Below average — CMS composite of the measures below.
The next survey window likely opens around May 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 Converse during CMS and state inspections, most recent first.
Failure to Refer Residents With Mental Illness for PASRR Screening: The facility did not properly coordinate PASRR assessments for residents with qualifying mental health diagnoses. A resident with bipolar disorder, a resident with schizophrenia, bipolar disorder, borderline personality disorder, and PTSD, and a resident with PTSD were not correctly referred for Level I PASRR screening, and staff acknowledged that the screenings were inaccurate or incomplete. The records also showed intact cognition for two residents and moderate cognitive impairment for one resident, along with psychotropic medication use for one resident.
Bathroom Sink Faucet Sprayed Water Onto Floor: A resident with RA, PTSD, and recurrent MDD had a bathroom sink faucet that sprayed water outward and onto the floor instead of downward. The resident said the problem had been present for months and had been reported to CNAs, and a CNA confirmed it had been reported to the charge nurse. Observation and interview with the MD confirmed the faucet issue and that a work order had been received but not repaired because other repairs were prioritized.
A resident with PTSD and moderate cognitive impairment had a comprehensive care plan that did not include his PTSD diagnosis or describe the care and services staff would provide to manage the condition. The MDS Coordinator acknowledged the care plan did not reflect the resident’s mental status or how staff should address behaviors associated with PTSD.
Care plan not revised after Foley catheter was discontinued. A resident’s MDS showed no appliance use and occasional urinary incontinence, but the care plan still listed Foley catheter care and an indwelling catheter goal even though the catheter order had been discontinued and no catheter was present. The MDS Coordinator acknowledged the care plan had not been resolved and stated it should have been updated to reflect the resident’s toileting needs.
Failure to honor a resident’s requested diet texture. A resident with intact cognition and diagnoses including RA, PTSD, and recurrent MDD repeatedly asked for a regular diet, but staff continued serving a mechanically altered/blended diet. She reported that staff ignored her requests, while CNA and nursing interviews confirmed she was not eating the facility trays and was instead getting other foods. The DON and DOR acknowledged concern about possible choking, but also stated the resident had the right to choose her diet plan and that her request for a diet upgrade was denied without further discussion.
Improper Beard Restraint Use and Hand Hygiene During Food Service: A dietary aide was observed preparing food and washing dishes with his mustache exposed because his beard restraint did not fully cover his facial hair. During lunch service, a staff member left the serving line wearing gloves, handled items in the pantry, returned to the line without changing gloves or washing hands, and continued plating food. Interviews confirmed both staff members should have used proper beard restraints and hand hygiene to prevent cross-contamination.
Inaccurate Face Sheet Diagnosis Documentation: A resident’s face sheet failed to list pain as a diagnosis even though the H&P, care plan, and physician orders all reflected ongoing pain management, including scheduled morphine. The resident reported chronic pain from an old military back injury, and the MDS nurse acknowledged the diagnosis had not been entered on the face sheet and that diagnoses had not yet been audited against the H&P.
Surveyors found an unlabeled vial of insulin on the 300/400 hall medication cart, not in a box and lacking a pharmacy label or resident name, although it had an open date. An LPN responsible for the cart reported that unlabeled medications are usually discarded or clarified with the prior nurse and acknowledged that medications should bear residents’ names to prevent sharing. The DON stated that insulin must be labeled with the medication name, resident name, directions, and open date, and that the pharmacy is responsible for labeling while nurses oversee the cart. Review of the facility’s policy confirmed that medication labels must include the drug name, prescribed dose, strength, expiration date, resident name, route, and instructions, requirements that were not met for this insulin vial.
The facility failed to maintain infection control practices and Enhanced Barrier Precautions (EBP) for three residents. A resident using a PureWick urinary system, care planned as at risk for UTI and on EBP, was observed with the PureWick tubing touching the floor, which staff and the DON acknowledged was an infection control and contamination concern. Two residents with chronic wounds, including unstageable pressure injuries, did not have required EBP signage or supplies at their doors, despite the facility’s EBP policy stating that residents with wounds or indwelling devices must be on EBP and staff relying on such signage and carts to identify these precautions.
A medication cart assigned to an LVN was observed left unlocked and unattended in a hallway, accessible to staff, the public, and residents, while the nurse was inside a resident's room and unable to monitor the cart. The DON and Administrator confirmed the cart was not secured as required by facility policy, which mandates that all medications be stored in locked compartments and not left unattended.
Surveyors found that several residents received insulin from pens that were not discarded after 28 days as required, and one resident missed ten days of prescribed Lorazepam due to a failure in timely medication reordering and communication among staff. These deficiencies were confirmed through observation, record review, and staff interviews, with staff acknowledging that procedures for medication disposal and reordering were not followed.
Insulin pens for several residents were found in the medication cart without open dates, despite facility policy and manufacturer instructions requiring dating and discarding after 28 days. Nursing staff and the DON confirmed that the pens should have been dated, but were unable to determine when the insulin was opened, leading to uncertainty about the safety and effectiveness of the medication being administered.
The facility did not ensure that all new and existing staff received required initial and annual trainings, as evidenced by missing documentation for multiple staff members across various roles. Personnel records and staff interviews confirmed that trainings on topics such as communication, QAPI, ethics, falls, HIV, and emergency preparedness were not consistently provided or documented, despite a facility policy outlining these requirements.
Four staff members, including a housekeeper, CMA, CNA, and LVN, did not receive required annual communication training as evidenced by a review of their personnel records. The facility's process involved the HR Coordinator initiating monthly in-services and department heads presenting them to staff, but documentation showed the communication training was not completed for these employees, contrary to facility policy.
The facility did not provide required annual QAPI program training to several staff members, including a housekeeper, CNA, dietary aide, CMA, and RN. Personnel records lacked evidence of this training, and interviews with facility leadership confirmed the deficiency in the training process and documentation.
The facility did not provide required annual ethics training to several staff members, including housekeeping, CNAs, RNs, and LVNs, as evidenced by missing documentation in personnel files. The process for delivering and verifying in-service trainings involved the HR Coordinator and department heads, but records showed that the annual ethics training was not completed for these employees.
Three CNAs did not receive the required 12 hours of annual in-service training, with personnel records lacking evidence of completion for key topics such as communication, QAPI, ethics, falls, restraint, and emergency preparedness. The HR Coordinator, DON, and Administrator confirmed the process for distributing and verifying in-service trainings but could not provide documentation or a policy confirming compliance.
The facility did not provide required behavioral health training to two dietary staff members, with one not receiving annual training and the other not receiving training upon hire. Documentation and interviews confirmed gaps in the training process, despite facility policy requiring annual education on behavior interventions.
A resident with severe cognitive impairment and total dependence on staff for care was repeatedly observed with their call light out of reach while in bed, despite care plan interventions and facility policy requiring accessibility. Staff interviews confirmed the call light was not accessible and acknowledged responsibility for proper placement.
A resident with multiple chronic conditions was discharged, but the required discharge MDS assessment was not completed or transmitted to CMS within the mandated timeframe. The MDS coordinator, responsible for this task, was unable to explain the oversight, and the assessment did not appear on the facility's tracking report. Interviews confirmed that the facility's monitoring systems failed to identify the missed assessment.
A resident with severe cognitive impairment and multiple medical conditions was incorrectly coded as receiving an anticoagulant on her MDS assessment, when she was actually prescribed and administered clopidogrel, an antiplatelet. The MDS nurse confirmed this was a coding error, as the medication should have been documented as an antiplatelet per CMS guidelines.
A resident with multiple medical conditions and moderate cognitive impairment was identified as a smoker requiring adaptive equipment, but the facility failed to include smoking-related interventions in the resident's care plan. Despite documentation and staff awareness of the resident's smoking status, the care plan did not address this need, contrary to facility policy.
A CNA did not follow proper perineal care procedures for a female resident with severe cognitive impairment and incontinence, failing to separate and clean the labia as required by facility policy. The resident was dependent for all ADLs and at risk for urinary tract infection, but the correct technique was not used during observed care.
A resident with chronic respiratory failure and other medical conditions was found to have their oxygen nasal cannula left uncovered on the nightstand when not in use, contrary to physician orders and infection control guidelines. Both an LVN and the DON acknowledged that the cannula should have been covered to prevent possible infection, but the facility lacked a specific policy for this practice.
A resident's personal refrigerator contained an unlabeled and undated food item brought in by family or visitors, in violation of facility policy requiring perishable foods to be labeled and dated. Staff interviews confirmed that night nurses were responsible for monitoring the refrigerator, but the required procedures were not followed.
A medication aide did not clean a blood pressure cuff between uses before measuring the blood pressure of a resident with multiple chronic conditions and a non-healing wound. This action was observed by surveyors, and both the aide and DON confirmed that the cuff should have been cleaned according to facility policy.
A resident with multiple medical conditions experienced several falls, but the facility's fall risk assessment inaccurately indicated a low risk and did not document the resident's fall history. Additionally, required neuro checks after a fall were not properly documented, and both the DON and ADON confirmed the lack of accurate recordkeeping and absence of a specific policy on clinical record accuracy.
CNAs did not fully close the privacy curtain while providing incontinent care to a resident with severe cognitive impairment and frequent incontinence, resulting in exposure of the resident's genital area in the presence of a roommate. Both CNAs and the DON confirmed that privacy should have been maintained and that staff had received training on resident rights.
A facility failed to include a high fall risk in a resident's care plan, despite the resident's severe cognitive impairment and multiple diagnoses. The resident was identified as high risk for falls in the admission assessment, but the care plan was not updated until after the resident fell. The DON and MDS Nurse acknowledged the oversight, citing busyness as a factor.
A resident with severe cognitive impairment and multiple health conditions received inadequate incontinence care from two CNAs, who failed to follow proper cleaning techniques. The CNAs did not use a new wipe for each pass and did not clean the genital area correctly, which could lead to infections. Interviews with facility staff confirmed the improper technique and emphasized the risk of infection due to inadequate care.
A resident with a full code status was found unresponsive, but the nursing staff failed to initiate CPR due to a misunderstanding of the resident's code status. The LVN on duty did not verify the code status and mistakenly believed the resident was a DNR because she was on hospice. CPR was not performed until EMS arrived, and the resident was pronounced deceased. This incident highlighted a significant failure to adhere to emergency protocols in the facility.
A facility failed to document a physician's order to crush medications for a resident with difficulty swallowing, despite the order being communicated by hospice. This oversight was confirmed through staff interviews and record reviews, highlighting a lapse in following proper medication administration protocols.
A resident with Parkinson's disease and dementia exited a facility through an alarming door without staff response, despite wearing a wander guard. The alarm was heard by multiple staff members but was not acted upon immediately, leading to an Immediate Jeopardy situation. The facility's policy on elopement was not followed, and the incident was not treated as a true elopement, contributing to the deficiency.
A resident's personal health care information was exposed when an LVN left a medication cart unattended with a laptop displaying the resident's details. The resident had conditions including cerebral infarction and dysphagia. The LVN acknowledged the risk of unauthorized access, and the DON emphasized the need for privacy screens.
A resident was discharged without a discharge MDS in the electronic record, despite having Parkinson's disease and dementia. The MDS coordinator missed the discharge MDS due to an oversight in scheduling, and neither the DON nor the Administrator were aware of the issue. This failure to adhere to the facility's policy on MDS implementation was identified during interviews and record reviews.
A medication cart was found unattended and unlocked, contrary to facility policy, posing a risk of unauthorized access to medications. The LVN responsible for the cart admitted it should have been locked. The RN Supervisor and DON confirmed the expectation for carts to be locked when unattended, aligning with the facility's policy.
Failure to Refer Residents With Mental Illness for PASRR Screening
Penalty
Summary
The facility failed to coordinate assessments with the PASRR program for residents with newly evident or possible serious mental disorders. Survey review found that Resident #67, Resident #48, and Resident #7 were not referred for a Level I PASRR screening when they had diagnoses of mental illness, and the facility’s PASRR process did not accurately reflect their qualifying conditions. Resident #67’s record showed diagnoses of bipolar disorder and depression, with an admission MDS indicating intact cognition and a PASRR I screening that showed no evidence or indicator of mental illness. During interview, the MDS Nurse stated the PASRR screening was inaccurate and needed to be redone and submitted to the local health authority. Resident #67 stated he had carried a bipolar disorder diagnosis since discharge from the military. The ADON stated the MDS Nurse was responsible for referring residents with mental illness for Level I PASRR screening. Resident #48’s record showed diagnoses including schizophrenia unspecified, bipolar disorder, borderline personality disorder, and PTSD, along with regular antipsychotic and antidepressant use and a BIMS score of 15. His PASRR Level I screening indicated evidence of mental illness, but the MDS Coordinator/RN stated she had inaccurately coded the screening and that his diagnoses were qualifying diagnoses that should have been referred for PASRR evaluation. Resident #7’s record showed PTSD, a prior PASRR Level I screening that did not identify mental illness, and an annual MDS showing moderate cognitive impairment. The MDS Coordinator/RN stated Resident #7 should have had another PASRR Level I screening and referral to the local authority. The facility policy stated that when a PASRR is filled out incorrectly, the MDS coordinator will contact the corresponding case worker to correct the form.
Bathroom Sink Faucet Sprayed Water Onto Floor
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for Resident #53 by not ensuring the sink faucet in her bathroom was functional and did not spray water onto the floor. Resident #53 was admitted with diagnoses including rheumatoid arthritis, PTSD, and recurrent major depressive disorder. Her quarterly MDS showed a BIMS score of 15/15, indicating no cognitive impairment, and she was dependent on staff for personal hygiene. Her care plan documented an ADL self-care performance deficit related to impaired mobility and that she required assistance from one staff member for oral care management and personal hygiene. During observation and interview, Resident #53 stated she had used her power motorized wheelchair for mobility but had chosen not to get out of bed for some weeks. She reported that when she previously used the bathroom sink, the water sprayed outward instead of downward and had done so for months, and that she had told several CNAs but the faucet had not been fixed. Observation of the bathroom confirmed the faucet sprayed outward, and when the pressure was increased, water sprayed onto the floor, with a wet towel observed on the floor in front of the sink. A CNA stated she had reported the issue to the charge nurse weeks earlier and had also observed the problem herself. The MD stated he had received a work order about the faucet needing repairs but had not repaired it because other repairs were a higher priority, and he confirmed during observation that the water sprayed out of the sink and onto the floor.
Care Plan Did Not Address PTSD Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #7 that included measurable objectives and timeframes to meet his medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment. Resident #7’s face sheet showed he was admitted with a diagnosis of PTSD, and his annual MDS assessment dated 5/2/26 indicated a BIMS score showing moderate cognitive impairment and also listed PTSD. Review of the Comprehensive Care Plan dated 4/10/26 showed it did not reflect Resident #7’s PTSD diagnosis and did not address how staff would assist him in managing the condition. During observation on 6/03/2026, Resident #7 was sitting at a dining room table, and an attempted interview showed he did not engage in conversation and propelled away. The MDS Coordinator stated on 6/4/26 that she was responsible for completing care plans and acknowledged that Resident #7’s care plan did not reflect his PTSD, the care or services he would receive, or his mental status, and that this could result in staff not knowing how to address behaviors associated with PTSD.
Care Plan Not Updated After Foley Catheter Discontinued
Penalty
Summary
The facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after assessments for one resident. Resident #42’s quarterly MDS assessment showed intact cognition, no use of appliances, and occasional urinary incontinence, but the care plan still included a focus for toileting assistance and managing a Foley catheter, along with a separate care plan focus for an indwelling catheter with a goal related to remaining free from catheter-related trauma. The resident’s physician order summary contained no active Foley catheter orders, and the physician order recap showed the Foley catheter had been discontinued effective 03/15/2026. During observation, Resident #42 was seen in her room transferring herself from her wheelchair to the bed and adjusting her covers without difficulty, and no Foley catheter was present. The MDS Coordinator reviewed the record and stated the Foley catheter was no longer active, had been discontinued in March 2026, and had not been resolved in the care plan. She also stated the resident was mostly continent, with only 1 or 2 incontinent episodes in the last 2 weeks, and that the care plan should have been revised to reflect toileting needs. The Administrator stated the MDS Coordinator was responsible for care plan accuracy and that care plans should be revised as resident conditions change. The facility policy stated that assessments are ongoing and care plans are revised as information and conditions change.
Failure to Honor Resident’s Requested Diet Texture
Penalty
Summary
The facility failed to provide food that accommodated a resident’s preference for a regular diet, despite the resident’s repeated requests for non-mechanically altered food. Resident #53 was admitted with diagnoses including rheumatoid arthritis, PTSD, and recurrent major depressive disorder. Her quarterly MDS showed a BIMS score of 15 out of 15, indicating no cognitive impairment, and her care plan reflected that she was on a regular diet/mechanical soft with thin liquids and that staff were to honor her meal choices. The care conference record also noted that she complained of diet texture and that follow-up was planned. During observation and interview, Resident #53 stated she had lived at the facility for years, had no teeth, and could not stand the food because staff insisted on serving her a mechanical blended diet. She said she ordered her own food and had CNAs prepare instant oatmeal, pasta, and other items for her, and that she had asked repeatedly for regular food but staff ignored her. She stated she had been eating a regular diet for years without problems. Observation later showed a CNA delivering a lunch tray that included a blended beef tator tot casserole, mixed vegetables, and a smoothie; the resident accepted only the smoothie and returned the rest of the tray untouched. Staff interviews confirmed that Resident #53 was not eating the facility-provided meals and was instead obtaining other foods. A CNA stated the resident never accepted her meal trays and sometimes accepted drinks, while an LVN said the resident had always bought her own food and did not eat the facility food. The ADON and DOR stated the resident had previously worked with ST because she would eat while lying down and scooping food from the plate, and they expressed concern about possible choking, though they were not aware of any choking incidents. The MDS Coordinator stated the resident requested a diet upgrade to regular food at the care conference, reported having had a swallow study and being able to eat regular food, and that the request was denied without further discussion; she also stated the resident was not informed of the outcome.
Improper Beard Restraint Use and Hand Hygiene During Food Service
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen. During observation, Dietary Aide A was seen preparing a cheeseburger while wearing a beard restraint that covered his beard hair to his chin and side of face, but did not cover his mustache. Later, the same aide was observed in the dish washing room putting meal trays, steam table pans, and cooking utensils through the dish washing machine while his mustache remained exposed and the beard restraint still covered only his chin. During lunch service, [NAME] B was observed leaving the serving line to go to the pantry while wearing gloves, opening the pantry door, returning to the line with a bag of chips, opening the bag, reaching into the bag with a gloved hand, placing chips on a plate, covering the plate, and placing it on a tray. [NAME] B did not change gloves or wash hands when returning to the serving line and continued serving plates for lunch. In interview, [NAME] B stated she should have changed her gloves and washed her hands when she returned to the kitchen with the chips and put on new gloves to continue serving. In interviews, Dietary Aide A stated he had taken a drink and forgot to pull the beard restraint back over his mustache, and stated the beard restraint should have covered his facial hair. The Dietary Manager stated beard restraints should cover all facial hair and that staff should remove gloves, wash hands, and put on new gloves when leaving and returning to the line. The Administrator stated hair and beard restraints should always be worn in the kitchen and that staff should change gloves and wash hands after touching their face, clothing, eating, toileting, or touching unclean surfaces to prevent contamination of food or food borne illness. Facility policies and the Food Code cited hair restraints, hand washing, glove use, and prevention of cross contamination.
Inaccurate Face Sheet Diagnosis Documentation
Penalty
Summary
The facility failed to ensure that Resident #28’s medical record was accurately maintained in accordance with accepted professional standards because the resident’s face sheet did not include a diagnosis of pain. Record review showed the resident was a [AGE]-year-old male admitted on [DATE] and remitted on 7/23/2025 with diagnoses including bipolar disorder, dementia, and diabetes. The face sheet dated 6/3/26 did not list pain as a diagnosis, even though the resident’s history and physical dated 4/23/2025 documented pain, and the care plan had a focus on pain. Additional record review showed the resident’s June 2026 physician orders included Morphine Sulfate 30 mg, one tablet twice daily, and the resident stated he had experienced pain for years due to an old military back injury. The BIMS assessment completed 5/13/26 showed a score of 14, indicating intact cognition. The MDS nurse stated she was responsible for entering diagnoses on face sheets and that the pain diagnosis had not been entered, and she had not yet audited diagnoses against the corresponding histories and physicals. The ADON stated he had been in his role for two months and had not yet audited all prior admissions for face sheet accuracy. The facility policy stated documentation in the medical record would be objective, complete, and accurate.
Unlabeled Insulin Vial Found on Medication Cart
Penalty
Summary
The deficiency involves the facility’s failure to ensure that all drugs and biologicals were properly labeled and stored according to professional standards on one of two medication carts reviewed (the 300/400 hall medication cart). During an observation, surveyors found a vial of insulin on this cart that was not in a box and lacked a pharmacy prescription label and resident name, although it had an open date. The LPN responsible for the 300/400 medication cart stated that if a medication does not have a label, they usually discard it or contact the nurse previously in charge of the cart, and acknowledged that residents’ names should be on medications to track usage and prevent sharing among residents. In a separate interview, the DON stated that insulin should be labeled with the medication name, resident’s name, directions, and the date it is opened, and confirmed that the nurse is in charge of the medication cart while the pharmacy is responsible for labeling medications. The DON indicated that if a medication does not have a label, staff must contact the pharmacy for one, and acknowledged that an unlabeled insulin could result in giving the wrong person the wrong insulin. Review of the facility’s “Medication Labeling and Storage” policy, revised February 2023, showed that medication labels must include, at a minimum, the medication name, prescribed dose, strength, expiration date when applicable, resident’s name, route of administration, and appropriate instructions and precautions, which was not met for the unlabeled insulin vial found on the 300/400 medication cart.
Failure to Maintain Infection Control Practices and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for three residents. For one resident, a female with dysphagia, diabetes, chronic kidney disease, cognitive communication deficit, and muscle weakness, records showed she used a PureWick urinary system and was care planned as having a PURE WICK urinary system and being at risk for UTI, with interventions including catheter care and monitoring urine. She was also on Enhanced Barrier Precautions per signage at her room. During observation, her PureWick catheter was seen on a pad to the right of the bed with the tubing touching the floor. A CNA assigned to her care and the LVN overseeing her hall both acknowledged that the PureWick tubing should not be on the floor and identified this as an infection control issue and a risk of contamination. The DON stated catheter tubing should not be on the floor due to the risk of bacteria on the outside of the tube. The facility also failed to implement Enhanced Barrier Precautions (EBP) correctly for two other residents with wounds. One male resident with chronic kidney disease, urinary retention, dysphagia, and an unhealed pressure injury/ulcer had orders for heel protectors due to multiple unstageable wounds. Another resident also had wounds. The facility’s Enhanced Barrier Precautions Program, revised March 2024, stated that EBPs are indicated for residents with wounds and/or indwelling medical devices, including chronic wounds such as pressure ulcers and urinary catheters. However, observations showed that these two residents did not have EBP signage or supplies (such as a cart) by their doors. Nursing staff, including LVNs and the DON, stated that residents with wounds or indwelling catheters should be on EBP, that staff rely on signage and carts to know a resident is on EBP, and that lack of EBP or signage could result in cross contamination, spread of infectious diseases, or wound infections.
Medication Cart Left Unlocked and Unattended in Hallway
Penalty
Summary
A medication cart assigned to a nurse (LVN A) was observed on two occasions to be left unlocked and unattended in a hallway, with the drawers facing the hallway and accessible to staff, the public, and residents passing by. During these times, LVN A was inside a resident's room with the door shut and could not see the cart. The Director of Nursing (DON) and the Administrator witnessed the unlocked cart and confirmed that LVN A was responsible for it. Upon being questioned, LVN A acknowledged leaving the cart unattended and unlocked while providing care in the resident's room. A review of the facility's policy on medication labeling and storage indicated that all medications and biologicals must be stored in locked compartments and only authorized personnel should have access to the keys. The policy also specified that medication carts should not be left unattended if open or otherwise accessible. The observed practice was not in accordance with the facility's policy or accepted professional standards, as the medication cart was left accessible to unauthorized individuals.
Failure to Discard Expired Insulin and Timely Reorder Medications
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for several residents, specifically in the management and administration of insulin and antianxiety medications. For five residents reviewed, surveyors found that insulin pens (Humalog, Lispro, Novolog) were not discarded after the required 28 days from opening, as per facility policy and manufacturer guidelines. These insulin pens remained in the nursing carts past their expiration, and nursing staff were unable to provide a reason for not discarding them. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged that it was the nurses' responsibility to remove expired insulin but could not explain why this was not done. Additionally, one resident did not receive their prescribed Lorazepam 0.5 mg for anxiety for ten consecutive days because the medication was not available. The medication was not reordered in a timely manner, and there was a lack of communication between medication aides, nurses, and the ADON regarding the need for a refill. The facility's policy required medication aides to reorder medications before they ran out and to notify the charge nurse if medications were unavailable. However, this process was not followed, resulting in missed doses. The residents involved had significant medical histories, including diabetes, schizoaffective disorder, neurocognitive disorder, paraplegia, and anxiety disorder. At the time of the deficiencies, some residents had severe cognitive impairment, while others were cognitively intact. The failures in medication management were identified through observation, record review, and staff interviews, with staff confirming that the required procedures for medication disposal and reordering were not followed.
Failure to Date Opened Insulin Pens in Medication Storage
Penalty
Summary
Facility staff failed to ensure that all insulin pens for multiple residents were labeled with the date they were opened, as required by both manufacturer instructions and facility policy. During observations, insulin pens for four residents were found in the nursing cart without open dates. The labels on these insulin pens specified that they should be discarded 28 days after opening, but the absence of open dates made it impossible to determine if the insulin was still safe and effective for use. For each of the four residents, record reviews confirmed active orders for daily insulin administration, and medication administration records showed that the insulin was being given as prescribed. Interviews with the LVN revealed that the nurse was unaware of when the insulin pens had been opened and therefore could not determine if the insulin should be discarded. The LVN acknowledged that the pens should have been dated upon opening, in accordance with the label instructions, but did not know if or when this had occurred. The DON confirmed that facility policy requires all insulin to be dated when opened and discarded after 28 days. The DON stated that nurses are responsible for labeling insulin with the open date and that periodic reviews of nursing carts are conducted by DON and ADON. However, the DON was unable to explain why the nurses had not written the open dates on the insulin pens, acknowledging that this omission could result in improper use of insulin.
Failure to Ensure Required Staff Training for New and Existing Employees
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for all new and existing staff, as evidenced by the lack of required annual and initial trainings for 11 out of 23 employees reviewed. Personnel records showed missing documentation of mandatory trainings such as communication, QAPI, ethics, falls, HIV, restraint, emergency preparedness, and behavioral health for various staff members, including housekeepers, certified medication aides, certified nursing assistants, licensed vocational nurses, registered nurses, dietary aides, and the dietary manager. Specifically, the dietary manager did not receive required trainings upon hire, and several other staff members lacked evidence of receiving annual trainings as outlined in facility policy. Interviews with the HR Coordinator, DON, and Administrator confirmed that the facility's process involved the HR Coordinator initiating monthly in-service trainings, which were then distributed to department heads to present to their staff. However, the system relied on department heads to ensure completion, and the HR Coordinator to verify compliance, which did not consistently occur. The HR Coordinator acknowledged uncertainty regarding why all required trainings for the dietary manager were not completed upon hire and recognized the importance of staff receiving both initial and annual trainings. A review of the facility's in-service education policy revealed a comprehensive list of required training topics to be covered annually or upon hire, including but not limited to communication, QAPI, infection control, emergency preparedness, ethics, and abuse prevention. Despite this policy, the facility did not ensure that all staff received the necessary trainings, as evidenced by the gaps found in personnel records and confirmed by staff interviews.
Failure to Provide Annual Communication Training to Staff
Penalty
Summary
The facility failed to provide annual communication training to four staff members, including a housekeeper, a certified medication aide (CMA), a certified nursing assistant (CNA), and a licensed vocational nurse (LVN). Review of personnel records for these employees showed no evidence of communication training being completed within the previous 12 months, despite the facility's policy requiring annual training on this topic. The HR Coordinator was responsible for initiating monthly in-service trainings and providing them to department heads, who were then expected to present the trainings to their staff. However, the records indicated that the required communication training was not completed for these staff members. Interviews with the HR Coordinator, DON, and Administrator confirmed that the process for delivering and verifying in-service trainings relied on department heads to present the material and the HR Coordinator to verify completion. Despite this process, the communication training was not documented as completed for the identified staff. The facility's policy specified that an educational calendar should include communication as a required topic each year, but this was not reflected in the training records for the affected employees.
Failure to Provide Annual QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory annual training on its Quality Assurance and Performance Improvement (QAPI) program to five employees, including a housekeeper, a certified nursing assistant (CNA), a dietary aide, a certified medication aide (CMA), and a registered nurse (RN). Review of personnel records for these staff members showed no evidence of QAPI training being completed within the previous 12 months. The HR Coordinator confirmed that while monthly in-service trainings were conducted on various topics, QAPI training was not documented as being provided annually to these employees. The facility's policy requires annual education on the QAPI program, but this was not followed for the staff in question. Interviews with the HR Coordinator, DON, and Administrator revealed that the process for delivering in-service trainings involved the HR Coordinator preparing materials and department heads presenting them to their staff, with the HR Coordinator responsible for verifying completion. Despite this process, the required QAPI training was not completed or documented for the identified staff members. The lack of annual QAPI training was acknowledged by facility leadership as a gap that could leave staff uninformed about essential quality assurance practices.
Failure to Provide Annual Ethics Training to Staff
Penalty
Summary
The facility failed to provide mandatory annual ethics training to 7 out of 23 employees reviewed, including housekeeping, certified nursing assistants, registered nurses, and licensed vocational nurses. Personnel records for these staff members showed no evidence of ethics training being completed within the previous 12 months, despite their varying hire dates. The HR Coordinator was responsible for initiating monthly in-service trainings and providing them to department heads, who were then expected to present the trainings to their staff. However, the records indicated that the required annual ethics training was not completed for these employees. Interviews with the HR Coordinator, DON, and Administrator confirmed that the process for delivering and verifying in-service trainings relied on department heads to present the material and the HR Coordinator to verify completion. The facility's policy required an educational calendar that included compliance and ethics training, but the lack of documentation in personnel files demonstrated that this requirement was not met for the identified staff members.
Failure to Provide Required Annual CNA In-Service Training
Penalty
Summary
The facility failed to ensure that three out of six reviewed CNAs received the required minimum of 12 hours of annual in-service training. Personnel records for these CNAs showed no evidence of completion of the mandated training topics, such as communication, QAPI, ethics, falls, restraint, and emergency preparedness. The HR Coordinator reported that in-service trainings were initiated monthly and provided to department heads, who were responsible for presenting them to their staff. However, the HR Coordinator was responsible for verifying completion, and there was no documentation that the required trainings were completed for the identified CNAs. Interviews with the HR Coordinator, DON, and Administrator confirmed the process for distributing and verifying in-service trainings but revealed gaps in ensuring all staff completed the required annual training. Additionally, when requested, none of the facility leaders were able to provide a policy addressing the required minimum 12 hours of annual in-service for CNAs prior to the survey exit.
Failure to Provide Required Behavioral Health Training to Dietary Staff
Penalty
Summary
The facility failed to provide behavioral health training in accordance with federal requirements and its own facility assessment for two staff members in the dietary department. Specifically, the Dietary Aide I did not receive annual behavioral health training, and the Dietary Manager did not receive behavioral health training upon hire. Personnel records and training in-service documentation reviewed by the HR Coordinator showed no evidence that these required trainings were completed within the specified timeframes. Interviews with the HR Coordinator, DON, and Administrator confirmed that the process for delivering and verifying in-service trainings involved the HR Coordinator preparing monthly topics and department heads presenting them to their staff. However, the system did not ensure that all staff, including new hires and those requiring annual updates, received behavioral health training as required. The facility's policy indicated that behavior interventions should be included in the annual educational calendar, but this was not consistently implemented for all staff.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident with severe cognitive impairment and total dependence on staff for activities of daily living had their call light within reach while in bed. Observations on two separate occasions found the call light clipped to the privacy curtain, out of the resident's reach, while the resident was sleeping in bed. The resident's care plan specifically included interventions for call light placement within reach and prompt response, as well as reminders to use the call light for assistance. Interviews with staff confirmed that the call light was not accessible to the resident and that it was the responsibility of CNAs and nurses to ensure proper placement. The resident in question had multiple diagnoses, including epilepsy, essential hypertension, muscle weakness, and unspecified dementia, and was assessed as having severe cognitive impairment with total dependence for mobility and self-care. The facility's own policy required that call lights be within easy reach of residents when in bed or confined to a chair. Both the DON and the administrator acknowledged that the call light should have been accessible and that staff were responsible for ensuring this during rounds and room checks.
Failure to Complete and Transmit Discharge MDS Assessment Timely
Penalty
Summary
The facility failed to complete and transmit a discharge Minimum Data Set (MDS) assessment for one resident within the required timeframe. Specifically, the discharge MDS assessment for a resident with multiple diagnoses, including chronic systolic heart failure, respiratory failure, hypertension, atherosclerotic heart disease, and unspecified dementia, was not completed or transmitted to CMS as required. The assessment remained open and unfinished after the resident's discharge, and the MDS coordinator acknowledged that it should have been completed by day 14 post-discharge but was unsure why it was overlooked. Interviews with the MDS coordinator, DON, and administrator confirmed that the responsibility for completing and tracking MDS assessments rested with the MDS coordinator, and that monitoring was supposed to occur through scheduled meetings and reports in the facility's electronic system. However, the discharge MDS assessment for this resident did not appear on the in-progress report, and there was no clear explanation for the omission. The facility's policy required comprehensive assessments to be completed and submitted according to CMS guidelines, but this process was not followed in this instance.
Inaccurate MDS Assessment Coding for Medication Type
Penalty
Summary
The facility failed to ensure that a resident's assessment accurately reflected her medication status. Specifically, the quarterly Minimum Data Set (MDS) assessment indicated that the resident was receiving an anticoagulant, when in fact she was prescribed and administered clopidogrel, an antiplatelet medication. The MDS nurse acknowledged that this was a coding error, as clopidogrel should have been recorded as an antiplatelet, not an anticoagulant, according to the CMS RAI guidelines. The resident involved was an elderly female with multiple diagnoses, including urinary tract infection, cerebral palsy, heart failure, peripheral vascular disease, hypothyroidism, and cognitive communication deficit, with a BIMS score indicating severe cognitive impairment. Review of her physician orders and medication administration records confirmed she was receiving clopidogrel for blood thinning purposes, but not an anticoagulant. The facility's policy requires comprehensive and accurate assessments in line with CMS guidelines, which was not followed in this instance.
Failure to Include Smoking Status in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple medical conditions, including a history of transient cerebral ischemic attacks, cerebral vascular disease, hyperlipidemia, hypertension, and muscle weakness. The resident was assessed as having moderate cognitive impairment and was dependent on staff for most activities of daily living. Despite documentation in the resident's records and a smoking assessment indicating the resident was a smoker and required adaptive equipment such as a smoking apron, the comprehensive care plan did not include any interventions or objectives related to the resident's smoking status. Observations confirmed that the resident was actively smoking in the designated area while using a smoking apron, and interviews with both the resident and staff corroborated the resident's smoking status and the use of adaptive equipment. The MDS nurse acknowledged that it was her responsibility to include smoking in the care plan and admitted to overlooking this requirement, which resulted in the absence of a care plan addressing the resident's smoking needs. The facility's own policy requires that care plans include measurable objectives and timeframes for all identified needs, but this was not followed in this case.
Failure to Provide Proper Perineal Care for Incontinent Resident
Penalty
Summary
A certified nursing assistant (CNA) failed to provide appropriate perineal care to a female resident who was incontinent of bowel and bladder. During an observed episode of incontinence care, the CNA did not separate the resident's labia or clean the base of the labia, as required by facility policy and standard perineal care procedures. The CNA acknowledged during an interview that she forgot to perform this step due to nervousness. The Director of Nursing (DON) confirmed that the CNA had previously demonstrated correct perineal care skills during a competency check-off, but did not follow the correct procedure during the observed care. The resident involved had severe cognitive impairment, was dependent on staff for all activities of daily living, and had a history of frequent urinary and constant bowel incontinence. The resident's care plan included monitoring for signs and symptoms of urinary tract infection. Facility policy specifically required separating the labia and cleaning from front to back during female perineal care, which was not followed in this instance.
Failure to Cover Oxygen Nasal Cannula When Not in Use
Penalty
Summary
A deficiency was identified when a resident who required intermittent oxygen therapy was not provided with safe and appropriate respiratory care according to professional standards. The resident, who had multiple diagnoses including chronic respiratory failure, heart failure, and diabetes, had a physician's order for as-needed oxygen via nasal cannula and instructions to keep the cannula covered in a plastic bag when not in use. During an observation, the resident's nasal cannula was found uncovered on the nightstand while the resident was not present in the room. Interviews with both an LVN and the DON confirmed that the nasal cannula should have been covered in a plastic bag when not in use to prevent possible infection, as per the physician's order. However, the facility did not have a specific policy regarding the covering of nasal cannulas and masks when not in use. The failure to follow the physician's order and professional guidelines for infection control was documented through observation, interviews, and record review.
Failure to Enforce Food Storage Policy for Resident Brought-In Foods
Penalty
Summary
The facility failed to implement and enforce its policy regarding the use and storage of foods brought in by family and visitors for residents. During an observation of a resident's personal refrigerator, a small plastic cup containing food was found without a date or label. The facility's policy requires that perishable foods be stored in resealable containers with tightly fitting lids, labeled with the resident's name, the item, and a use-by date. However, this policy was not followed in this instance. The resident involved was an older female with multiple diagnoses, including type 2 diabetes mellitus, cholelithiasis, rheumatoid arthritis, intestinal obstruction, and dysphagia. She was cognitively intact and independent with eating. Interviews with staff, including an LVN and the DON, confirmed that night nurses were responsible for monitoring the resident's refrigerator daily, but the required labeling and dating of food items were not performed. This lapse in procedure was directly observed and acknowledged by facility staff.
Failure to Clean Blood Pressure Cuff Between Resident Uses
Penalty
Summary
A medication aide (MA C) failed to clean a blood pressure cuff between uses, specifically before measuring the blood pressure of a resident with multiple comorbidities, including chronic kidney disease, heart failure, type 2 diabetes mellitus, hypertension, and a chronic non-healing wound. The resident was severely cognitively impaired and required significant assistance with daily activities. The aide used the same blood pressure cuff on another resident and then on this resident without cleaning it, as observed by surveyors. Interviews with the medication aide and the Director of Nursing confirmed that the blood pressure cuff should have been cleaned between uses to prevent possible infection, in accordance with the facility's policy on cleaning and disinfecting reusable items. The failure to follow infection control protocols was directly observed and acknowledged by staff, and the facility's policy required such equipment to be cleaned and disinfected between residents.
Failure to Maintain Accurate Clinical Records and Fall Risk Assessments
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for a resident with multiple medical conditions, including diabetes, vascular dementia, and hemiplegia. Specifically, the fall risk assessment for the resident was inaccurate, as it indicated a low risk for falls despite the resident having experienced four falls within a six-month period. The assessment also failed to document a history of falls, and the fall prevention interventions were not updated following the assessment. The Director of Nursing confirmed the inaccuracy of the fall risk assessment and acknowledged that the resident should have been classified as moderate to high risk for falls. Additionally, the facility did not accurately document neurological checks following an unwitnessed fall. Although neuro checks were required every 30 minutes for three intervals after the fall, documentation was only present for the one-hour mark, with no records for the earlier checks. The Assistant Director of Nursing confirmed that the nurse reported performing the checks but failed to document them in the electronic record. Both the DON and ADON acknowledged the lack of accurate documentation and stated that there was no facility policy specifically addressing the accuracy of clinical records and assessments.
Failure to Provide Privacy During Incontinent Care
Penalty
Summary
Certified Nursing Assistants (CNAs) A and B failed to ensure personal privacy for a resident while providing incontinent care. During the provision of care, the privacy curtain was not completely closed, resulting in the resident's genital area being exposed. This occurred while the resident's roommate was present in the room. Both CNAs acknowledged that the privacy curtain should have been fully closed during care and confirmed that they had received resident rights training within the past year. The resident involved had significant cognitive impairment, as indicated by a BIMS score of 3, and was frequently incontinent of bowel and bladder. The care plan specified that the resident required extensive assistance with activities of daily living, including incontinence care, and directed staff to provide privacy by pulling the curtain around the bed. The Director of Nursing (DON) confirmed that privacy must be provided during care and that staff had been trained on resident rights and privacy policies.
Failure to Address High Fall Risk in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, and psychosocial needs. The resident, a 74-year-old male with severe cognitive impairment and multiple diagnoses including COPD, respiratory failure, atrial fibrillation, and type 2 diabetes, was identified as high risk for falls in his admission fall risk assessment. However, the care plan did not address this high fall risk until after the resident experienced an actual fall. The Director of Nursing (DON) acknowledged that the resident's high fall risk should have been included in the comprehensive care plan from the beginning. The MDS Nurse, responsible for completing the initial and quarterly care plans, admitted to missing the inclusion of the fall risk due to being very busy. The facility's policy requires that each resident be assessed for fall risk on admission and that interventions be developed and implemented based on the level of risk, but this was not done in a timely manner for the resident in question.
Inadequate Incontinence Care Leads to Deficiency
Penalty
Summary
The facility failed to provide appropriate incontinence care for a resident who was incontinent of bladder, which could lead to urinary tract infections. The resident, a male with severe cognitive impairment and multiple health conditions including type 2 diabetes and dementia, was observed receiving inadequate care from two CNAs. During the care, one CNA improperly cleaned the resident's genital area by using multiple passes with one wipe in a back-and-forth motion, rather than using a new wipe for each pass and cleaning in a proper outward motion. This improper technique was acknowledged by the CNA during an interview, who admitted to not being aware of the mistake until it was pointed out. Interviews with the staffing coordinator and the ADON revealed that the CNAs were trained to use a specific technique for incontinence care, which was not followed in this instance. The staffing coordinator and ADON both emphasized that improper cleaning techniques could lead to infections, as the area was not being properly cleaned. The facility's policy on perineal care was also reviewed, which outlined the correct procedure for cleaning male residents, including retracting the foreskin and cleaning the shaft of the penis. The failure to adhere to these procedures placed the resident at risk for developing infections.
Failure to Provide CPR to Full Code Resident
Penalty
Summary
The facility personnel failed to provide basic life support, including CPR, to a resident who required emergency care prior to the arrival of emergency medical personnel. The resident, an elderly female with a history of cerebral infarction, dysphagia, hyperlipidemia, and malignant neoplasm of the colon, was documented as a full code, meaning she should have received resuscitation efforts. However, when the resident was found unresponsive with no pulse or respirations, the nursing staff did not initiate CPR as required by professional standards of practice. The incident occurred when a CNA found the resident unresponsive and alerted an LVN, who mistakenly believed the resident was a DNR due to her hospice status and did not verify the code status. The LVN failed to initiate CPR and instead contacted hospice and the DON. It was only after reviewing the resident's chart later that the LVN realized the resident was a full code, but by then, it was too late to start resuscitation efforts. The hospice RN and EMS were eventually called, but CPR was not initiated until EMS arrived, and the resident was pronounced deceased shortly thereafter. Interviews with facility staff revealed a lack of adherence to protocol and a misunderstanding of the resident's code status. The DON confirmed that the LVN did not check the resident's EMR or chart for the correct code status at the time of the incident. The facility's protocol required verification of code status and initiation of CPR for full code residents, which was not followed in this case. The failure to provide timely CPR to a full code resident was identified as an Immediate Jeopardy situation, indicating a serious breach in the standard of care expected in such situations.
Failure to Document Physician Orders for Crushed Medications
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices for Resident #1, who required medications to be crushed due to difficulty swallowing pills. Despite having a physician order from hospice to crush medications, this order was not entered into the electronic medication administration record (EMAR). This oversight was discovered during interviews and record reviews, revealing that the order to crush medications was not properly documented in the EMAR, which could potentially lead to Resident #1 choking on uncrushed medications. Interviews with various staff members, including LVNs and a hospice nurse, confirmed that the order to crush medications was communicated but not properly entered into the EMAR. The facility's Director of Nursing (DON) acknowledged that the admitting nurse should have ensured the physician orders were correctly entered into the system. The facility's policy on medication administration emphasizes the importance of following the six rights of medication administration, which includes proper documentation. The failure to document the order to crush medications in the EMAR represents a significant lapse in following these standards, putting Resident #1 at risk for harm.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision for a resident who walked out of the facility through an alarming door without staff responding. The resident, who had a history of Parkinson's disease and dementia, was identified as being at moderate risk for wandering. Despite wearing a wander guard, the resident managed to exit the facility, triggering an alarm that went unheeded by staff for several minutes. This incident placed the resident at risk of being unsupervised, leading to the identification of an Immediate Jeopardy situation. Interviews with staff revealed that the alarm was heard by multiple employees, including a CNA and a Maintenance Director, but was not immediately acted upon. The Maintenance Director eventually noticed the resident outside and brought her back inside. Staff members, including a CNA and an LVN, admitted to hearing the alarm but did not respond due to being occupied with other tasks. The Director of Nursing and the Administrator did not consider the incident a true elopement since the resident did not leave the property, and thus did not notify the physician or the resident's representative. The facility's policy on elopement requires nursing personnel to report and investigate all reports of missing residents, but this was not followed in this case. The lack of immediate response to the door alarm and the failure to treat the incident as a serious elopement event contributed to the deficiency. The facility's inaction and lack of training on elopement response were significant factors leading to the deficiency, as staff were not adequately prepared to handle such situations.
Confidentiality Breach During Medication Pass
Penalty
Summary
The facility failed to protect the confidentiality of a resident's personal health care information during a medication pass. An LVN left a medication cart unattended for approximately five minutes, during which time the laptop on the cart displayed a resident's picture, name, and a progress note about their dietary intake via a PEG tube. This lapse in protocol was observed by surveyors, highlighting a breach in maintaining the privacy of resident information. The resident involved had been admitted to the facility with diagnoses including cerebral infarction, dysphagia, and depression. During an interview, the LVN admitted to not remembering leaving the laptop open and acknowledged the potential risk of unauthorized access to resident medical records. The Director of Nursing stated that the expectation was for the screen to be set to a privacy screen with no identifiable resident information visible. The facility's policy on confidentiality emphasized the importance of not sharing sensitive and personal information about residents.
Failure to Complete Discharge MDS for Resident
Penalty
Summary
The facility failed to ensure that assessments accurately reflected the resident's status, specifically for a resident who was discharged without a discharge Minimum Data Set (MDS) in the electronic record. This oversight was identified during interviews and record reviews, which revealed that the resident, who had been admitted with Parkinson's disease and dementia, was discharged without the necessary documentation. The resident's admission record indicated a discharge date, and a physician's order for discharge was signed, but the discharge MDS was missing from the resident's chart. Interviews with facility staff, including the MDS coordinator, Director of Nursing (DON), and the Administrator, revealed a lack of awareness and oversight regarding the missing discharge MDS. The MDS coordinator admitted to missing the discharge MDS due to an oversight in her scheduling process, which involved manually noting due dates in a calendar. The facility's policy on the implementation of the MDS, which requires comprehensive assessments to be completed and submitted according to CMS guidelines, was not adhered to in this instance.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as required by professional principles. During an observation, a medication cart assigned to an LVN was found unattended and unlocked, with the lock button unengaged. This incident occurred while the LVN was away from the cart for a few minutes to assist a resident's family member. The LVN acknowledged that the cart should have been locked when unattended. Interviews with the RN Supervisor and the Director of Nursing (DON) confirmed that the facility's expectation was for medication carts to be locked when not in use. The RN Supervisor stated that she ensures compliance by observing the carts on the floor, and both she and the DON recognized the risk of residents accessing medications not intended for them. A review of the facility's Storage of Medications policy reiterated the requirement for compartments containing medications to be locked when not in use and for transport trays or carts not to be left unattended.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 1,050 citations issued within 25 miles in the last 12 months — including the 21 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Converse
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Army Residence Community Health Care Center | 0.9 mi | ★★★★★ | 0 | 0 |
| Crestway Nursing & Rehabilitation | 1 mi | ★★★★★ | 2 | 0 |
| Advanced Rehabilitation & Healthcare Of Live Oak | 1.5 mi | ★★★★★ | 3 | 0 |
| Avir At Heritage | 2.8 mi | ★★★★★ | 3 | 0 |
| Windcrest Nursing And Rehabilitation | 3.5 mi | ★★★★★ | 12 | 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 July 2026) and official state health department websites.