Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Autumn Leaves Nursing And Rehab Inc during CMS and state inspections, most recent first.
Missing Log for Discontinued Narcotic Storage: The facility failed to maintain a log for the discontinued narcotic drug storage and could not provide a system for reconciling controlled medications ready for disposal. During observation, the Acting DON showed several narcotic cards with accurate counts, but stated she had no log for the cabinet, no access to the prior DON’s software, and no way to check for missing medications. The ADON said the DON should have had the log, and the Administrator acknowledged a log should exist for drug destruction narcotics.
Failure to Care Plan Key Resident Needs: The facility did not include important care areas in several residents’ care plans, including a mechanical lift for a resident needing 2-person transfers, refusals of a left-hand splint and special diet, limited ROM for a resident with CVA and hemiplegia, wandering for a resident with dementia and bipolar disorder, and falls for a resident with dementia and a fall history. Interviews with CNA, RN, MDS, ADON, DON, and the administrator confirmed the missing care plan items, and the MDS Coordinator stated these items should have been care planned.
Failure to act on pharmacy GDR recommendations affected three residents. One cognitively intact resident with anxiety, depression, and insomnia had pharmacist-recommended dose reductions for oxcarbazepine and trazodone, plus a later recommendation to trial discontinue alprazolam, but the NP marked the requests as not agreed to without documenting resident education or the discussion. Another resident with severe cognitive impairment had a PRN lorazepam order that exceeded the usual PRN psychotropic limits without documented prescriber follow-up. A third resident with dementia and no coded behaviors remained on daily Zyprexa despite a pharmacist recommendation to reduce the dose, and the family said they were never contacted about the request.
Failure to Consistently Offer Evening Snacks: Residents reported that snacks were often left at the nurse station and not routinely offered at bedtime, including to residents who were bedbound or unable to reach the station. Staff gave inconsistent accounts of who was responsible for passing out snacks, while the Dietary Supervisor, RN, DON, and ADM each described different processes for snack distribution. The facility policy stated bedtime snacks would be provided each night for all residents, including those on puree diets.
A CNA used an inappropriate method to check a resident for possible incontinence by patting and squeezing her buttock through clothing. The resident had dementia with severe cognitive impairment, needed help with toileting and other ADLs, and a family member said the interaction was embarrassing and baby-like. The DON stated this was not regular practice and that there were better ways to assess wetness while preserving dignity.
Unnecessary psychotropic medication use and missing PRN stop date: A resident had a PRN lorazepam order for anxiety with no stop date listed, despite the facility policy requiring PRN psychotropics ordered for 14 days to have a stop date and physician review for continued need. Another resident with dementia received daily Zyprexa for months even though the MDS showed no behaviors, behavior monitoring documented 0 episodes, and staff noted no dangerous behaviors or documented nonpharmacological interventions supporting ongoing antipsychotic use.
Failure to provide contracture management for a resident with bilateral hand contractures. A resident with stroke-related hemiplegia, dementia, and pain in both hands had no documented contracture prevention device in the care plan or orders for either hand, and staff gave inconsistent accounts about who was responsible for splints after therapy. During observation, the resident’s left hand was contracted with no splint, brace, or carrot in place, and staff acknowledged the resident had gone months without hand devices despite prior therapy involvement.
A resident with Alzheimer’s disease, COPD, and hypothyroidism had hydrogen peroxide and Isopropyl Alcohol 50% left unsecured in the room. Surveyors observed the chemicals in the room on multiple occasions, and the DON and Administrator stated these items should not be in resident rooms and should be stored in a med cart or med room. The resident’s care plan also noted an ADL self-care deficit and impaired balance.
Improper Catheter Securement and Incontinent Care: A resident with a suprapubic catheter was observed with the tubing hanging in a dependent loop below the drainage bag and no securement device in place, despite an order for catheter care and stabilization checks. In a separate event, two CNAs provided peri-care to an incontinent resident but left feces in the vaginal area before applying a clean brief, and interviews showed inconsistent understanding of proper front-to-back cleansing technique among staff.
A resident with dementia, CAD, and hypercholesterolemia had physician orders for a BMP, lipid panel, and liver panel every 3 months, but EHR review showed no results for any of the ordered labs. The ADON said the lab system had recently been integrated with the EHR, could not find the results, and stated she may have overlooked the resident during lab auditing; the DON said the missing labs were likely an oversight during the transition to automatic requisitions.
A resident with dysphagia had a used tube feeding syringe left on the bedside dresser with dried residue and condensation, rather than being stored in a bag or discarded. Another resident with a suprapubic catheter had the catheter bag lying on the floor during repeated observations, despite an order for catheter care every shift and a policy requiring the drainage bag to stay off the floor. Staff, including the ADON, Acting DON, and Administrator, acknowledged the improper handling of both items.
Two residents remained on prophylactic antibiotic orders without documented provider rationale supporting the therapy. One resident with neuropathic bladder and neurocognitive disorder was ordered cephalexin daily for urinary prophylaxis, and another resident with dementia and neuromuscular bladder dysfunction was ordered Macrobid daily for prophylaxis. The ADON said both had recurring UTIs, while the DON and Administrator acknowledged concerns about starting antibiotics without culture support and stated the residents should not have been on prophylactic antibiotics.
A resident with cancer, impaired cognition, incontinence, and vision deficits, who required extensive ADL assistance, was not consistently treated with respect and dignity. Despite a care plan emphasizing preservation of self-esteem during ADL care, night-shift CNAs were reported by the resident and multiple family members to speak in a rude, scolding manner, make demeaning comments about incontinence and rolling out of bed, enter the room without knocking or announcing themselves, and at times refuse to provide incontinence care until the resident got back into bed. One CNA acknowledged the resident had complained about rude night-shift staff but only reported it to a charge nurse who later left, and an anonymous resident on the same hall also reported rude and disrespectful behavior by night-shift CNAs. Administration and the DON stated they had not been informed of these complaints, despite a facility policy stating residents have the right to be treated with courtesy, consideration, and respect.
A resident with hemiplegia, contractures, and total dependence for ADLs had a care plan and ADL documentation requiring two staff to be present for all personal care, including toileting and bed mobility. On two separate occasions, video footage showed two different CNAs each performing incontinent care alone, rolling and repositioning the resident without a second staff member present, while only a visitor or no one else was in the room. Facility nursing leadership and an LVN confirmed in interviews that the care plan required two-person assistance for all care tasks for this resident and that completing such tasks alone was not appropriate.
Two CNAs failed to lock the bed wheels before raising, turning, and repositioning a dependent resident with multiple medical conditions, including hemiplegia and dementia, during incontinent care. The bed remained unlocked throughout the care episode, contrary to facility policy and staff expectations, resulting in a deficiency related to accident hazard prevention and supervision.
A resident with end stage renal disease did not receive timely removal of dialysis port dressings as ordered by the dialysis center, despite repeated instructions and documentation from dialysis staff. Facility staff demonstrated inconsistent understanding of dialysis port care procedures, and the care plan lacked specific interventions for dressing removal, resulting in ongoing issues with dressing management and complications at the access site.
The facility failed to ensure call lights were within reach for three residents, all of whom had significant mobility and cognitive impairments. Despite requiring substantial assistance for ADLs and being at risk for falls, the call lights were often found draped over the bed or on the floor, making them inaccessible. Staff interviews confirmed the expectation for call lights to be within reach, but this was not consistently practiced, leading to a deficiency in accommodating resident needs.
A malfunctioning exit door alarm on Hall 200 caused excessive noise, disrupting residents' sleep and meals. Staff and residents reported the issue, which persisted for months despite maintenance attempts. The facility's administration acknowledged the problem, which affected the homelike environment.
Multiple residents requiring oxygen therapy did not receive care consistent with professional standards, including improper storage of nasal cannulas, unclean oxygen concentrator filters, and incorrect oxygen flow rates. Staff interviews confirmed that nurses were responsible for equipment maintenance and monitoring, but deficiencies in these areas were observed, placing residents at risk for respiratory complications.
Expired medications were found in the medication storage room, narcotic counts for a resident's insomnia medication were inaccurate, and another resident's order for Midodrine lacked documented blood pressure hold parameters. These deficiencies involved failures in medication storage, administration accuracy, and proper documentation by nursing staff and pharmacy services.
Surveyors found that multiple medications and biologicals, including creams, eye drops, nasal sprays, and skin cleansers, were left unsecured in resident rooms without proper physician orders or self-administration assessments. Several residents with cognitive impairment had access to these items, and staff interviews confirmed that facility policy was not followed regarding secure storage and documentation. The lack of secure storage and oversight was observed across several cases, with staff acknowledging the risks and their responsibility for ensuring compliance.
A resident with significant physical and cognitive impairments was not assisted out of bed as often as he preferred, despite expressing his wishes to staff and having a care plan reflecting this preference. Observations and interviews revealed that staff did not consistently offer or document offers of assistance, and the resident remained in bed even after requesting to get up. Facility leadership and policy confirmed that residents should be given the choice to get out of bed.
A resident's MDS assessment did not accurately reflect the use of an anticonvulsant and a hypoglycemic medication, despite both being prescribed and administered as documented in the medical record. Staff interviews revealed uncertainty and errors in coding medications by their pharmacological class, leading to incomplete documentation on the MDS.
Two residents dependent on staff for ADLs did not receive timely assistance with personal hygiene. One was left in a urine-soaked brief for hours despite requests for help, while another was not shaved for an extended period, leaving her with long facial hair. Staff interviews confirmed delays and lack of follow-through on care responsibilities.
A resident with a suprapubic catheter did not receive required catheter care, resulting in a catheter bag that was excessively full and left on the floor, with urine backing up into the tubing. Staff confirmed the bag should have been emptied every shift and kept off the floor, but documentation showed care was not provided as ordered, leading to a deficiency in catheter care and infection prevention.
Two residents with feeding tubes did not have physician orders specifying the volume, frequency, and type of flush, nor orders for site cleaning, residual checks, or tube placement verification. Staff interviews confirmed these omissions, and facility policy required such orders to ensure safe care.
A resident with chronic kidney disease, neuromuscular bladder dysfunction, and an indwelling catheter received daily Nitrofurantoin as a prophylactic antibiotic for an extended period, despite ongoing urinary tract infections and no evidence of effectiveness. Facility staff acknowledged that this use did not meet McGeer criteria, and the resident was not provided a probiotic as typically recommended for long-term antibiotic use. The facility's policies on antibiotic stewardship were not followed, and the decision to continue the medication was deferred to hospice after the resident's health declined.
A nurse failed to use required PPE while administering medication via a PEG tube to a resident with multiple complex conditions and an indwelling medical device, despite the resident being on enhanced barrier precautions for MDRO risk. Staff interviews confirmed knowledge of EBP protocols and PPE availability, but the deficiency occurred due to non-compliance during a high-contact care activity.
A resident with a history of UTI, sepsis, and an indwelling catheter was prescribed and administered Ciprofloxacin for a UTI, despite urine culture results showing resistance to this antibiotic. Facility staff did not notify the physician of the resistance, and the resident continued to receive the ineffective medication, in violation of the facility's antibiotic stewardship policy.
A facility failed to provide a resident's medical records to her attorney within the required timeframe, potentially affecting continuity of care. The request was received but not processed due to confusion over ownership responsibilities and advice from an attorney friend to delay. The facility's policy requires records to be provided within two working days, but this was not met.
A facility failed to provide timely respiratory care for three residents requiring oxygen therapy, as their oxygen tubing and humidifier bottles were not changed weekly as ordered. Observations and interviews revealed that the equipment was outdated, and staff cited supply shortages as the reason for not adhering to the schedule. The residents had significant medical conditions necessitating consistent respiratory support.
Missing Log for Discontinued Narcotic Storage
Penalty
Summary
The facility failed to establish a system of records for the receipt and disposition of all controlled drugs in sufficient detail to allow an accurate reconciliation of the facility’s only discontinued narcotic drug storage reviewed for reconciliation. During an observation and interview, the Acting DON unlocked the discontinued narcotic drug storage and showed several narcotic medication cards inside. Three cards were checked at random, and each had accurate counts on the attached count sheets, but the Acting DON stated that she did not have a log for the medications in that cabinet. She said the previous DON was supposed to help make a log of the discontinued narcotic drug storage, and that she did not have access to the software the previous DON used to log controlled medications ready for disposal. The Acting DON stated she did not have a log to check the medications against if they went missing and that she was the only person with a key to the discontinued narcotic drug storage. The ADON said she did not handle the discontinued narcotic drug storage and that the DON should have had a log. The Acting DON later said she did not have access to the scanning system for logging drug destruction and that after the surveyor checked the storage, she reviewed the counts and found them correct. The Administrator stated they should have a log for drug destruction narcotics and that someone could take one of the medications and they would be unaware it was missing. The facility policy stated controlled substances should be disposed of in accordance with regulations and recorded on the drug destruction log.
Failure to Care Plan Transfers, Refusals, ROM, Wandering, and Falls
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for multiple residents with identified medical, nursing, and psychosocial needs. Resident #41, a female with diagnoses including metabolic encephalopathy, type II diabetes, hypertensive heart disease with heart failure, hyperlipidemia, and muscle weakness, had an admission MDS showing moderate cognitive impairment, substantial/maximal assistance needs for transfers and most ADLs, and a recent fall history. Her care plan addressed generalized weakness and recent hospitalization, but it did not include the mechanical lift that staff and therapy were using for transfers. During observation, she stated that staff sometimes transferred her without the mechanical lift and that this was scary, while other observations showed staff using the mechanical lift appropriately. Interviews with CNA, RN, MDS, ADON, DON, and the administrator confirmed that the mechanical lift was not on the care plan even though staff identified her as a 2-person transfer and some staff used the lift. Resident #84, a male with spastic hemiplegic cerebral palsy, bilateral above-the-knee amputations, dysphagia, and hypertensive chronic kidney disease, had a quarterly MDS showing intact cognition, a left-hand contracture, and no splint. Staff interviews indicated he did not want to wear a left-hand splint and that he was on a regular diet despite a mechanical soft diet order and a waiver. The care plan did not include refusal of the left-hand splint or refusal of the special diet. RN, MDS, ADON, DON, and administrator interviews confirmed that these refusals were not care planned, even though staff stated the resident’s preferences and refusals should have been reflected in the care plan. The facility also failed to develop care plans for other identified care areas. Resident #09, a female with CVA, dysphagia, anemia, memory impairment, and limited range of motion to the upper and lower extremities on one side, had no care plan for limited ROM despite the MDS and observation showing right-sided hemiplegia. Resident #98, a female with dementia, bipolar disorder, and type II diabetes, had an annual MDS that coded wandering 1 to 3 days a week with risk for entering dangerous places, but no wandering care plan was present. Resident #108, a female with dementia, history of falls, and unsteadiness on feet, had a quarterly MDS showing severe cognitive impairment and a fall since the last assessment, and the facility incident log documented falls on 10/11/2025 and 12/08/2025, but no fall care plan was developed or implemented for those events. The MDS Coordinator stated she was responsible for creating care plans and acknowledged that these care areas should have been care planned.
Failure to Act on Pharmacy GDR Recommendations
Penalty
Summary
The facility failed to act on pharmacy consultant recommendations related to drug regimen review for three residents. For one resident with anxiety, depression, and chronic migraine, the quarterly MDS showed she was cognitively intact and receiving an antianxiety medication, an antidepressant, and an anticonvulsant. Her physician orders included alprazolam at bedtime for anxiety, oxcarbazepine twice daily for mood stabilization, and trazodone at bedtime for insomnia. The consultant pharmacist recommended gradual dose reductions for oxcarbazepine and trazodone, and later recommended a trial discontinuation of alprazolam after a short continuation period, but the NP marked the recommendations as disagree with the notation that the patient would not agree. Record review and interviews showed there was no documentation that the resident was educated about the medication reductions or that the conversation was documented. The resident stated she did not remember who spoke with her about her medications and said she did not agree or disagree to any reduction or discontinuation. The NP stated the resident would not agree to lowering or stopping the medications, but also stated she did not document the conversation she had with the resident. Facility leadership stated they expected documentation of the resident’s refusal and education regarding the medications, and they identified that the purpose of a GDR was to determine whether the lowest effective dose was being used or whether a medication could be discontinued. For another resident with Alzheimer’s disease, COPD, and anxiety, the MDS showed severe cognitive impairment and no coded behaviors or episodes of anxiety. The resident had a PRN lorazepam order, and the pharmacist noted that PRN psychotropic orders are limited to 14 days unless the prescriber documents the need for extension and duration. The ADON stated the resident had GDRs for PRN lorazepam in October and March but could not find proof that the MD responded to the request to discontinue the medication and had no documentation of follow-up attempts. For a third resident with dementia, history of falls, and unsteadiness on feet, the MDS showed severe cognitive impairment, no behaviors coded, and daily antipsychotic use. The pharmacist recommended decreasing Zyprexa from 5 mg daily to 2.5 mg daily to ensure the lowest effective dose, but the dose remained unchanged on the MAR across multiple months, and behavior monitoring showed zero episodes of behaviors during those months. The ADON and NP stated the resident had been on Zyprexa for dementia and that the family had not been spoken to about the pharmacist’s request, while the family stated they were never contacted about the dose reduction request.
Failure to Consistently Offer Evening Snacks
Penalty
Summary
Meals and snacks were not consistently served at times in accordance with residents’ needs, preferences, and requests, and suitable, nourishing alternative snacks were not reliably provided outside of scheduled meal times for 5 of 5 residents reviewed for snacks. The facility failed to offer an evening nourishing snack routinely on 4/5/2026 to 4/6/2026. Residents interviewed stated that snacks were often left at the nurse station and that they had to get them themselves, which was not always possible for residents who were unable to get out of bed or travel to the nurse station. During confidential interviews, one resident stated that staff left snacks at the nurse station and residents had to get them, but not all residents were able to get out of bed to do so and not every resident was offered evening snacks. Another resident on Hall 100 said staff did not always ask if she wanted a snack in the evening and that staff placed snacks at the nurse station. A resident on Hall 100 said staff had not offered bedtime snacks and that she sometimes kept crackers in her drawer because she was unsure whether snacks were put out in the evenings. A resident on Hall 500 said she did not recall being offered snacks but kept snacks in her room. A resident on Hall 200 said staff did not offer him bedtime snacks and that he could not make his way to the nurse’s station because he was bedbound. Staff interviews showed inconsistent responsibility for offering and distributing snacks. A CNA said residents should get evening snacks and that kitchen staff brought snack trays to the nurse station, but nurses or CNAs passed them out only if they were not too busy. An RN said snacks were placed at the nurse’s station after every meal and that nurses and aides were responsible for passing them out, while the Dietary Supervisor said snacks were placed at the nurse station at 10 AM, 2 PM, and 7 PM and that nurses were responsible for passing them out. The DON stated all nurses should be offering snacks at night, and the ADM stated CNAs were responsible for offering evening snacks. The facility policy stated that bedtime snacks would be provided each night for all residents, including residents with puree diets, and that nursing staff should reference the diet order list before passing foods to residents.
Inappropriate Incontinence Check Compromised Resident Dignity
Penalty
Summary
The facility failed to treat Resident #108 with respect and dignity when a CNA used inappropriate techniques to check the resident for possible incontinence. Resident #108 was an [AGE]-year-old female with dementia, a history of falls, and unsteadiness on feet. Her quarterly MDS showed a BIMS score of 03, indicating severe cognitive impairment, and she required substantial assistance with toileting and showers, supervision for dressing and personal hygiene, and daily antipsychotic medications. Her care plan identified an ADL deficit related to dementia and stated she required 1 staff assistance with ADL care. A family-provided video showed the CNA patting and squeezing Resident #108's buttock through her clothing for less than 30 seconds. During interview, the CNA stated she did not recall doing so, but said if she had, it might have been to check for wetness of the resident's clothing and acknowledged there were better ways to check. The resident's family member stated the resident would have been furious from embarrassment if she were not stricken with dementia and felt the interaction was inappropriate and baby-like. The DON stated this was not regular practice and that touching a resident's buttock to check for incontinence could make the person feel inferior or less than an adult, and the Administrator stated staff education on resident rights would cover checking residents for incontinence while maintaining dignity.
Unnecessary Psychotropic Medication Use and Missing PRN Stop Date
Penalty
Summary
The facility failed to ensure Resident #23’s drug regimen was free from unnecessary psychotropic medication use because the resident had an active PRN order for lorazepam 0.5 mg every 12 hours as needed for anxiety with a start date of 02/02/26 and no end date listed. Resident #23’s quarterly MDS dated 04/23/26 showed a BIMS score of 14, indicating intact cognition, and she was able to make herself understood and understand others. The facility’s policy stated that PRN psychotropic medications ordered for 14 days should have a stop date and then be evaluated by the physician to determine whether continued scheduling was needed. The facility also failed to ensure psychotropic medication use for Resident #108 was supported by adequate clinical justification. Resident #108 had dementia, a history of falls, and unsteadiness on feet, and a quarterly MDS showed a BIMS score of 03 with no behaviors coded. The resident received daily Zyprexa 5 mg at bedtime throughout February, March, April, and part of May 2026, and the behavior monitoring records showed 0 episodes of behaviors during those months. The care plan identified the medication as being for a mood disorder, and the record review did not show documented behavioral symptoms supporting the ongoing antipsychotic use. During interviews, facility staff stated that Resident #108 had come to the facility on Zyprexa and that a GDR had been recommended by the pharmacist, but the NP had not agreed to the reduction. The ADON stated she was unaware of any nonpharmacological interventions that had been tried and said the resident had only a brief period of swatting at staff during care, with no behaviors that were a danger to herself or others. The NP stated the resident was on Zyprexa for dementia-related behaviors, including resisting care and attempting to bite when she did not want to bathe, and acknowledged that other medications with less serious side effects could be tried. The DON stated antipsychotics are not recommended for residents with dementia who do not have behaviors that are potentially dangerous to themselves or others and identified nonpharmacological interventions that could have been used.
Failure to Provide Contracture Management for Bilateral Hand ROM
Penalty
Summary
The facility failed to ensure Resident #107 received appropriate treatment and services to prevent further decrease of range of motion for her bilateral hand contractures. Resident #107 was an elderly female with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting her right dominant side, contracture of the left hand, contracture of the right hand, unspecified dementia, and pain in both hands. Her MDS indicated unclear speech, severe communication limitations, memory problems, impairment on one side of her upper and lower extremities, and substantial to maximal assistance with eating. Record review showed the care plan identified deficits related to dementia, impaired balance, limited mobility, stroke with left-sided hemiplegia, and left hand contractures, but the interventions did not include a contracture prevention device. The care plan also identified carpal tunnel syndrome and osteoarthritis with edema to the right arm at times, but again did not include a contracture prevention device. Physician orders reviewed did not address the right- or left-hand contractures. During observation, Resident #107 was in bed with her left hand contracted and no carrot, splint, or brace in place on the left hand. Her right hand was initially covered by the blanket, and later observation showed a splint on the right hand, while the left hand still had no splint, brace, or carrot. Staff interviews showed inconsistent understanding of responsibility for contracture devices and documentation. The DOT stated therapy had worked with the resident and that nursing was responsible for splints after therapy, but also said the left hand could not be splinted because it was too painful and difficult, and the right-hand splint had been on back order for months. ADONs stated the resident had not had a splint or brace in either hand for months and agreed there were no splints in place during the survey. One ADON said the resident should have orders for splints, carrots, or braces to prevent worsening contractures, while another said there had been miscommunication between therapy and nursing. Therapy documentation reviewed indicated no recent change or deficit and stated contractures were managed by nursing staff. An OT evaluation and plan of treatment later documented goals for a right resting hand splint and washcloth or carrot to the left hand, and noted the resident was being seen to assess current splint use and possible decrease in ROM in both hands.
Unsecured Chemicals Left in Resident Room
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents for Resident #29 by allowing hydrogen peroxide and Isopropyl Alcohol 50% to remain unsecured in the resident’s room. Resident #29’s record showed diagnoses including Alzheimer’s disease, COPD, and hypothyroidism, and a Quarterly MDS indicated the resident was understood and understood others with a BIMS score of 15, indicating cognitive intactness. The care plan revised on 01/14/26 identified an ADL self-care performance deficit related to Alzheimer’s and impaired balance. During an observation on 5/4/26 at 10:16 a.m., a bottle of hydrogen peroxide and Isopropyl Alcohol 50% was found in Resident #29’s room while the resident was not present. On 5/5/26 at 9:00 a.m., the chemicals were still in the room, and the resident was uninterested in discussing them during an attempted interview. The Acting DON stated on 05/07/2026 that residents should not have hydrogen peroxide or Isopropyl Alcohol 50% in their rooms and that these items should be stored in a medication cart or medication room. The Administrator also stated that residents should not have these chemicals in their rooms and that medications or medically related chemicals should be stored in medication rooms or medication carts. The facility policy on Delivery, Receipt, and Storage of Medication stated that only authorized facility staff should have access to medication storage areas.
Improper Catheter Securement and Incontinent Care
Penalty
Summary
The facility failed to ensure appropriate care for residents with bowel and bladder incontinence and failed to provide appropriate catheter care for a resident with a suprapubic catheter. The report identified deficiencies involving two residents reviewed for urinary and bowel incontinence. One resident had diagnoses including obstructive and reflux uropathy and acute cystitis, had a suprapubic catheter order with catheter care every shift, and was assessed as having moderate cognitive impairment and an indwelling catheter. Another resident was admitted with diagnoses including metabolic encephalopathy, diabetes, hypertensive heart disease with heart failure, hyperlipidemia, and muscle weakness, and was documented as always incontinent of bowel and bladder and requiring substantial to maximal assistance with ADLs. For the resident with the suprapubic catheter, staff observed catheter tubing with a dependent loop below the drainage bag and yellow urine with sediment collecting in the loop. The catheter was not secured to the resident’s leg, and no catheter securement device was in place at the time of observation. The LVN performing catheter care acknowledged that the securement device had been missing earlier and stated she waited to replace it until catheter care so she could do it all at once. The acting DON and Administrator both stated the catheter should have been secured and noted the risk of dislodgement. For the incontinent resident, staff observed two CNAs providing perineal care after a bowel movement, but feces remained in the vaginal area before a new brief was applied. One CNA used the same wipe after folding it and continued wiping, and the other CNA cleansed the bottom in a downward direction. During the re-assessment, the DON removed feces from the vaginal area. Interviews with the CNAs showed they believed the resident was clean before the brief was placed and that staff were trained differently, while other nursing staff and administration stated proper care required wiping front to back, ensuring the perineal area was clean, and using correct technique before applying a clean brief.
Ordered labs not obtained for resident with CAD and hypercholesterolemia
Penalty
Summary
The facility failed to provide or obtain ordered laboratory services for Resident #108, who was admitted with diagnoses of dementia, history of falls, and unsteadiness on feet and had severe cognitive impairment on the quarterly MDS. The resident also had coronary artery disease and hypercholesterolemia, and the care plan reflected these conditions. Physician orders dated May 2026 included a BMP, lipid panel, and liver panel every 3 months, but record review of the EHR on 05/06/2026 showed no lab results for any of these ordered tests. During interview, the ADON stated the lab had recently been integrated with the EHR and that the lab was automatically notified when labs were due, but she could not find any results for the resident’s BMP, lipid panel, or liver panel. She reported calling the lab and being told there were no results for those tests, and stated the missing labs may have been related to the integration of the lab system and EHR. The ADON said it was her job to track lab orders and results and that she must have overlooked Resident #108 when auditing the labs. The DON stated she expected labs to be obtained as ordered and said the missing labs were likely an oversight during the transition from manual to automatic lab requisitions.
Infection Control Failures With Tube Feeding Syringe and Catheter Bag
Penalty
Summary
The facility failed to maintain an infection prevention and control program for two residents. For one resident with diagnoses including Autistic Disorder, intermittent asthma, and dysphagia, record review showed the resident required tube feeding. During observation, a feeding tube syringe was found lying on the bedside dresser with a dried white substance on the tip and condensation inside the syringe, and it had not been stored inside a bag. The resident was unintelligible during the attempted interview. The Acting DON and the Administrator stated that used tube feeding syringes should be either thrown away or stored in a bag, and that nurses were responsible for ensuring proper storage or disposal. For another resident with obstructive and reflux uropathy and acute cystitis, record review showed an order for a suprapubic catheter and catheter care every shift, including checking that the stabilization device was in place. The resident’s care plan identified him as at high risk for continuous UTIs. During observation, the resident was lying in bed with the urinary catheter bag on the floor, and a later observation showed the bag was still on the floor. The ADON stated the catheter bag should have been hung on the bed frame and not on the floor, and the Acting DON stated she found the bag on the floor and fixed it. The facility policy for indwelling urinary catheter care stated the drainage bag should be kept below the level of the bladder and off the floor at all times to prevent contamination and damage. The facility also provided an undated tube feeding policy that did not describe how to properly store or dispose of tube feeding syringes after use. The observations, record review, and staff interviews showed that the syringe and catheter bag were not maintained in accordance with the facility’s infection control practices.
Antibiotic Stewardship Failure With Prophylactic Antibiotic Orders
Penalty
Summary
The facility failed to promote antibiotic stewardship by allowing two residents to remain on prophylactic antibiotic therapy without documented written rationale from the provider supporting the use of the antibiotics. Resident #16 had diagnoses including neuropathic bladder and neurocognitive disorder, and her care plan identified prophylactic antibiotic therapy. Her order summary showed cephalexin 500 mg by mouth once daily for urinary prophylaxis, started on 02/02/26, with no end date. Resident #68 had diagnoses including dementia and neuromuscular dysfunction of the bladder, and her care plan also identified prophylactic antibiotic therapy related to UTI. Her order summary showed Macrobid 100 mg by mouth once daily for prophylaxis, started on 03/25/26, with no end date. During interview, the ADON stated both residents were taking prophylactic antibiotics and said they had a history of recurring UTIs, which she felt was a proper indication for the orders. The Acting DON stated she was not a fan of starting any antibiotic without a culture and said the facility was working with nurses to speak with physicians regarding prophylactic antibiotics; she also stated the risk was that it could be an unnecessary medication for an unknown organism. The Administrator stated both residents should not have been on prophylactic antibiotics and said the risk was that it could create a resistant or super bug bacteria. The facility policy on Antibiotic Stewardship stated appropriate indications for antibiotic use include criteria met for active infection or suspected sepsis and pathogen susceptibility based on culture and sensitivity, or therapy begun while culture is pending.
Failure to Ensure Respectful and Dignified Treatment of a Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was treated with respect and dignity in accordance with resident rights. The resident was an older male with prostate cancer, secondary bone cancer, and brain cancer, who had moderately impaired cognition (BIMS score of 7), was always incontinent of bowel and bladder, had moderately impaired vision, and required substantial/maximal assistance with all ADLs. His care plan included interventions to ensure and promote self-esteem and dignity during ADL care and to praise all efforts at self-care. Despite this, the resident reported multiple negative incidents with night-shift CNAs, stating that one CNA consistently talked badly to him, including comments such as “you peed all over yourself, you know better than that” and “you got yourself down there, you can get yourself up” after he rolled off the bed onto a mattress on the floor. He stated this made him feel bad and that he did not complain to facility administration because he feared his treatment would worsen. A grievance filed by a responsible party documented that during a visit, staff entered the resident’s room around 8:00 p.m. without announcing their names or purpose, instructed the resident to turn toward the wall, and commented about how he had urinated and soiled the covers and that he knew what he was doing when he put himself on the floor. The grievance also stated that the resident told the responsible party that aides frequently spoke to him in this manner but that he wanted to “keep the peace.” The grievance form recorded that, when interviewed, the resident reportedly stated the aides “cut up” with him, that he did not feel mistreated, and that some aides were short with him but most would stay and talk. However, during subsequent interviews, multiple responsible parties (RPs E, F, and G) reported that the resident frequently complained to them about staff being rude or rough, talking to him like a “drill sergeant,” and making comments that he knew what he was doing when he rolled out of bed or urinated in bed. One responsible party reported witnessing CNAs enter without knocking or announcing themselves, speak in a rude and disrespectful tone, and tell the resident he had to get back into bed before they would change him. Additional information from staff and another resident further supported concerns about disrespectful interactions. CNA A stated that the resident had previously complained to her that night-shift CNAs were rude to him; she did not report this to administration, instead telling a charge nurse who later left the facility. CNAs C and D, who worked night shift, denied being rude or witnessing rude behavior, and CNA C stated she could not change the resident when he was on the mattress on the floor due to her own injuries. An anonymous resident on the same hall reported that night-shift CNAs had been rude and disrespectful to them but declined to provide details or names. The DON and ADM both stated they had not been informed of prior complaints about rude treatment toward this resident. The facility’s written Statement of Resident Rights affirmed the resident’s right to be treated with courtesy, consideration, and respect, which was not upheld in the described interactions and unreported complaints.
Failure to Follow Two-Person Assistance Care Plan During Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to implement a comprehensive, person-centered care plan requiring two staff to be present for all care provided to a bedfast resident with significant physical impairments. The resident was an elderly female with hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, and a contracture of the left hand. An MDS assessment documented that she did not speak and required substantial assistance for all functional needs, including toileting, hygiene, transfer, and dressing. Her care plan dated 11/25/2025 specified that she was bedfast and required two staff to assist with all personal care needs, including bathing, toileting, bed mobility, dressing, eating, and transfers. A progress note from the same date indicated she required two people to assist with toileting, and an ADL sheet in the nurse’s station binder stated that two people were to be in the room any time care was provided. On one occasion, video footage from the resident’s room showed that a CNA performed incontinent care alone, contrary to the care plan. The video from 1/7/2026 at 2:31 p.m. showed CNA B completing incontinent care while the resident’s bed was raised and pulled away from the wall. CNA B adjusted a fabric incontinent pad under the resident while she was rolled on her right side, then rolled her onto her back, placed a pillow under her legs, and positioned a wedge pillow by her right side. The only other person present in the room was a visitor seated against the opposite wall, who did not assist with care and was observed watching and using a phone. A grievance/concern report documented that the DON recorded information that CNA B had conducted incontinent care by herself on that date after the resident’s family member yelled at her to change the resident and threatened to call the State if she did not. On another occasion, video footage showed a second CNA also providing incontinent care alone, again in conflict with the resident’s care plan. The video from 1/10/2026 at 3:49 p.m. showed CNA C performing incontinent care with the bed raised and against the wall. CNA C unfastened the resident’s incontinent brief, placed it between the resident’s legs, then placed her hands behind the resident’s knees and pulled her toward herself to push the brief under her. CNA C rolled the resident onto her right side toward the wall and held her in that position with one hand while completing the care. No other staff were present in the room assisting with care. In interviews, the LVN and DON confirmed that the care plan required two staff to be in the room for any tasks for this resident and that it would not be appropriate to complete a two-person task alone, as the directive in the care plan was for resident safety.
Failure to Lock Bed Wheels During Resident Care
Penalty
Summary
Certified Nursing Assistants (CNAs) A and B failed to lock the bed wheels of an 81-year-old female resident before raising her bed, performing peri-care, and repositioning her in bed. The resident, who had a history of hemiplegia, hemiparesis, generalized muscle weakness, osteoarthritis, dementia, and aphasia, was completely dependent on staff for all activities of daily living, including transfers and toileting. The care plan for this resident identified her as being at risk for falls and required adherence to the facility's fall protocol. During an observed episode of care, the CNAs unlocked the bed wheels to move the bed away from the wall and then proceeded to raise the bed and provide incontinent care without relocking the wheels. While turning the resident from side to side and repositioning her using a draw sheet, the bed remained unlocked and moved gently as the care was provided. Both CNAs later acknowledged during interviews that they had forgotten to lock the bed wheels and recognized that this was not in accordance with safety protocols. Interviews with the Director of Nursing (DON), a Licensed Vocational Nurse (LVN), and the facility Administrator confirmed that staff are expected to lock bed wheels before providing care or repositioning any resident in bed. The facility's policy on routine resident care also states that equipment with wheels should be in the locked position when not being moved. The failure to lock the bed wheels during care constituted a deficiency in maintaining a resident environment free from accident hazards and providing adequate supervision to prevent accidents.
Failure to Provide Timely Dialysis Port Care
Penalty
Summary
The facility failed to ensure that a resident requiring hemodialysis received care consistent with professional standards and the resident's care plan. Specifically, the facility did not remove the dialysis port dressing as ordered by the dialysis center on multiple occasions, despite repeated instructions from the dialysis center to remove the dressing within 2-4 hours after dialysis. Documentation from the dialysis center indicated that the bandages were not removed by facility staff before the resident's next dialysis treatment, and this issue was communicated to the facility several times through written notes and direct notifications to the charge nurse. The resident involved had end stage renal disease, type 2 diabetes, and schizophrenia, and was cognitively intact. The care plan included monitoring the dialysis access site for signs of infection and encouraging attendance at dialysis appointments, but did not include specific interventions for removing or changing the port-access dressings. Multiple records from the dialysis center documented that the dressings were left in place, sometimes covered with additional dressings, leading to swelling, pain, bleeding, and skin damage at the access site. The dialysis center staff reported providing education to the facility staff about the importance of timely dressing removal, but the problem persisted over several weeks. Interviews with facility staff revealed inconsistent understanding of the procedures for dialysis port care. Some nurses stated that the dressing should be removed and the port left open to air after dialysis, while others were unsure about the correct protocol. Several staff members did not know the resident or were not aware of the specific requirements for dialysis port care. The facility's policy referenced providing routine AV shunt care per physician orders, but the observed practice did not align with the instructions provided by the dialysis center.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for three residents, leading to a deficiency in accommodating resident needs and preferences. Resident #64, who had hemiplegia, hemiparesis, and an acquired absence of the left leg above the knee, was observed without a reachable call light. Despite being totally dependent on staff for most activities of daily living (ADLs) and having moderate cognitive impairment, Resident #64's call light was draped over the foot of the bed, making it inaccessible. The resident reported having to holler for assistance when the call light was out of reach. Similarly, Resident #74, who had anxiety, depression, stroke, and hemiplegia, was found with a call light draped over the head of the bed, out of reach. This resident also required substantial assistance for ADLs and was at risk for falls. During observations, the call light was found on the floor, and the resident expressed difficulty in reaching it, resorting to calling out for help. The care plan for Resident #74 included the use of a call bell for assistance, yet the call light was not consistently accessible. Resident #76, diagnosed with morbid obesity, diabetes, stroke, and hemiplegia, also experienced issues with call light accessibility. Despite requiring substantial assistance for ADLs and being at risk for falls, the call light was observed on the floor or draped over the foot of the bed, out of reach. Interviews with staff, including CNAs, LVNs, and the DON, revealed a consensus that call lights should be within reach, yet this was not consistently ensured. The facility's policy and recent in-service training emphasized the importance of call light accessibility, but these measures were not effectively implemented for the residents involved.
Excessive Door Alarm Disrupts Residents' Environment
Penalty
Summary
The facility failed to maintain a homelike environment for residents on Hall 200 due to a malfunctioning exit door alarm. Observations on multiple occasions revealed that the exit door near the designated smoking area and laundry was not functioning correctly, causing it to alarm excessively. This issue was noted on several dates, with the alarm sounding when staff members entered or exited the door, and it was only silenced when another staff member securely shut the door. The persistent noise from the alarm was reported to be disruptive to residents, affecting their sleep and meals. Interviews with residents and staff highlighted the extent of the problem. Residents expressed frustration with the constant noise, describing it as annoying and disruptive to their daily lives. Staff members, including a CNA and an LVN, confirmed that the alarm had been a persistent issue, with the CNA noting that the problem had been ongoing since at least February 2025. The Maintenance Supervisor acknowledged that the door had intermittent issues for the last four months, and despite attempts to fix it, the problem persisted until a company was called to address it. The facility's administration was aware of the issue, with the Administrator and the VP of Operations acknowledging the excessive alarming of the Hall 200 exit door. They noted that the maintenance staff had been attempting to resolve the issue through trial and error. Despite these efforts, the excessive noise continued to affect residents' quality of life, as confirmed by the facility's Quality Assurance and Performance Improvement policy, which emphasized the importance of maintaining comfortable sound levels for residents.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for multiple residents requiring oxygen therapy, as evidenced by several specific deficiencies in the handling and maintenance of respiratory equipment and adherence to physician orders. One resident's nasal cannula was found improperly stored in a trashcan, which the resident denied placing there, and a CNA confirmed that cannulas should be stored in a bag when not in use to prevent infection. The responsibility for proper storage was acknowledged by both CNAs and nursing staff. Another resident's oxygen concentrator was observed with a thick layer of dust on the external filter, which became airborne when touched, indicating that the filter had not been cleaned as required. Additional residents were found with oxygen concentrator filters containing white, fuzzy particles, suggesting a lack of regular cleaning and maintenance. Staff interviews confirmed that nurses were responsible for cleaning external filters weekly, and that unclean filters could negatively impact residents' health. There was also a failure to ensure that oxygen was administered at the correct flow rate as ordered by the physician. One resident was observed receiving oxygen at 5 liters per minute (LPM) instead of the ordered 2 LPM, and staff were unaware of the discrepancy until it was pointed out. Interviews with nursing staff and administration confirmed that nurses were responsible for checking oxygen settings every shift and for educating residents and families about not adjusting oxygen settings. The care plans and medical records for some residents did not consistently reflect current oxygen orders or interventions, further contributing to the deficiencies.
Medication Storage, Narcotic Count, and Hold Parameter Deficiencies
Penalty
Summary
The facility failed to ensure proper pharmaceutical services and medication management in several key areas. In the medication storage room, expired over-the-counter medications and expired Lorazepam vials were found, indicating that medications were not being routinely checked and removed after expiration. The Director of Nursing (DON) acknowledged responsibility for removing expired medications but had not done so, and central supply was also cited as responsible for expired over-the-counter medications. This lapse resulted in expired drugs being accessible in the facility’s medication storage areas. Additionally, the facility did not maintain accurate narcotic counts for a resident prescribed Belsomra 10 mg for insomnia. During a medication cart review, a discrepancy was found between the documented and actual number of tablets remaining. The nurse on duty did not identify the off count during her shift and was unaware of the reason for the discrepancy, later stating that the medication may have been signed out but not administered. This error was not detected until after the fact, and the nurse responsible for the previous shift was not present to clarify the situation at the time of discovery. The facility also failed to ensure that a resident receiving Midodrine for hypotension had appropriate hold parameters for blood pressure documented in the physician’s order and Medication Administration Record (MAR). The order for Midodrine did not specify under what blood pressure conditions the medication should be held, and the MAR reflected that doses were held for parameters not met, but without clear documentation of what those parameters were. Nursing staff and the DON confirmed that hold parameters should have been obtained and documented, but this was not done at the time of the deficiency.
Failure to Securely Store Medications and Biologicals
Penalty
Summary
Surveyors identified that the facility failed to ensure all drugs and biologicals were stored in locked compartments in accordance with state and federal laws for five residents. Multiple medications, including Benadryl cream, Neosporin, Systane eye drops, Oxymetazoline nasal spray, Visine eye drops, and chlorhexidine gluconate skin cleanser, were found unsecured in residents' rooms or on bedside tables. In several cases, these medications were not ordered by a physician, and there was no documentation of a self-administration assessment or care plan authorizing residents to keep medications at bedside. Residents involved had varying degrees of cognitive impairment, as indicated by their BIMS scores and care plans. For example, one resident with moderate cognitive impairment had Benadryl and Neosporin at her bedside, while another with severe cognitive impairment had Visine eye drops accessible. In another instance, a resident's representative brought in a nasal spray and left it in the room without notifying staff, and a medication cup with an unidentified white powdery substance was also found. Staff interviews confirmed that these medications should not have been left unsecured and that proper assessments and orders were lacking. Facility policy required that self-administration of medications be assessed by the interdisciplinary team, with physician orders and secure storage in compliance with regulations. However, interviews with nursing staff, the ADON, DON, and Administrator revealed inconsistent understanding and implementation of these policies. Staff acknowledged that medications and skin cleansers should not be left in resident rooms without proper authorization and secure storage, and that it was the responsibility of all staff to ensure compliance. The lack of secure storage and proper documentation placed residents at risk for adverse reactions or overdose, as noted in the findings.
Failure to Support Resident Choice for Out-of-Bed Assistance
Penalty
Summary
The facility failed to promote and facilitate resident self-determination by not assisting a resident, who was dependent on staff for most activities of daily living, to get out of bed as often as he preferred. The resident, who had hemiplegia, hemiparesis, an above-the-knee amputation, and depression, expressed a desire to be gotten out of bed daily and reported that staff told him they were too busy to assist him. Multiple observations over two days confirmed the resident remained in bed despite his requests to get up, and there was no documentation in his progress notes indicating that offers were made or that he refused assistance. Interviews with staff revealed inconsistent accounts regarding the resident's preferences and refusals, with some staff stating he did not ask to get up or refused when offered, while others acknowledged he normally asked to get out of bed. The care plan indicated the resident wanted to be up as soon as possible, but staff did not consistently honor this preference. Facility leadership confirmed that staff should be offering residents the choice to get out of bed and recognized the potential negative outcomes of not doing so. The facility's operations manual also emphasized the right of residents to make choices about their daily lives.
Inaccurate MDS Medication Coding for a Resident
Penalty
Summary
The facility failed to ensure that a resident's Minimum Data Set (MDS) assessment accurately reflected the medications administered during the assessment period. Specifically, the MDS for one resident did not indicate the use of an anticonvulsant (Gabapentin) or a hypoglycemic medication (Ozempic), despite both being prescribed and administered as documented in the resident's medical records and Medication Administration Record (MAR). The resident had diagnoses including Type 2 diabetes and multiple sclerosis, and was receiving Gabapentin for insomnia and Ozempic for diabetes management. Interviews with facility staff revealed that the MDS Coordinator was responsible for coding the MDS assessments and care plans. The MDS Coordinator acknowledged coding Ozempic as an injection but was unsure if it should also be coded as a hypoglycemic medication. She also associated Gabapentin with nerve pain rather than its pharmacological classification as an anticonvulsant, despite recognizing that the MDS should be coded by drug class. The Director of Nursing (DON), Administrator, and Corporate MDS Coordinator all confirmed that the medications should have been coded according to their pharmacological classifications on the MDS. The facility's policy requires that MDS assessments be completed and coded per the Resident Assessment Instrument (RAI) manual, based on clinical assessments and interventions. The failure to accurately code the resident's medications on the MDS assessment was confirmed through record review and staff interviews, indicating a lapse in following established procedures for accurate resident assessment documentation.
Failure to Provide Timely ADL Assistance and Personal Hygiene Care
Penalty
Summary
The facility failed to provide necessary services to maintain personal hygiene for two residents who were dependent on staff for activities of daily living (ADLs). One resident, an elderly female with chronic obstructive pulmonary disease, cerebral infarction, muscle weakness, and moderate cognitive impairment, was left in a urine-soaked brief for extended periods. She reported that after activating her call light, a CNA would turn it off and state they would return later, but did not come back in a timely manner. The resident described feeling red, chafed, and uncomfortable due to the delay in care. Staff interviews confirmed that the CNA prioritized other tasks, such as picking up meal trays, over changing the resident's wet brief. Another resident, also an elderly female with cerebral infarction, anemia, hyperlipidemia, and moderate cognitive impairment, was observed with long facial hair and stated she did not recall when she was last shaved. She expressed that the facial hair bothered her and that she would like to be shaved. Despite this, observations over several days showed that her facial hair remained unshaven. A CNA interviewed was unsure if the resident refused care and admitted to not asking or attempting to shave her, even though it was the responsibility of CNAs to provide such grooming assistance for dependent residents. The facility's policy on ADLs requires that residents unable to perform these tasks independently receive appropriate support for hygiene, grooming, and personal care. Interviews with the DON and Administrator confirmed that staff are expected to ensure residents are not left in wet briefs and that grooming needs, such as shaving, are addressed for those dependent on care. The failure to provide timely and adequate assistance with ADLs for these residents was directly observed and confirmed through staff and resident interviews.
Failure to Provide Proper Catheter Care and Maintain Catheter Bag Position
Penalty
Summary
A deficiency occurred when a resident with a suprapubic catheter did not receive appropriate catheter care as required by physician orders and facility policy. The resident's catheter bag was observed to be completely full, with urine backing up into the tubing, and the bag was found lying on the floor rather than being properly secured. The bag was so heavy that it could not be hung on the bed frame, and the resident was unaware of the situation until it was brought to her attention. Staff interviews confirmed that the catheter bag should have been emptied every shift and that its condition indicated it had not been emptied as required. The care plan and medical orders specified regular catheter care and monitoring, but documentation showed that as-needed catheter care had not been provided. Staff, including a CNA, LVN, and the DON, acknowledged that the catheter bag should not have been left full or on the floor, and that such conditions could lead to cross-contamination and infection. The facility's policy required catheter bags to be kept off the floor and emptied at least every eight hours. The failure to follow these protocols resulted in the resident's catheter bag becoming excessively full and improperly positioned, directly leading to the cited deficiency.
Lack of Comprehensive Physician Orders for Feeding Tube Management
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent complications for two residents with feeding tubes. Specifically, both residents did not have physician orders specifying the volume, frequency, and type of flush to administer via the feeding tube. Additionally, there were no physician orders for the frequency of cleaning and care of the feeding tube site, the frequency of residual checks to assess gastric emptying, or the frequency of checking tube placement. These omissions were identified through record reviews and interviews with staff, who confirmed that such orders were necessary and should have been obtained upon admission or readmission. One resident was a female with severe protein-calorie malnutrition, gastrostomy status, and dysphagia, who was dependent on tube feeding and water flushes. Her physician orders included nocturnal tube feeds and water flushes but lacked details on flushes before and after feeding, site cleaning, residual checks, and placement verification. Another resident, a male with dysphagia, feeding difficulties, and dementia, also required tube feeding due to weight loss. His orders included the type and rate of tube feeding but similarly omitted essential details regarding flushes, cleaning, residual checks, and placement verification. Interviews with nursing staff and facility leadership revealed that the admitting nurse was responsible for obtaining feeding tube orders, and nursing management was expected to audit these orders for accuracy. Staff acknowledged the importance of having specific physician orders to ensure safe and consistent care, especially given the use of agency staff who may not be familiar with facility protocols. The facility's own policy and external clinical guidelines both emphasized the need for physician orders covering all aspects of feeding tube management, which were not present in these cases.
Unnecessary Prophylactic Antibiotic Use Without Adequate Indication or Monitoring
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically by administering Nitrofurantoin Macrocrystal as a prophylactic antibiotic without adequate indication. The resident, an elderly female with neuromuscular dysfunction of the bladder, chronic kidney disease stage 3, an indwelling catheter, and severe cognitive impairment, was prescribed and received Nitrofurantoin daily for prophylactic purposes over an extended period. Documentation showed that the antibiotic was started months prior and continued despite the resident's ongoing urinary tract infections and a lack of evidence that the medication was effective in preventing these infections. Interviews with facility staff, including the ADON, LVN, and DON, revealed that the antibiotic was prescribed due to the resident's frequent urinary tract infections associated with her indwelling catheter. Staff acknowledged that the use of prophylactic antibiotics did not meet McGeer criteria for infection management and that the resident continued to experience infections while on the medication. The ADON also noted that the resident was not started on a probiotic, which is typically recommended when a resident is on long-term antibiotics, and could not provide a reason for this omission. The DON and other staff confirmed that the facility generally followed physician orders and McGeer criteria, but in this case, the criteria were not met. The facility's Infection Prevention and Control Program policy emphasized antibiotic stewardship, including the use of medical criteria and standardized definitions for infections, as well as regular reviews of antibiotic usage. Despite these policies, the resident continued to receive a prophylactic antibiotic without adequate monitoring or justification, and the decision to continue the medication was deferred to hospice care after the resident was placed on hospice. Staff interviews indicated awareness of the risks associated with unnecessary antibiotic use, but the medication regimen was not adjusted accordingly.
Failure to Adhere to Enhanced Barrier Precautions During Medication Administration
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically by not ensuring that staff adhered to enhanced barrier precautions (EBP) during care of a resident with a gastrostomy tube. On the observed date, an LVN administered medication via a PEG tube to a resident without wearing the required personal protective equipment (PPE), despite the resident being on EBP due to the presence of an indwelling medical device and risk for multidrug-resistant organisms (MDRO). The resident was a 49-year-old male with multiple complex medical conditions, including cerebral palsy, dysphagia, aphasia, epilepsy, gastroparesis, and a gastrostomy tube, and was dependent on staff for all activities of daily living. Interviews with staff, including the LVN involved, confirmed that PPE was not used during the medication administration, and the LVN acknowledged forgetting to don the required equipment. Other staff members, including CNAs and additional LVNs, demonstrated awareness of the EBP requirements and the importance of PPE use for residents with indwelling devices or wounds. They indicated that the facility had sufficient PPE available and that staff had been in-serviced on EBP and PPE protocols. Facility leadership, including the ADON, DON, and Administrator, confirmed that all staff had been educated on EBP and that PPE should be worn during direct care activities for residents requiring enhanced precautions. The facility's infection prevention and control policy, as well as CDC guidance, were reviewed and supported the need for targeted gown and glove use during high-contact care activities for residents at risk for MDRO transmission. Despite these policies and available resources, the failure to implement EBP during medication administration for the resident constituted a deficiency in the facility's infection control practices.
Failure to Ensure Appropriate Antibiotic Stewardship for UTI
Penalty
Summary
The facility failed to ensure appropriate antibiotic stewardship for a resident with a history of urinary tract infection, severe sepsis with septic shock, and neuromuscular dysfunction of the bladder. The resident, who had an indwelling catheter and moderate cognitive impairment, was prescribed Ciprofloxacin for a urinary tract infection following a hospital visit for a catheter change. The medication was administered as ordered, and the resident received all scheduled doses. However, the hospital urine culture taken at the time of the emergency room visit revealed the presence of Proteus mirabilis, which was resistant to Ciprofloxacin. Despite the availability of these culture and sensitivity results, there was no documentation that the physician was notified of the resistance, and the resident continued to receive an ineffective antibiotic. Interviews with facility staff, including the ADON, DON, and nursing staff, confirmed that the results were not communicated to the physician, and no change in antibiotic therapy was made. The facility's antibiotic stewardship policy required that culture and sensitivity results be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued. The lack of communication and failure to act on the culture results led to the resident receiving an antibiotic that was not effective against the identified organism, contrary to facility policy and best practices for antibiotic stewardship.
Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to provide a resident's medical records to her attorney within the required two working days after a request was made. The request was received on 07/31/2024, but the records were not sent, which could potentially disrupt continuity of care. The resident in question was an elderly female with a history of paroxysmal atrial fibrillation, dementia with behavioral disturbance, and asthma. She was usually able to understand and be understood by others, with a moderate cognitive impairment as indicated by her BIMS score. Upon receiving the request, the facility's HR staff mistook it for a subpoena and contacted corporate HR for guidance. Corporate HR advised that the previous owner was responsible for the records since the resident had been discharged before the current owner took over. The previous owner was contacted and picked up the request on 08/02/2024 but did not send the records, as advised by an attorney friend. The attorney friend suggested waiting due to the statute of limitations, and the previous owner followed this advice, not contacting the law firm directly. The facility's policy states that residents or their legal representatives have the right to access and obtain copies of their records with two working days' notice. However, the facility did not fulfill this obligation, as the request was not processed in a timely manner. The administrator acknowledged that delays could occur when requests are sent to the corporate level for processing, which contributed to the failure to provide the records as required.
Failure to Provide Timely Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for three residents who required oxygen therapy, as per their care plans and physician orders. The deficiency was identified through observations, interviews, and record reviews, which revealed that the oxygen tubing and humidifier bottles for these residents were not changed and dated as ordered. This failure was observed in three residents, each with significant medical conditions requiring consistent respiratory support. Resident #1, who had a history of respiratory failure and other serious health issues, was found with an empty humidifier bottle dated several weeks prior, and her oxygen tubing had not been changed as per the weekly schedule. Similarly, Resident #2, who also required oxygen therapy, reported that her tubing had not been changed in three weeks, despite notifying staff. Her equipment was also dated weeks earlier than the observation date. Resident #3, with a history of COPD and sleep apnea, was found with outdated equipment, and his oxygen concentrator was not operating during the observation. Interviews with nursing staff and the Director of Nursing revealed that the failure to change the equipment was due to a lack of supplies. The staff acknowledged the deficiency but cited supply shortages as the reason for not adhering to the scheduled changes. The facility's policy required weekly changes of the oxygen equipment, but the new person responsible for ordering supplies had not ensured the availability of necessary items, leading to the observed deficiencies.
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Illustrative
What surveyors actually found near you
We read the 94 citations issued within 25 miles in the last 12 months — including the 9 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 Henderson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Henderson Health & Rehabilitation Center | 2 mi | ★★★★★ | 1 | 0 |
| Avir At Overton | 12.8 mi | ★★★★★ | 19 | 1 |
| Arbor Grace Guest Care Center | 14 mi | ★★★★★ | 13 | 1 |
| Willow Rehab & Nursing | 14.3 mi | ★★★★★ | 7 | 0 |
| Highland Pines Nursing Home | 23.5 mi | ★★★★★ | 10 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.