Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Avir At Commerce during CMS and state inspections, most recent first.
Incomplete Care Planning for Dirty Eyeglasses: Three residents with impaired vision had dirty prescription glasses during observation. Two care plans addressed visual aids being clean and in good repair, but one resident’s care plan did not include glasses-cleaning interventions. Staff said cleaning glasses was expected as part of daily care, but it was not specifically assigned on CNA assignments and was not consistently reflected in the care plans.
RN coverage and DON staffing deficiency: The facility failed to maintain an RN on duty for 8 consecutive hours each day and did not have a DON working full time. Record review showed multiple days with no RN hours and several days with less than 8 hours of RN coverage. Interviews confirmed that some RN absences were due to requested time off, early departures, and lack of another RN to provide coverage, and the Administrator acknowledged the facility did not have a DON.
PASRR coordination was not documented for three residents with PASRR-positive status and cerebral palsy. Two residents had care plans and PCSPs recommending habilitation coordination, and one resident also had independent living skills services recommended, but the EMR contained no notes showing these services were provided. Staff interviews confirmed that monthly PASRR-related visits were expected, yet documentation was not being maintained in the residents’ records.
Food safety standards were not followed when unpasteurized eggs were found in the kitchen refrigerator and two residents were served fried eggs, sometimes soft fried with runny yolks. In a separate kitchen observation, a Maintenance Supervisor entered without a hairnet or beard guard, despite staff stating these restraints were required to prevent hair from contacting food.
Smoking Area Safety and Disposal Deficiencies: During a smoke break, five residents were observed in a smoking area with cigarette butts on the ground, trash in the red cigarette butt receptacle, and a malfunctioning self-closing ashtray. Staff interviews showed the DSD, Maintenance Director, Housekeeping Supervisor, ADON, and Administrator were aware the area should be kept clear and the ashtrays functioning, but the facility’s smoking policy requiring metal containers with self-closing cover devices and designated receptacles was not being followed.
A resident with CVA-related ADL deficits and moderate cognitive impairment did not receive scheduled bathing and grooming care. She was observed in bed with oily hair, a white substance in her hair, and jagged fingernails with black debris under them, while records showed multiple missed bath/shower entries. Staff said CNAs were responsible for bathing and nurses were to monitor completion, but a CNA did not document or report the resident’s alleged refusal, and the resident said missing her bath made her feel dirty.
Acetone Left on Resident Dresser: A resident with intact cognition and an ADL self-care deficit had a bottle of 100% pure acetone nail polish remover observed on her dresser. The resident said a family member brought it in, and staff stated acetone should not be in the building or left at bedside and that all staff were responsible for monitoring residents’ bedside items.
Unsecured Foley Catheter: A resident with an indwelling Foley catheter and intact cognition had the tubing found unsecured during repeated observations. After an LPN changed the catheter due to leakage, the tubing was later seen under the resident’s thigh and remained unsecured on subsequent days, despite the care plan and facility policy requiring catheter securement with a leg strap or leg band.
Missing Oxygen Sign Outside Resident Door: A resident with asthma and wheezing had an active order for O2 at 2L via NC PRN for SOB and was observed wearing oxygen in bed while no oxygen sign was posted outside the room door. The LVN, ADON, and Administrator all stated an oxygen sign should have been on the door and that staff were responsible for ensuring it remained posted; the Administrator also stated the facility was out of signs.
Failure to Honor Food Preference: A cognitively intact resident with diabetes and cerebral palsy was served lima beans despite a documented dislike on her tray card. During lunch, she stated she did not like lima beans and should not have received them. The ADON, Dietary Manager, and Administrator all acknowledged the preference should have been followed, and dietary staff said they missed the dislike when preparing the tray.
Hospice Records Not Kept Current: A resident with end-stage Alzheimer’s disease and hospice services had no updated CTI, POC, medication list, or nursing/aide notes in the hospice binder, and the facility did not coordinate hospice care planning or ensure hospice documentation was included in the chart. The RN case manager said hospice coordination was done in person, while the ADON and Administrator acknowledged the binder was not updated with the required hospice information.
Failure to Use EBP PPE During Catheter Care: Staff entered a resident's room, performed hand hygiene, donned gloves, and began catheter care without gowns despite EBP requiring gown and glove use for high-contact care. The resident had an indwelling catheter, bowel incontinence, and diagnoses including Alzheimer's disease, BPH, and CKD. Interviews showed one CNA was not trained on PPE for this resident, another forgot to wear PPE, and the ADON and Administrator stated staff were expected to use EBP PPE for direct care.
A resident’s room had a damaged windowsill with a visible hole, separated wood, and exposed inner material at resident height. The resident said the issue had been present since move-in and had been reported in TELS, while the Maintenance Supervisor said he had known about it for a while, had previously patched it, and had not completed the repair. The ADON and Administrator said they were not aware of the problem until recently.
The facility did not provide enough CNAs on night shifts to meet the staffing ratio outlined in its facility assessment, resulting in only one CNA being present for a resident census that exceeded 30. Staff reported delays in care, use of mechanical lifts without proper assistance, and management awareness of the ongoing staffing shortages. The DON and Administrator confirmed that staffing levels were below the planned ratios, and time sheets supported that only one CNA was scheduled during affected shifts.
A resident with Parkinsonism and mental health diagnoses, who was cognitively intact and required significant assistance, was not treated with dignity when a CNA spoke loudly and patted the resident's hand during care. The CNA admitted to making pressuring statements to residents, and an LVN reported witnessing disrespectful communication. Facility leadership was unaware of the CNA's behavior prior to the incident, which did not align with the facility's policy on resident rights.
A medication cart was found unlocked and unattended near the nurse's station while the assigned LVN was on break. The cart was moved by a housekeeper, and the LVN later admitted to forgetting to lock it. Facility policy and staff interviews confirmed that medication carts must be locked when not in use, but this protocol was not followed.
Two residents in the facility were not provided with complete informed consent for their psychotropic medications. One resident with severe cognitive impairment was prescribed multiple medications without documented consent, while another resident with bipolar disorder was aware of his medication but had not signed the consent form. Staff interviews revealed a lack of clarity in responsibility for ensuring consent forms were completed, leading to these deficiencies.
The facility failed to resolve grievances from three residents regarding cold coffee. A resident with COPD, another with Alzheimer's, and a third with liver cancer all reported dissatisfaction with the coffee temperature, which was served below the desired level. Despite multiple complaints, the issue remained unaddressed, with observations confirming the coffee was lukewarm.
A facility failed to document pre and post-dialysis assessments for a resident with ESRD, as required by professional standards. Despite having a care plan for dialysis three times a week, assessments were missing on multiple occasions. Interviews revealed that the LVN did not document assessments in the electronic medical records or follow up with the dialysis center for missing communication sheets. The facility's policy required staff training and communication with the dialysis center, which was not consistently followed.
The facility failed to establish a system for logging and securing controlled medications awaiting disposal. Controlled drugs, including Ativan/Benadryl gel and Hydrocodone-apap tablets, were stored in a locked closet in the DON's office without proper logging. The DON was the only person with the key, and the facility's policy required accountability records to be maintained, which was not done, potentially risking medication loss and diversion.
The facility failed to use the correct scoop size for serving chicken alfredo during a lunch meal, using a 6 oz scoop instead of the required 8 oz. This error was observed after 10 resident trays had been served, potentially affecting the nutritional intake of residents. The Dietary Manager and another staff member acknowledged the mistake, which was contrary to the facility's policies on portion control.
The facility failed to provide palatable and appropriately heated food for several residents, who reported cold, bland, and unappetizing meals. The Dietary Manager and surveyors confirmed these issues during a meal sampling. The Dietary Manager acknowledged ongoing complaints about repetitive menus and seasoning, while the Administrator was unaware of specific complaints about blandness.
A LTC facility failed to maintain effective infection control, with staff not adhering to hand hygiene and PPE protocols. An LVN did not change gloves or sanitize hands during wound care for a resident with a pressure ulcer. A CNA wore PPE in the hallway after assisting a resident in contact isolation, and an LVN did not sanitize hands between glove changes while administering insulin. These actions could lead to infection control issues.
The facility did not follow its smoking policy, leading to unsafe conditions in the smoking area. Observations showed flammable items in a red metal trash can meant for cigarette butts, posing a fire risk. Staff interviews revealed inconsistencies in policy enforcement, with the HR Coordinator and Maintenance Supervisor acknowledging the need for regular checks, but the Administrator expecting daily oversight.
The facility failed to ensure accurate advanced directives for two residents. One resident's OOH-DNR form was incomplete, lacking a physician's signature and license number, while another resident's code status was not updated from full code to DNR despite signing a DNR form. These oversights could lead to residents' end-of-life wishes not being honored.
A resident with mobility challenges was unable to easily open her room door, which was hard to open due to the building's shift. Despite reporting the issue multiple times, no work orders were recorded, and the Maintenance Supervisor had not addressed the problem. The Administrator expected the door to be fixed, and the facility's policy emphasized accommodating individual needs.
A facility failed to provide appropriate care for a resident with an indwelling catheter. The resident was observed without a securement device, and the catheter drainage bag was on the floor, contrary to care plans and physician orders. Staff interviews confirmed the necessity of a leg strap and proper placement of the drainage bag to prevent dislodgement and infection, as outlined in facility policy and Lippincott procedures.
The facility failed to provide appropriate respiratory care for two residents with COPD, as oxygen was administered at incorrect levels and tubing was not changed weekly as required. Staff interviews revealed a lack of oversight and communication regarding supply availability and adherence to physician orders.
A facility failed to provide trauma-informed care for a resident with PTSD by not conducting a trauma screening upon admission and not documenting triggers in the care plan. Staff interviews revealed confusion about the trauma-informed care process, and the facility's policy requiring trauma assessments was not followed.
A LTC facility reported a medication error rate of 24.24%, involving two residents. One resident did not receive scheduled medications on time, while another received an incorrect dosage of MiraLAX. The LVN responsible cited being the sole person on duty for medication administration and admitted to not receiving proper training. The DON and Administrator were unaware of the specific risks associated with these errors.
A resident in an LTC facility experienced significant medication administration delays on two consecutive days, with medications given 1 hour and 36 minutes late on the first day and 4 hours and 55 minutes late on the second day. The delays were due to an LVN being the sole person responsible for medication administration in the facility. Despite informing the DON and Administrator, no additional support was provided. Interviews revealed a lack of awareness of the risks associated with late medication administration.
A facility failed to secure medications and wound care supplies properly, as observed with an unlocked medication cart and unsecured insulin pen, and wound care supplies left on a resident's dresser. Staff acknowledged the importance of securing these items to prevent unauthorized access and ensure resident safety, as per facility policies.
A facility failed to coordinate hospice care and maintain accurate records for a resident receiving hospice services. The resident's updated plan of care and medication list were not included in their medical records, and the hospice binder was not properly maintained. Interviews with staff revealed a lack of clarity and responsibility for maintaining hospice documentation, with recent staffing changes contributing to the oversight. The facility's hospice contract and policy required accurate documentation, which was not followed.
A malfunction in the wander guard system on the north side door was identified when the alarm failed to activate during a test by the Maintenance Supervisor. Although other doors functioned correctly, this issue posed a risk of resident elopement. The Maintenance Supervisor was responsible for weekly checks, and the facility had six residents at risk of elopement. Interviews revealed a lack of policy on door checks, despite the facility's policy on wandering and elopements requiring regular supervision and device checks.
The facility failed to provide a nourishing, well-balanced diet for residents, as observed during a lunch meal review. A resident with multiple health conditions reported frequent food shortages, and another had previously filed a grievance about the dietary department running low on food. During the survey, the facility ran out of the main lunch meal and alternate meat, requiring the test tray to be used for a resident. Staff interviews revealed inconsistencies in ensuring adequate food portions, despite the facility's policy to meet residents' nutritional needs and preferences.
Incomplete Care Planning for Dirty Eyeglasses
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for three residents with impaired vision who wore prescription glasses. Resident #1 had COPD, malnutrition, lumbar radiculopathy, dysphagia, hyperlipidemia, hypertension, impaired vision, and moderate cognitive impairment. Her care plan included ensuring visual aids were available, clean, free from scratches, and in good repair, but during observation she was wearing glasses with a film-like pattern on both lenses and stated she did not have anything to clean them with except tissues, which did not work well. Resident #2 had autistic disorder, diabetes mellitus type II, hyperlipidemia, hypertension, major depression disorder, impaired vision, and staff-identified memory and decision-making deficits. His care plan addressed impaired visual function and fall risk, but it did not include interventions for cleaning his eyeglasses. During observation, both lenses had a light-colored dust-like substance, and he stated they were dirty but still worked. He was unable to recall whether staff assisted him with cleaning his glasses. Resident #3 had cerebral infarction, dysphagia, congestive heart failure, osteoarthritis, hypertension, Guillain-Barre Syndrome, impaired vision, and intact cognition. Her care plan included ensuring visual aids were available, clean, free from scratches, and in good repair, but during observation her glasses had a yellow dried substance on the left lens. When told they appeared dirty, she removed them, shook them, and confirmed they were dirty, but could not provide further information about staff assistance with cleaning them. Staff interviews showed that cleaning glasses was expected by some staff as part of daily care, but it was not specifically assigned on CNA assignments and was not consistently addressed in the care plans.
RN Coverage and DON Staffing Deficiency
Penalty
Summary
The facility failed to designate a registered nurse to serve as the director of nursing on a full-time basis or to have a registered nurse on duty for at least 8 consecutive hours a day, 7 days a week. Survey review found that the facility did not have 8 hours of RN coverage on 17 of 121 days reviewed, including multiple dates in October and December 2025 and January and February 2026. The facility also did not have a designated DON to work full time of at least 40 hours a week from 01/20/26 through the date of survey on 02/12/26. Record review of RN timesheets showed no RN hours on several dates, including 10/10/25, 10/11/25, 10/12/25, 10/16/25, 10/17/25, 10/18/25, 10/19/25, 11/15/25, 12/1/25, 12/14/25, 12/21/25, 12/25/25, and 1/24/26. The record also showed less than 8 hours of RN coverage on 1/18/26, 1/27/26, 1/28/26, and 2/6/26. RN K’s time sheet showed no hours on several October dates, RN L’s time sheet showed no hours on several December dates, and the ADON’s time sheet showed no hours or reduced hours on several dates in January and February. During interviews, Human Resources confirmed the facility had no RN coverage on several October dates because RN K had requested those days off and verified there were no time punches for other listed dates. The ADON stated she had not worked some of the dates in question, had left early on others for appointments, and that no other RN was available to cover those times. The Administrator stated the facility did not have a waiver for the DON, acknowledged awareness of the requirement for an RN to be in the facility for 8 hours daily, and said the facility did not have a DON when he started. The report also noted that the facility had 49 residents at risk of not receiving adequate care because staff with the ability to perform assessments as needed were not available.
PASRR Service Coordination Documentation Missing
Penalty
Summary
The facility failed to coordinate PASRR-related assessments and services to the maximum extent practicable for three residents reviewed for PASRR. The deficiency centered on the lack of documentation in the electronic medical record showing that required PASRR-related services were provided or coordinated, including habilitation coordination for two residents and independent living skills services for one resident. The report states these omissions could cause residents with mental health disorders and psychiatric conditions to have a delay in services or not receive specialized services or equipment that may be needed. For one resident, the record showed a PASRR-positive status related to a developmental disability, a care plan identifying habilitation coordination, and PCSP meetings recommending habilitation coordination services. The resident had cerebral palsy, a BIMS score of 15, and could understand others and make herself understood. However, the EMR contained no documentation of habilitation coordination notes. For another resident, the record showed PASRR-positive status related to an intellectual/developmental disability, a care plan identifying habilitation coordination, and a PASRR Comprehensive Service Plan recommending habilitation coordination. This resident also had cerebral palsy, a BIMS score of 15, and could understand others and make himself understood. The EMR likewise contained no documentation of habilitation coordination notes. For the third resident, the record showed PASRR-positive status related to an intellectual/developmental disability, a care plan identifying both habilitation services and independent living skills, and a PASRR Comprehensive Service Plan recommending habilitation coordination and independent living skills. The resident had cerebral palsy and memory problems. The EMR contained no documentation of habilitation coordination notes or independent living skills notes. Interviews with the Habilitation Coordinator Supervisor, MDS Coordinator, ADON, Social Services, and Administrator confirmed that documentation was not being left in the facility or maintained in the residents’ records after visits, and staff gave differing descriptions of who was responsible for PASRR documentation and coordination.
Food Safety Lapses in Egg Handling and Kitchen Hair Restraints
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety when a box of 80 unpasteurized eggs was found in Refrigerator 1 during kitchen observation. The Dietary Manager stated she did not know the eggs were unpasteurized until surveyor intervention. She also stated that two residents, Resident #23 and Resident #35, received fried eggs, and that their eggs were sometimes soft fried with fully set whites and a warm, liquid yolk, although mostly hard fried. Resident #23 said she received fried eggs that were sometimes runny or soft fried and sometimes fried hard, and Resident #35 said she received fried eggs but could not say whether they were hard or soft fried. The facility also failed to ensure the Maintenance Supervisor wore required hair restraints while in the kitchen. During observation, he entered the kitchen without a hair net or beard covering, walked past the stove, and washed a part belonging to the ice machine at the sink. He stated he was supposed to put on a beard guard when entering the kitchen but forgot, and that he had not been wearing a hairnet because he wore a baseball cap, with hair hanging outside the cap. The Dietary Manager, ADON, and Administrator each stated that hairnets and beard guards were required in the kitchen and that the Dietary Manager was responsible for overseeing compliance and ensuring the correct type of eggs were in the kitchen.
Smoking Area Safety and Disposal Deficiencies
Penalty
Summary
The facility failed to establish and follow smoking policies regarding the smoking area and smoking safety for 1 of 1 smoking areas reviewed. During an observation of a group smoke break involving five residents, cigarette butts were seen on the ground outside in the smoking area, trash was present in the red noncombustible cigarette butt receptacle can, and the self-closing ashtray was malfunctioning. Cigarettes were also placed on top of the self-closing ashtray with other old cigarette butts. The facility policy titled, Smoking Policy- Resident, dated October 2022, stated that metal containers with self-closing cover devices are available in the smoking area and ashtrays are emptied only into designated receptacles. During interviews, the Director of Dietary Services stated she was responsible for the smoke break and that trash should not be in the red receptacle, cigarette butts should not be on the ground, and ashtrays should be fully functioning. The Maintenance Director stated he was unaware of the trash in the receptacle, cigarette butts on the ground, and the malfunctioning ashtrays, and said he was responsible for ensuring the facility was in good repair. The Housekeeping Supervisor stated she was unaware of the cigarette butts on the ground, trash in the disposal can, and malfunctioning ashtray. The ADON and Administrator both stated the smoking area should be free of cigarette butts and trash and that the ashtrays should function properly; the Administrator also stated housekeeping and maintenance should check the area daily and that he was responsible for educating and in-servicing staff on smoking safety.
Failure to Provide Scheduled Bathing and Nail Care
Penalty
Summary
The facility failed to ensure Resident #40 received scheduled bathing and grooming care. Resident #40 was a female admitted with a diagnosis of cerebral infarction due to embolism of the left middle cerebral artery. Her quarterly MDS showed a BIMS score of 11, indicating moderately impaired cognition, and she required partial/moderate assistance with personal hygiene and substantial/maximum assistance with showering or bathing. Her care plan directed that she receive assistance from one staff member with bathing/showering and that her nails be checked, trimmed, and cleaned on bath day and as needed. The resident’s shower schedule showed she was to receive showers on Monday, Wednesday, and Friday, but the record contained no documentation that scheduled baths/showers were provided on multiple dates. During observations, she was found lying in bed wearing a hospital gown or shirt, with oily hair and a white substance noted in her hair. Her fingernails on both hands were observed to be jagged, approximately 0.25-0.50 cm long, and had a thin line of black substance under them. The resident stated she preferred a bed bath, did not know when she last received one, and said not getting her bed bath made her feel dirty. Staff interviews indicated CNAs were responsible for providing baths/showers and that nurses were supposed to monitor completion by reviewing shower sheets daily. One CNA stated she believed the resident refused a bed bath but did not report it to the charge nurse or document it. An LVN observed the resident’s condition and agreed the hair and nails were unclean and untrimmed, and stated the issue had not been reported. The ADON and Administrator stated showers or bed baths were to be completed according to schedule and that nurses were responsible for holding CNAs accountable by reviewing the shower sheets daily.
Acetone Left on Resident Dresser
Penalty
Summary
The facility failed to ensure the resident environment remained as free of accident hazards as possible for one resident when acetone was found stored on the resident’s dresser. During observation on 02/10/26 at 8:50 a.m., the surveyor saw a small clear bottle labeled 100% pure acetone nail polish remover on the dresser of a female resident who had been admitted with chronic systolic heart failure. Her quarterly MDS dated 01/18/26 showed she made herself understood and understood others, with a BIMS score of 15 indicating intact cognition, and she required set-up or clean-up assistance with personal hygiene. The resident’s care plan, revised 12/15/25, identified an ADL self-care performance deficit and included an intervention for staff set-up participation with personal hygiene. During interview, the resident stated a family member brought the acetone to her and she was unsure whether staff knew she had it. Staff interviews reflected that acetone should not be in the building or left at bedside, and that all staff were responsible for monitoring items at residents’ bedsides and ensuring items were stored properly and securely. The Administrator stated he was not aware the resident had acetone at her bedside.
Unsecured Foley Catheter
Penalty
Summary
The facility failed to ensure a resident with an indwelling Foley catheter received appropriate treatment and services to prevent urinary tract infections when the catheter was not secured on 02/10/26, 02/11/26, and 02/12/26. Resident #23 was a female resident with neuromuscular dysfunction of the bladder, intact cognition with a BIMS score of 15, and an indwelling catheter related to obstructive uropathy. Her care plan directed staff to ensure correct placement of the catheter gravity drainage bag and tubing, keep the tubing and bag below the bladder, and avoid kinking the tubing. On 02/10/26, an LVN changed the resident’s catheter due to leakage, but during observation the catheter tubing was found under the resident’s left thigh and unsecured. On 02/11/26 and again on 02/12/26, the resident stated the catheter tubing was not secured, and surveyor observation confirmed it remained unsecured. CNA B stated the catheter should be anchored to the leg to prevent trauma and reported that she had told LVN A on 02/10/26 that the tubing was not secured. LVN A stated the catheter should always be secured and acknowledged she did not pay attention on Tuesday or Wednesday to ensure it was secured, and later noticed it was not secured on 02/12/26. The facility policy stated catheter care was intended to prevent CAUTIs and required the catheter to remain secured with a leg strap or leg band.
Missing Oxygen Sign Outside Resident Door
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for a resident who was ordered oxygen at 2L via nasal cannula every 8 hours as needed for shortness of breath. Resident #40 was a female with diagnoses including asthma and wheezing, had a BIMS score of 11, and her care plan identified oxygen therapy related to decreased oxygen saturations and those diagnoses. During observation on 02/09/26, 02/10/26, 02/11/26, and 02/12/26, she was seen lying in bed wearing oxygen at 2L/min via nasal cannula, but no oxygen sign was posted outside her door on any of those dates. During interview, LVN A stated an oxygen sign should be on the outside of the resident’s door and that all staff were responsible for ensuring it was posted. The ADON stated the expectation was that an oxygen sign should be on the door facing the hall and that nurses were responsible for ensuring it was always there. The Administrator also stated an oxygen sign should be outside the door and that nursing and maintenance were responsible for ensuring it was posted, but he had not noticed it was missing until the surveyor’s intervention. The Administrator stated the facility was currently out of signs.
Failure to Honor Resident Food Preference
Penalty
Summary
The facility failed to provide food that accommodated Resident #16’s stated preference for no lima beans. Resident #16 was a 54-year-old female with diagnoses including diabetes, high blood pressure, and cerebral palsy. Her quarterly MDS dated 01/26/26 indicated she understood and was understood by others, had a BIMS score of 15, and was independent in eating and oral hygiene. Her physician orders called for a regular diet, and her care plan noted a regular diet with potential for malnutrition related to cerebral palsy and diabetes. The lunch meal ticket for 02/09/26 listed a dislike of lima beans. During lunch observation, Resident #16 was eating in the main dining room and stated she did not like lima beans but received them anyway, saying she would have to pick them out of the vegetables. The ADON reviewed the meal ticket with the surveyor and acknowledged the preference should have been caught when the nurse passed the tray. The Dietary Manager stated she expected Resident #16 not to receive lima beans and said the kitchen staff were responsible for reading the tray card and not serving disliked items. Dietary staff said they did not notice the dislike and did not think about the Italian blend containing lima beans. The Administrator stated he expected the kitchen staff, CNAs, and nurses to ensure the tray card directions were followed. The facility policy stated residents should receive a nourishing, palatable diet that takes into consideration each resident’s preferences and that reasonable efforts would be made to accommodate resident choices and preferences.
Hospice Records Not Updated or Coordinated
Penalty
Summary
The facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for a resident receiving hospice services, and did not ensure the resident’s hospice records were included in the facility record. Resident #14 was a female admitted with a diagnosis of Alzheimer’s disease, had an order to admit to hospice, and was assessed as having a life expectancy of less than 6 months with a BIMS score of 5, indicating severe impairment. Her comprehensive care plan identified a terminal prognosis related to end-stage Alzheimer’s disease and included interventions to work cooperatively with the hospice team to meet her spiritual, emotional, intellectual, physician, and social needs. Survey review of the hospice binder found no updated CTI, plan of care, medication list, or nurses’ and aides’ notes since the last IDT meeting. The RN case manager stated the resident had been admitted to hospice for Alzheimer’s disease and that the last IDT meeting was on 12/23/25, with hospice coordination occurring in person. The ADON stated she was unaware the hospice binder was not updated and confirmed the binder did not include all needed information, while the Administrator stated he expected mutually agreed documents to be placed in the binder and that nurses and nurse management were responsible for keeping it updated. The facility policy required obtaining the most recent hospice plan of care, hospice election form, physician certification and recertification, hospice personnel contact information, on-call instructions, hospice medication information, and hospice physician and attending physician orders.
Failure to Use EBP PPE During Catheter Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one resident reviewed for infection control. Resident #6 was a male with diagnoses including Alzheimer's disease with late onset, benign prostatic hyperplasia with lower urinary tract symptoms, and chronic kidney disease stage 3A. The resident's MDS indicated he was admitted following a short-term hospital stay with an indwelling catheter and was always incontinent of bowel. His care plan, dated 11/23/25, included enhanced barrier precautions with staff required to wear gowns and gloves during high-contact resident care activities, and the order summary report also indicated EBP with gown and gloves for high-contact activities starting 12/10/25. During an observation on 02/11/26 at 1:35 p.m., CNA B and CNA H entered Resident #6's room, performed hand hygiene, put on gloves, and began catheter care without gowns on. A sign on the outside of the room indicated EBP of gown and gloves were required for high-contact care, and a box of supplies was stored outside the room. During interviews, CNA H stated she was not trained to wear PPE when providing care to Resident #6 and believed only residents with wounds were on EBP. CNA B stated she forgot to wear PPE and could not recall recent training, and both CNAs stated residents with wounds and catheters required PPE. The LVN, ADON, and Administrator stated staff were expected to wear EBP PPE for direct care to Resident #6, that EBP meant gown and gloves, and that it was used for residents with catheters, wounds, communicable disease, or infection. The ADON and Administrator also stated no EBP in-service had been conducted during their recent time in role, and the Administrator stated nursing administration was responsible for ensuring EBP PPE was used during direct patient care.
Damaged Windowsill Left Unrepaired in Resident Room
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for Resident #16 because the windowsill in the resident’s room was not in good repair. During observation, the lower interior portion beneath the window had a visible hole and separated wood measuring approximately 10-12 inches long and 1-2 inches wide, with cracked, splintered, and deteriorated wood and exposed inner material. The damaged area was at resident height, accessible to the resident, and had no protective covering or repair in place at the time of observation. Resident #16 stated the broken windowsill had been there when she moved into the room several months earlier and that she had reported it through the TELS application, though she did not remember the date. The Maintenance Supervisor stated he had known about the window for a while but had not completed the repair, saying he had let it slip and later did not have budgeted money to fix it after the facility changed owners. He also stated he had used a bonding agent to patch it previously, but the windowsill broke again. The ADON and Administrator stated they were not aware of the issue until this week, and the Administrator said he bought the tools to fix it after learning about it.
Insufficient CNA Staffing on Night Shifts
Penalty
Summary
The facility failed to provide a sufficient number of nursing staff, specifically Certified Nursing Assistants (CNAs), on a 24-hour basis to meet the needs of all residents in accordance with the facility assessment and resident care plans. On multiple dates, the facility operated with only one CNA on the night shift (10 PM-6 AM), despite a resident census that exceeded the staffing ratio outlined in the facility assessment, which required at least one CNA per 30 residents. Census records showed that on the dates in question, the number of residents ranged from 44 to 49, but only one CNA was scheduled for the night shift. Interviews with staff members revealed that working short-staffed was a recurring issue, with some staff reporting that they were the only CNA for the entire building during certain shifts. Staff described difficulties in providing timely care, with residents having to wait for assistance and some care tasks being delayed. Staff also reported that the shortage of CNAs led to situations where mechanical lifts were used without the required assistance, as nurses were not always available to help. Staff consistently stated that management was aware of the staffing shortages and the challenges in meeting residents' needs. The Director of Nursing (DON) and the Administrator acknowledged the staffing challenges, with the DON stating that the facility often operated below the planned CNA staffing levels for each shift. The Administrator indicated that the facility assessment allowed for one to two CNAs on the night shift, depending on census, and that the direct care staff ratio was intended to be one CNA per 30 residents. Despite this, time sheets confirmed that only one CNA was present on the night shift during the dates reviewed, even when the census exceeded 30 residents. The facility's policy required sufficient nursing staff to ensure resident safety and well-being in accordance with care plans and the facility assessment.
Failure to Treat Resident with Dignity and Respect During Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to treat a resident with respect and dignity during care. The resident, an older female with Parkinsonism, anxiety disorder, and major depressive disorder, was cognitively intact and required significant assistance with daily activities. On the day of the incident, the CNA spoke to the resident in a loud manner and patted her hand while attempting to provide care, actions that were not consistent with maintaining a calm and respectful environment as outlined in the resident's care plan. Interviews revealed that the CNA admitted to tapping the resident's hand in response to the resident's physical and verbal aggression, and acknowledged making statements to residents that could be perceived as disrespectful or pressuring. A licensed vocational nurse (LVN) who witnessed the incident reported that the CNA raised her voice at the resident and had previously spoken to residents in a manner that was not dignified, including making demands and disregarding refusals of care. The LVN stated she had to intervene and had reported the CNA's behavior to management. Further interviews with facility leadership indicated that the director of nursing (DON) and administrator were not previously aware of the CNA's pattern of loud or disrespectful communication with residents. The facility's policy required all employees to treat residents with kindness, respect, and dignity, but the CNA's actions on the day in question did not align with these expectations. The incident was documented and investigated, with staff and leadership interviews confirming the failure to provide care in a manner that promoted the resident's dignity and quality of life.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
A deficiency occurred when a medication cart in the South Hall was left unlocked and unattended next to the nurse's station. During an observation, the cart was found unlocked while the assigned nurse, LVN C, was on break and not present in the hallway. A housekeeper moved the unlocked cart, believing the nurse was on break. LVN C later confirmed that she had been on break and had forgotten to lock the cart, acknowledging the importance of keeping it secured, especially given the presence of dementia patients in the facility. Interviews with the DON and the Administrator confirmed that facility policy requires medication carts to be locked at all times when not in use or out of the nurse's view. Record review of the facility's policy, revised April 2007, also indicated that medication carts must be securely locked when unattended. The failure to secure the medication cart was directly observed and acknowledged by staff, constituting a breach of professional standards for the storage of drugs and biologicals.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that two residents were fully informed and provided consent for their psychotropic medications. Resident #1, a female with severe cognitive impairment due to Alzheimer's disease, was prescribed multiple psychotropic medications including trazadone, Xanax, lorazepam, and sertraline. However, the informed consent forms for these medications lacked clinical indications for use, benefits of the medications, and a statement of consent. Despite her cognitive impairment, the facility did not ensure that the necessary information was documented to confirm informed consent. Resident #9, a male with a diagnosis of bipolar disorder and a BIMS score indicating cognitive intactness, was prescribed Zyprexa, an antipsychotic medication. Although Resident #9 was aware of the medication's purpose and its risks and benefits, the consent form for this medication was not signed by him or his representative. This oversight indicates a failure in the facility's process to secure and document informed consent for psychotropic medications. Interviews with facility staff, including an LVN and the DON, revealed that there was a lack of clarity and responsibility in ensuring that consent forms were completed and signed. The DON acknowledged that the responsibility for ensuring complete consent forms had shifted after the departure of the ADON, and the Administrator expected nursing management to monitor this process. The facility's policy required written consent for psychotropic medications, but this was not adhered to, leading to the deficiencies noted in the report.
Failure to Address Grievances on Coffee Temperature
Penalty
Summary
The facility failed to promptly resolve grievances related to coffee temperature for three residents. Resident #42, a female with COPD and moderately impaired cognition, complained that the coffee was served cold and stated that the facility staff attributed the issue to state regulations. Despite being aware of the complaints, the facility staff did not address the issue, leaving the resident dissatisfied with the coffee temperature. Resident #47, a female with Alzheimer's disease and moderately impaired cognition, also reported that the coffee was cold. She expressed that multiple complaints had been made without improvement, and she desired her coffee to be served hot as she had been accustomed to throughout her adult life. During an observation, Resident #47 confirmed that the coffee was cold, reinforcing her grievance. Resident #44, a male with liver cancer and intact cognition, similarly complained about the cold coffee. He mentioned that the coffee was not served at the desired temperature due to a policy limiting it to 140 degrees F or less. Despite his grievances, the issue remained unresolved. Observations confirmed that the coffee was served at 119.8 degrees F, which was considered lukewarm. The facility's Administrator and Dietary Manager acknowledged receiving complaints but did not identify any problems with the coffee temperatures, despite the residents' dissatisfaction.
Failure to Document Dialysis Assessments
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received appropriate pre and post-dialysis assessments, as per professional standards of practice. The resident, a male with end-stage renal disease (ESRD), was dependent on dialysis and had a care plan indicating he attended dialysis sessions three times a week. Despite this, there were multiple instances where pre and post-dialysis assessments were not documented in the resident's records, specifically on several dates in October and November. Interviews with facility staff revealed that the Licensed Vocational Nurse (LVN) responsible for the resident's care was aware that the resident sometimes did not return with the communication sheets from the dialysis center. However, the LVN did not document the assessments in the resident's electronic medical records or follow up with the dialysis center for missing communication sheets. The Director of Nursing (DON) expected nurses to perform these assessments, but the process was not consistently followed. The facility's policy on the care of residents with ESRD required staff to be trained in the specific needs of these residents, including the completion of assessments and communication with the dialysis center. However, the lack of documentation and communication indicated a failure to adhere to these policies, potentially affecting the quality of care provided to the resident.
Failure to Log and Secure Controlled Medications
Penalty
Summary
The facility failed to establish a system for the receipt and disposition of controlled drugs, which is necessary for accurate reconciliation and maintaining drug records. During an observation, it was noted that several controlled medications, including Ativan/Benadryl gel, Hydrocodone-apap tablets, Alprazolam tablets, and Tramadol tablets, were stored in a basket inside a controlled medication closet in the Director of Nursing's (DON) office, awaiting disposal. The DON stated that she was the only person with the key to the locked closet and was responsible for reconciling medications for disposal. However, she had not located a blank destruction log to record these medications, which is a critical step in ensuring accountability and preventing drug diversion. The Administrator expected narcotic medications to be logged and secured appropriately, but acknowledged that the DON was the only one with the key, implying there was no risk of medications going missing. Despite this, the facility's policy required accountability records for discontinued controlled substances to be maintained with the unused supply until destroyed, and stored for five years or as required by law. The lack of a proper logging system for controlled substances awaiting disposal indicates a failure to comply with these policies, potentially placing residents at risk for loss of prescribed medications and drug diversion.
Failure to Use Correct Scoop Size for Meal Portions
Penalty
Summary
The facility failed to ensure that the meals served met the nutritional needs of residents during a lunch meal, specifically with the serving of chicken alfredo. The dietary spreadsheet indicated that an 8 oz scoop should be used for serving, but observations revealed that a 6 oz scoop was used instead. This discrepancy was noted after approximately 10 resident trays had already been served and delivered. The Dietary Manager acknowledged the error, stating that the correct scoop size was documented on the dietary spreadsheet and that she was responsible for ensuring the correct scoop size was used. Further interviews revealed that another staff member, [NAME] E, also misread the spreadsheet and used the incorrect scoop size, placing residents at risk of not receiving adequate nutrition. The Director of Nursing (DON) and the Administrator both expressed expectations that the dietary staff should use the correct scoop size to ensure residents receive the correct portions. The facility's policies on tray service and portion control emphasize the importance of accurate portion sizes for resident wellbeing and safety, but these were not adhered to during the incident.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility failed to provide food that was palatable and served at an appetizing temperature for four residents. Residents reported that the food was cold, bland, and unappetizing. Specific complaints included cold meals, bland taste, and unappealing textures, such as gravy with the consistency of milk and dry eggs. These issues were confirmed during interviews with the residents, who expressed dissatisfaction with the quality and temperature of the food served. The Dietary Manager and surveyors sampled a lunch tray and found the food to be unappetizing, with bland and mushy vegetables. The Dietary Manager acknowledged receiving constant complaints about the food, mainly regarding repetitive menus and over-seasoning, which led to reduced seasoning. However, the Dietary Manager was unaware of complaints about blandness and overcooked vegetables until the test tray was sampled. The Administrator also received monthly food complaints but was unaware of specific issues with blandness. The facility's Food and Nutrition Services policy requires that food be palatable, attractive, and served at a safe and appetizing temperature.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several observed deficiencies in hand hygiene and personal protective equipment (PPE) usage. One incident involved a Licensed Vocational Nurse (LVN) who did not change gloves or perform hand hygiene while providing wound care to a resident with a stage 3 pressure ulcer. The LVN left the resident's room to gather supplies without removing her gown or performing hand hygiene, and later re-entered the room to continue treatment without proper hand hygiene. This lapse in protocol was acknowledged by the LVN, who admitted that such actions could lead to infection control issues. Another deficiency was observed when a Certified Nursing Assistant (CNA) wore PPE in the hallway after assisting a resident in contact isolation due to shingles. The CNA did not remove her gown and gloves or perform hand hygiene before leaving the resident's room, and subsequently interacted with another resident. The CNA admitted to not following proper procedures, which could contribute to the spread of infection. The Director of Nursing (DON) and the Administrator both expressed expectations that staff should adhere to proper PPE and hand hygiene protocols to prevent infection. A third incident involved an LVN who failed to perform hand hygiene between glove changes while obtaining a resident's blood sugar and administering insulin. The LVN acknowledged the oversight, attributing it to distraction from a loud alarm. The DON reiterated the importance of hand hygiene after removing dirty gloves to prevent infection risk. The facility's policies on hand hygiene and transmission precautions were not followed in these instances, leading to potential infection control issues.
Failure to Maintain Safe Smoking Practices
Penalty
Summary
The facility failed to adhere to its established smoking policy, which mandates maintaining safe smoking practices for residents. During an observation, it was noted that four residents were smoking in the designated smoking area with staff present. However, the red metal trash can, intended solely for cigarette butts and ashes, contained flammable items such as an empty cigarette box, a piece of a paper towel, a blue sticky note, and a sonic cup. This improper disposal of trash in the smoking can was observed, which could potentially lead to a fire hazard. Interviews with facility staff, including the HR Coordinator, Maintenance Supervisor, and Administrator, revealed a lack of compliance with the facility's smoking policy. The HR Coordinator acknowledged that staff responsible for supervising residents during smoking should ensure the red can is free of trash. The Maintenance Supervisor confirmed that all staff are responsible for keeping the red can clear of trash and that he checks it weekly. However, the Administrator expected the Maintenance Supervisor to check the can daily. This inconsistency in practice and oversight contributed to the failure to maintain a safe smoking environment, as outlined in the facility's policy.
Failure to Ensure Accurate Advanced Directives
Penalty
Summary
The facility failed to ensure the right to formulate an advanced directive was provided for two residents. For one resident, the Out-of-Hospital Do Not Resuscitate (OOH-DNR) form was incomplete, missing the physician's signature and license number, despite the resident having a physician's order for DNR status. This resident had a moderately impaired cognition with a BIMS score of 9, indicating some level of understanding and communication ability. The comprehensive care plan for this resident indicated a DNR status, but the lack of a complete OOH-DNR form could lead to a failure in honoring the resident's end-of-life wishes. For another resident, the facility did not update the code status from full code to DNR after the resident signed a DNR form. This resident had an intact cognition with a BIMS score of 15, indicating full understanding and communication ability. Despite the resident's clear wishes and a completed DNR form signed by all responsible parties, the active physician's order still indicated a full code status. Interviews with the social worker and administrator revealed that the oversight was due to a lack of proper documentation and monitoring, which could result in the resident's wishes not being carried out in an emergency.
Failure to Ensure Accessible Room Door for Resident
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable homelike environment for a resident who was unable to easily use the door to her room. The resident, who had chronic pain, difficulty in walking, muscle weakness, unsteadiness of feet, and lack of coordination, reported that her room door was extremely hard to open. Despite having moderately impaired cognition, she was usually able to understand others and was independent with bed mobility and transfers, using a walker. The comprehensive care plan did not address the need for easy use of functional items, and no work orders were recorded for the hard-to-open door. During an observation, the surveyor noted that the door required significant force to open, which the resident confirmed had been reported to the facility staff multiple times. The Maintenance Supervisor acknowledged awareness of the issue, attributing it to the building's shift, and admitted to not having tried other solutions due to time constraints. The Administrator expected the door to have been fixed and stated that issues should be entered into the system to generate a work order, which would alert the team for follow-up. The facility's policy emphasized accommodating individual needs and preferences, including modifications to the physical environment.
Failure to Secure Indwelling Catheter and Maintain Infection Control
Penalty
Summary
The facility failed to provide appropriate treatment and service of care for a resident with an indwelling catheter. The resident, a male with a diagnosis of obstructive uropathy secondary to prostate cancer, was observed on multiple occasions without a securement device for his indwelling catheter, and the catheter drainage bag was found resting on the floor. These observations were made despite the care plan and physician orders indicating the necessity of securing the catheter to the leg to promote comfort and minimize tension or tissue trauma. Interviews with facility staff, including a CNA, an LVN, the DON, and the Administrator, confirmed that the resident should have had a leg strap to prevent dislodgement and that the drainage bag should not have been on the floor due to infection control concerns. The facility's policy and Lippincott procedures also emphasized the importance of securing the catheter and keeping the drainage bag off the floor to prevent contamination and catheter-associated urinary tract infections (CAUTI).
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, both of whom required oxygen therapy due to chronic obstructive pulmonary disease (COPD). Resident #11 was observed with oxygen set at incorrect levels, first at 5 liters and then at 3 liters per nasal cannula, despite a physician's order for 2 liters. Additionally, the oxygen tubing for Resident #11 had not been changed since 10/28/24, contrary to the facility's policy of weekly changes on Sunday nights. Resident #15 also experienced a lapse in care, as her oxygen tubing had not been changed since 10/25/24. The facility's policy required weekly changes, but due to a lack of nasal cannulas, the tubing was not replaced. The Licensed Vocational Nurse (LVN) on duty admitted to signing the medication administration record out of habit, despite not having changed the tubing due to the unavailability of supplies. Interviews with staff, including the Director of Nursing (DON) and the Administrator, revealed a lack of oversight and communication regarding the availability of necessary supplies and adherence to physician orders. The DON acknowledged the responsibility of charge nurses to follow orders and ensure tubing changes, but was unaware of the supply shortage until informed by an LVN. The Administrator deferred clinical responsibilities to the DON, indicating a gap in administrative oversight of clinical practices.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to ensure that a resident who is a trauma survivor received culturally competent, trauma-informed care. Specifically, the facility did not conduct a trauma screening upon admission for a resident with a history of trauma, including PTSD, which is a mental health condition that can develop after experiencing or witnessing a traumatic event. The resident, who had severely impaired cognitive skills and was dependent on staff for daily activities, did not have any identified triggers documented in their care plan, which is crucial for preventing re-traumatization. Interviews with facility staff revealed a lack of clarity and responsibility regarding the trauma-informed care process. The social worker, who was new to the facility, was unsure of the process and acknowledged that the trauma assessments should have been completed on admission and quarterly. The MDS nurse admitted that the care plans should have included the resident's PTSD triggers to alert staff on how to manage them. The Director of Nursing and the Administrator both emphasized the importance of having trauma assessments completed and accessible to staff to meet residents' needs effectively. However, the facility's policy on trauma-informed care, which requires identifying past trauma as part of the comprehensive assessment, was not followed in this case.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported rate of 24.24% due to 8 errors out of 33 opportunities. This involved two residents, one of whom did not receive their scheduled medications on time, and another who received an incorrect dosage of a prescribed medication. The errors were observed during a survey, and interviews with staff confirmed the issues. Resident #4, a female with multiple diagnoses including dementia, depression, and congestive heart failure, did not receive her medications on time on a specific date. The medications included Bumetanide, Vitamin D3, Eliquis, Isosorbide mononitrate, Potassium chloride, and Ranolazine, but Tylenol was not administered as ordered. The LVN responsible for administering the medications cited being the only person on duty for medication administration as a reason for the delay. Resident #25, another female with diagnoses including gastrointestinal hemorrhage and atrial fibrillation, received an incorrect dosage of MiraLAX. The LVN failed to use the cap provided with the MiraLAX bottle for accurate measurement, potentially leading to under or over-administration. The LVN admitted to not receiving proper training for medication administration and reported the heavy workload to the DON and Administrator, who were unaware of the specific risks associated with late or incorrect medication administration.
Medication Administration Delays in LTC Facility
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as observed during a survey. The resident, a female with a history of dementia, depression, chronic pain, hypertension, and congestive heart failure, did not receive her medications at the scheduled times on two consecutive days. On the first day, her medications were administered 1 hour and 36 minutes late, and on the second day, they were administered 4 hours and 55 minutes late, both beyond the 1-hour grace period allowed by the facility's policy. The resident's medications included Eliquis, an anticoagulant, and Ranolazine, used for chronic chest pain, both of which were scheduled to be administered twice daily. The late administration of these medications was attributed to the fact that the LVN responsible for medication administration was the only person available to give medications in the entire building. The LVN reported that the medication load was too heavy for one person, and she had informed the DON and the Administrator about the issue, but no additional support was provided. Interviews with the LVN, DON, and Administrator revealed a lack of awareness and understanding of the risks associated with late medication administration. The LVN acknowledged the potential for reduced medication effectiveness and the risk of administering doses too close together. Despite the facility's policy requiring medications to be administered within 60 minutes of the scheduled time, the DON and Administrator were unable to articulate the potential consequences of the delays, indicating a gap in oversight and training.
Medication and Wound Care Storage Deficiencies
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored securely and labeled correctly, as observed with one of the medication carts and two residents. On November 5th, a nurse left the south side nurse's treatment cart unlocked and unattended, with an insulin pen placed on top of the cart. The nurse admitted to not locking the cart because she believed she could hear if someone accessed it while she was in a nearby room. This oversight was acknowledged by the nurse, who understood the importance of securing medications to prevent unauthorized access or potential drug diversion. Additionally, the facility did not properly secure wound care supplies for a resident with a stage IV pressure ulcer. The supplies, including a wound cleanser and gel, were left on the resident's dresser instead of being stored in the nurse's treatment cart. The charge nurse responsible for the resident did not notice the supplies were left out, and the Regional Compliance Nurse confirmed that such items should be stored securely to ensure resident safety. The Director of Nursing and the Administrator both emphasized the expectation that wound care supplies be stored properly and not left at the bedside. The facility's policies on medication administration and storage were not adhered to, as evidenced by the unlocked medication cart and unsecured wound care supplies. The Director of Nursing and the Administrator reiterated the importance of following these policies to maintain a safe environment for residents. The failure to secure medications and wound care supplies could potentially place residents at risk, as noted by the staff involved in the observations and interviews.
Failure to Coordinate Hospice Care and Maintain Accurate Records
Penalty
Summary
The facility failed to collaborate effectively with hospice representatives and coordinate the hospice care planning process for a resident receiving hospice services. This deficiency was identified through interviews and record reviews, which revealed that the facility did not ensure the resident's updated plan of care and most recent medication list from hospice were included in their current medical records. The hospice binder, which should have contained updated information, was not maintained properly, with the most recent plan of care update being over a month old and the medication report being nearly two months old. Interviews with facility staff, including an LVN, the DON, and the Administrator, highlighted a lack of clarity and responsibility regarding the maintenance of hospice documentation. The LVN was unsure if physical copies of hospice information were kept at the facility, while the DON acknowledged the importance of updated hospice paperwork but had not yet ensured its accuracy due to recent staffing changes. The Administrator expected nursing management to maintain updated hospice binders, emphasizing the importance of communication and continuity of care. The facility's hospice contract and policy required accurate and up-to-date documentation, which was not adhered to in this case.
Wander Guard System Malfunction on North Side Door
Penalty
Summary
The facility failed to ensure the proper functioning of the wander guard system on the north side door, which is crucial for preventing resident elopement. During an observation, the Maintenance Supervisor tested the door, and the alarm did not activate, indicating a malfunction. Although the other two wander guard doors were functioning correctly, this particular door posed a risk as it did not alert staff to potential elopement. The Maintenance Supervisor mentioned that he checks the doors weekly and had found them functioning properly during the last inspection. However, on this occasion, the system failed to operate as expected. Interviews with the Administrator and the DON revealed that the Maintenance Supervisor was responsible for ensuring the wander guard system's functionality. They stated that if the system was not working, a staff member should be stationed at the door to prevent residents from leaving the facility. The facility had six residents at risk of elopement who wore wander guards. The Regional Nurse Consultant noted that there was no policy on checking the doors, and the facility's policy on wandering and elopements emphasized the need for adequate supervision and regular checks of the wander guard devices. The TELS logbook indicated that the door was checked and working properly a week prior to the incident.
Inadequate Food Supply for Residents
Penalty
Summary
The facility failed to provide residents with a nourishing, palatable, well-balanced diet that meets their daily nutritional and special dietary needs, as observed during a lunch meal review. On the date of the survey, the facility did not prepare an adequate amount of food for the lunch meal, which could potentially affect all residents by placing them at risk of not receiving adequate nutritive food value needed to promote or maintain health. This deficiency was highlighted by the experiences of two residents who reported issues with food availability. One resident, a male with diagnoses including liver cancer, cerebral vascular disease, congestive heart failure, and anemia, reported that the facility frequently ran out of food, and he had to send out for food. He mentioned that he was often told there was not enough food for extras, and he had received minimal portions for breakfast. Another resident, who had been discharged, had previously filed a grievance about the dietary department frequently running low on food or out of certain items, such as eggs and biscuits. During the survey, it was observed that the facility ran out of the main lunch meal and the alternate meat, requiring the test tray to be used for a resident. The Dietary Supervisor acknowledged the shortage and mentioned that while running out of food usually did not happen, they had ready-to-cook meats available if needed. Despite this, staff interviews revealed inconsistencies in ensuring adequate food portions, with some staff unaware of any complaints or issues. The facility's policy stated that each resident should be provided with a diet that meets their nutritional needs and preferences, but the observed deficiency indicated a failure to adhere to this policy.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 93 citations issued within 25 miles in the last 12 months — including the 3 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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Commerce
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Legend Healthcare And Rehabilitation - Greenville | 13.8 mi | ★★★★★ | 5 | 0 |
| Greenville Gardens | 14.3 mi | ★★★★★ | 14 | 0 |
| Briarcliff Health Center Of Greenville | 14.7 mi | ★★★★★ | 15 | 1 |
| Greenville Health & Rehabilitation Center | 15.1 mi | ★★★★★ | 2 | 0 |
| Birchwood Nursing And Rehabilitation | 15.2 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Avir At Commerce.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.