried tan or brown substances, and in some cases appeared to have rust on the poles. Resident #4 had diagnoses including cerebral infarction, dysphagia, and aphasia, a BIMS score of 6, and was dependent on staff for eating and receiving enteral feeding. The resident’s feeding pump was observed infusing in the room on multiple occasions, and the base of the enteral feeding pole had dried, tan, unknown substances. The DON confirmed the pole base was splattered with dried enteral feeding and needed to be cleaned. Resident #65 had diagnoses including cerebral infarction, dysphagia, convulsions, and aphasia, was rarely/never understood, had severely impaired cognitive skills, and was dependent on staff for ADLs and enteral nutrition. The resident’s feeding pump was also observed infusing with dried tan substances splattered on the base of the feeding pole, and the DON confirmed it needed to be cleaned. Resident #64 had diagnoses including dysphagia, seizures, and hemiplegia, was severely cognitively impaired, and received enteral feeding and water through a pump. Surveyors observed a dry light brown substance on the pump and a dark brown substance resembling rust on the pole and base on repeated observations, and the Administrator and DON confirmed the pole should not have dry substance or rust and should be cleaned. Resident #77 had metabolic encephalopathy, hemiplegia, dysphagia, gastrostomy, and thyroid disorder, with severe cognitive impairment and dependence for all ADLs; the pump and pole had dried tan substances and brown areas that appeared to be rust, and the DON confirmed the pump and pole should have been cleaned and the pole replaced. Resident #161 had cerebral infarction, dysphagia, and gastrostomy, was rarely/never understood, severely cognitively impaired, and dependent on staff for ADLs and enteral nutrition; the feeding pole base was covered with dried tan substances, and the Administrator and DON confirmed it was covered with dried enteral feeding and should be replaced with a clean pole.
Medication Administration Error by LPN
Penalty
Summary
The facility failed to follow physician orders during medication administration for a resident, as observed with one of the nurses, LPN A. The facility's policy on medication administration requires comparing the medication source with the Medication Administration Record (MAR) to verify the resident's name and medication name. However, during an observation, LPN A administered Albuterol Sulfate 25mg/3ml per nebulizer to a resident instead of the prescribed Arformoterol. The MAR for March 2025 indicated that LPN A signed out Arformoterol as administered, but not Albuterol. The resident involved was admitted with diagnoses including Cerebral Infarction, Hemiplegia, Wheezing, Shortness of Breath, and Pneumonia, and was severely cognitively impaired. Interviews with the Assistant Director of Nursing and LPN A confirmed the medication error, and the Director of Nursing acknowledged that medications should be compared to the MAR for verification. This incident highlights a failure in adhering to the facility's medication administration policy, resulting in a medication error.
Infection Control Deficiency During Medication Administration
Penalty
Summary
The facility failed to ensure proper infection control practices during medication administration, as observed with three LPNs. The facility's policy on medication administration and hand hygiene requires hand washing before and after administering medications and when donning or doffing gloves. However, LPN B did not perform hand hygiene after cleaning a blood pressure cuff and before or after administering medications. LPN A failed to perform hand hygiene before donning PPE, and after doffing and donning new PPE when entering and exiting a resident's room. Similarly, LPN C did not perform hand hygiene before donning PPE. During an interview, the Director of Nursing confirmed that staff should wash hands before donning and after doffing gloves.
Failure in Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for several residents, resulting in Immediate Jeopardy. Resident #27, who was at high risk for pressure ulcers due to contractures and immobility, developed a pressure ulcer on the palm of the left hand caused by long fingernails and a stage 3 pressure ulcer on the right buttock. The facility did not have signed physician orders for the treatment of these ulcers, and the care plan was not updated to reflect the new stage 3 ulcer. Observations revealed that Resident #27 did not have hand rolls as required by the care plan, and there was a foul odor from the resident's hands, indicating inadequate hygiene and care. Resident #78 had a stage 4 pressure ulcer on the left lateral ankle that was not consistent with the characteristics of staging, and Resident #151 developed pressure wounds on the right foot due to pressure from the footboard. The facility also failed to administer prescribed treatments for pressure ulcers for Residents #478 and #479, and Resident #478's wound was inconsistent with staging. The facility's policies on pressure ulcer prevention and management were not followed, as evidenced by the lack of comprehensive skin assessments and failure to implement and document appropriate interventions. Interviews with staff revealed a lack of knowledge and adherence to care plans and policies. CNAs and LPNs were unsure of the frequency of nail trimming and hand cleaning for Resident #27, and there was confusion about the staging and treatment of pressure ulcers. The facility's failure to provide consistent and professional care for pressure ulcers led to the development and worsening of these conditions in multiple residents, highlighting significant deficiencies in the facility's care practices.
Failure to Provide Necessary Nail Care Results in Resident Harm
Penalty
Summary
The facility failed to provide necessary nail care for a resident who was unable to perform activities of daily living independently. The resident, who was cognitively intact but dependent on staff for personal hygiene, had not received toenail care since admission. This neglect resulted in the resident experiencing pain due to long toenails, with one toenail adhering to the skin. Despite a physician's order for a podiatry consultation, the facility did not provide podiatry services until several months later, after the issue was brought to their attention by a surveyor. Observations and interviews revealed that the resident's toenails were excessively long, causing discomfort and pain. The facility's policy required regular assessments and care for residents' nails, but staff failed to notice the resident's nail condition until it was highlighted by the surveyor. The resident expressed pain and dissatisfaction with the lack of care, and the facility's failure to provide timely podiatry services resulted in actual harm to the resident.
Failure to Educate Residents on Advance Directives
Penalty
Summary
The facility failed to provide education for Advance Directives to residents or their responsible parties for 33 out of 34 sampled residents. The facility's policy, dated February 20, 2024, mandates that residents or their representatives be informed about their rights to refuse medical or surgical treatment and to formulate an advance directive. However, the facility was unable to provide documentation that this information had been offered to the majority of the residents reviewed. The medical records of the residents involved show a range of cognitive abilities, as indicated by their Brief Interview for Mental Status (BIMS) scores. Some residents, such as those with scores of 14 or 15, were cognitively intact, while others had moderate to severe cognitive impairments, with scores as low as 0. Despite these varying levels of cognitive function, the facility did not ensure that all residents or their representatives were educated about advance directives upon admission. During an interview, the facility's Administrator acknowledged that the responsibility for advance directives lies with the Admission Director at the time of admission and with Social Services within 48 hours after admission. The Administrator confirmed that advance directives should be offered and documented at the time of admission, but the facility failed to do so for the majority of the residents reviewed.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse for four residents, as required by their policy on Abuse, Neglect, and Exploitation. The policy mandates reporting all alleged violations to the Administrator, state agency, and other required agencies within specified timeframes, particularly within 24 hours if the events do not result in serious bodily injury. However, the facility did not adhere to this policy. For instance, Resident #157, who was cognitively intact, reported feeling nervous and upset due to a CNA's comments, but the allegation of verbal abuse was not reported to the state agency. The Director of Nursing decided not to report the incident after discussing it with the resident. Additionally, Resident #107, who was also cognitively intact, was involved in multiple incidents of alleged abuse. Resident #35, who was moderately cognitively impaired, alleged verbal aggression from Resident #107, but this was not reported to the state until the following day. Similarly, Resident #43, also moderately cognitively impaired, alleged physical aggression from Resident #107, and the Administrator was informed of this incident three days after it occurred. These failures to report allegations of resident-to-resident abuse in a timely manner highlight the facility's non-compliance with its own policies and state regulations.
Failure to Investigate and Report Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate alleged incidents of resident-to-resident abuse for three residents and did not submit a 5-day follow-up report to the state in a timely manner for two residents. The facility's policy requires immediate investigation and documentation of abuse allegations, with reports to be made to the Administrator and relevant agencies within specified timeframes. However, the facility did not adhere to these protocols, resulting in deficiencies in handling abuse allegations. Resident #107, with intact cognition, was involved in an incident where they were alleged to have been physically aggressive toward Resident #43, who had moderately impaired cognition. The facility did not present a thorough investigation of this allegation. Additionally, Resident #35, who was moderately cognitively impaired, alleged verbal aggression from Resident #107. The facility delayed obtaining statements and implementing interventions, failing to protect the residents involved. For Resident #58, who was moderately cognitively impaired, an allegation of staff-to-resident physical abuse was reported, but the 5-day follow-up report was not submitted to the state until several months later. Similarly, Resident #98, who was severely cognitively impaired, was involved in a resident-to-resident abuse incident, and the 5-day follow-up report was also delayed. The Administrator confirmed the oversight in reporting these follow-ups, indicating a lapse in the facility's compliance with reporting requirements.
Inadequate Wound Care Competency and Management
Penalty
Summary
The facility failed to ensure that the Licensed Practical Nurses (LPNs) responsible for wound care had the necessary competencies and skills to provide adequate care for pressure ulcers. This deficiency was identified for three LPNs who were responsible for wound care for seven residents. The competency forms for LPNs A and C were incomplete, lacking documentation and signatures from a reviewer, indicating a lack of proper assessment of their skills. Several residents developed facility-acquired pressure ulcers, which were not adequately documented or treated according to physician orders. For instance, Resident #27 developed a Stage 3 pressure ulcer on the right buttock, and there were no signed physician's orders for treatment. Similarly, Resident #78 had a Stage 4 pressure ulcer on the left lateral ankle, with inconsistent assessments by LPN B. Resident #123's vascular wound worsened without timely identification by LPN C, and Resident #151's pressure ulcer progressed to Stage 3 without proper intervention. The facility also failed to perform wound care treatments as ordered for Residents #478 and #479. Resident #478's sacral and umbilicus pressure ulcers were not treated on the specified days, and Resident #479's pressure ulcer care was inconsistently performed. The Director of Nursing acknowledged awareness of the issue and confirmed that pressure ulcers should be identified before reaching Stage 3. The Area Director of Clinical Services confirmed that the facility had prior issues with pressure ulcers, indicating a pattern of inadequate wound care management.
Medication Storage and Supervision Deficiency
Penalty
Summary
The facility failed to ensure proper storage and supervision of medications, as observed in several instances involving nursing staff. On multiple occasions, medications were left unattended and out of sight during administration. Specifically, an RN left a medication cup on an overbed table while washing hands in the bathroom, and two LPNs similarly left medication trays unattended in residents' rooms while they went to wash their hands. These actions were contrary to the facility's policy, which mandates that medications must be under direct observation or locked during administration. Additionally, a medication cart on the 2nd floor was found unlocked, unattended, and out of the line of sight, with a tube of Diclofenac Sodium Gel 1% in the drawer lacking a resident's name label. The LPN responsible acknowledged the oversight, confirming that the cart should have been locked and medications properly labeled. Interviews with nursing staff and the Director of Nursing corroborated these findings, emphasizing that medication carts should be locked when not in use and medications should be labeled with the resident's name.
Improper Food Storage in Nourishment Refrigerators
Penalty
Summary
The facility failed to ensure proper storage of food items in the nourishment refrigerators located in the 200 and 400 hall nutrition rooms. Observations revealed multiple food items, including a bottle of tea, a sandwich, a water bottle, a container of watermelon, a Mexican meal, a jar of salsa, a bottle of Jungle punch, and a Snickers ice-cream bar, were unlabeled and undated. This was in violation of the facility's policy, which mandates that all food items brought in by family or visitors must be labeled and dated, and discarded if not consumed within three days. Interviews with facility staff, including the Assistant Director of Nursing (ADON), a Licensed Practical Nurse (LPN), the Administrator, and the Dietary Manager (DM), confirmed that the nourishment refrigerators are intended for resident use only and that all items should be labeled and dated. The DM noted that the kitchen was not responsible for these refrigerators and that housekeepers were tasked with discarding unlabeled and undated items on Fridays. Despite these procedures, the deficiency was identified during the survey, indicating a lapse in adherence to the facility's food storage policy.
Deficiencies in Pressure Ulcer and Nail Care Management
Penalty
Summary
The Quality Assurance Performance Improvement (QAPI) committee at the facility failed to effectively identify and address issues related to pressure ulcers and nail care for several residents. The committee did not implement appropriate actions or monitor the effectiveness of these actions, leading to deficiencies in care. Specifically, the facility's QAPI program did not adequately address the needs of residents with pressure ulcers, as evidenced by the presence of Stage 3 pressure wounds, which should have been identified and treated earlier. The facility's policy required regular assessments and monitoring, but these were not effectively carried out, resulting in the progression of pressure ulcers to more severe stages. The facility's administration and nursing leadership were not fully informed or involved in the management of pressure ulcers. The Administrator did not attend weekly wound meetings and relied on the Director of Nursing (DON) for updates, which led to a lack of awareness about the severity of the pressure wounds. The DON was aware of the presence of Stage 3 pressure wounds but did not ensure that the wound nurses were properly certified to stage these wounds. Additionally, the Medical Director was not informed about the severity of the pressure wounds, indicating a breakdown in communication and oversight within the facility's leadership. The facility also failed to provide adequate nail care for a vulnerable resident, resulting in actual harm when the resident's toenails adhered to the skin, causing pain. This incident highlights the facility's failure to provide care consistent with professional standards of practice. The lack of proper assessments, documentation, and communication contributed to the deficiencies in care, as the facility did not ensure that staff were adequately trained and informed about the residents' needs and the facility's policies.
Removal Plan
- Identification of residents affected or likely to be affected
- All residents had an updated Braden Assessment completed
- Ensure initial skin assessments were completed
- Facility policies and procedures related to skin care, wound care, and pressure injury prevention were reviewed and revised
- Provided education to all licensed nurses on the completion of the Braden Score Assessment policy, and completed treatments on all new admissions
- Daily audit of the Treatment Administration Record to ensure accurate and complete documentation of skin related treatments as ordered
- Daily audits of skin related treatments including documentation, Braden Assessments, and orders
- PIP initiated to report on above monitoring and will continue
Infection Control Lapses During Medication Administration
Penalty
Summary
The facility failed to adhere to its infection prevention and control policies during medication administration, as observed in several instances involving multiple nursing staff. Specifically, one LPN did not clean the rubber seal of an insulin pen before attaching the needle, which is a deviation from the facility's policy requiring the use of an alcohol pad to wipe the seal. Additionally, four nurses, including LPNs and an RN, did not perform appropriate hand hygiene before or after administering medications, despite the facility's policy mandating hand washing as part of the medication administration process. Furthermore, one LPN failed to clean reusable equipment, such as a blood pressure cuff, between resident uses, which is contrary to the facility's infection control practices. These observations were confirmed through interviews with the nursing staff and the Director of Nursing, who acknowledged the lapses in following the established protocols for infection control and hand hygiene. These deficiencies highlight a significant gap in the facility's adherence to its own infection prevention and control policies, potentially compromising resident safety.
Deficiencies in Wound Care Management
Penalty
Summary
The facility failed to provide appropriate care and services for wounds for two residents, leading to deficiencies in wound management. Resident #123, who had severe impaired cognition and was totally dependent on staff for activities of daily living, developed wounds on the right heel and ankle. These wounds were initially classified as pressure ulcers but were later reclassified as vascular/diabetic wounds. Despite a recommendation for antibiotics on 8/23/2024 due to signs of infection, the antibiotic treatment was delayed and not started until 8/27/2024. This delay in treatment was confirmed during interviews with the LPN and the Director of Nursing (DON), who acknowledged that the antibiotic should not have been delayed. Resident #479, who had multiple diagnoses including end-stage renal disease and diabetes, developed a diabetic ulcer on the left calf. The ulcer was not identified until it had 100% necrotic tissue, indicating a significant delay in detection and assessment. The wound continued to decline, with measurements showing an increase in size and heavy purulent drainage. During an interview, an LPN expressed concerns about the lack of timely reporting and assessment of the wound, attributing it to staffing shortages and the rushed nature of the CNAs' work. The deficiencies highlight a failure in the facility's wound care management, particularly in timely assessment, classification, and treatment of wounds. The delay in starting antibiotics for Resident #123 and the late identification of the ulcer in Resident #479 demonstrate lapses in the facility's processes for monitoring and addressing wound care needs, which were confirmed through staff interviews.
Inadequate Catheter Care for Residents
Penalty
Summary
The facility failed to provide appropriate care and services for residents with indwelling catheters, specifically for two residents. Resident #71, who was admitted with a history of urinary retention and other medical conditions, had physician orders for catheter care that were not followed. The facility did not document the required catheter bag changes every two weeks for several months, leading to complications such as urinary tract infections and severe discomfort for the resident. Despite the resident's cognitive intactness, there were multiple instances where the catheter bag was not changed as ordered, and the resident experienced pain and required hospital intervention due to a malfunctioning catheter. Resident #91, admitted with severe cognitive impairment and multiple health issues, also did not receive proper catheter care. The facility failed to have documented physician orders for the use of an indwelling urinary catheter in August 2024, and there was no evidence of catheter care being provided as required. Observations revealed that the resident's catheter bag was often elevated, which is not in line with best practices for catheter care, potentially contributing to the resident's health issues. Interviews with facility staff, including the DON and medical director, confirmed that physician orders were not consistently followed, and there was a lack of documentation regarding catheter care. The facility's failure to adhere to its own policies and physician orders for catheter care resulted in inadequate care for residents with indwelling catheters, increasing the risk of infections and other complications.
Failure to Provide PEG Tube Care
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with a Percutaneous Endoscopic Gastrostomy (PEG) tube. The facility's policy on the care and treatment of feeding tubes, revised on May 31, 2023, mandates that feeding tubes be used according to physician orders and that the resident's care plan should address the use of the feeding tube, including strategies to prevent complications. However, for one resident with severe cognitive impairment and multiple medical conditions, including dysphagia and severe protein malnutrition, the facility did not document PEG site care in the Treatment Administration Record (TAR) for June and July 2024. Observations in the resident's room on multiple occasions revealed that the PEG tube feeding was ongoing, but there was no evidence of PEG site care being performed. Additionally, enteral feeding supplements and syringes were observed on the bedside table, labeled and dated, indicating that the feeding process was being carried out, but without the necessary site care. This lack of documentation and observed care indicates a failure to adhere to the facility's policy and ensure the resident received the required PEG site care.
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Illustrative
What surveyors actually found near you
We read the 158 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Memphis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Majestic Gardens At Memphis Rehab & Snc | 0 mi | ★★★★★ | 43 | 0 |
| Harborview Post Acute | 2.9 mi | ★★★★★ | 1 | 0 |
| Regional One Health Subacute Care | 3 mi | — | 0 | 0 |
| Allen Morgan Health And Rehabilitation Center | 3.3 mi | ★★★★★ | 2 | 0 |
| Highlands Health And Rehabilitation Center | 3.3 mi | ★★★★★ | 2 | 1 |
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