Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Grace Care Center Of Henrietta during CMS and state inspections, most recent first.
Surveyors found that two outdoor dumpsters were overflowing with bagged garbage stacked above the rim, lids left open, and multiple trash bags and cardboard boxes on the ground. A CNA reported that staff routinely piled trash on top of full dumpsters or left it on the ground and that the dumpsters had not been emptied in weeks, despite concerns being reported to the Administrator. The Maintenance Director stated the dumpsters were not being collected due to nonpayment, acknowledged responsibility for trash on the ground, and admitted he had not recently hauled trash to the landfill. Both the Maintenance Director and Administrator recognized that the overflowing, uncovered dumpsters could attract pests.
The facility did not ensure complete and accurate documentation of insulin administration and blood glucose monitoring for four diabetic residents. Nurses failed to record insulin doses, blood sugar results, and meal announcements as ordered, with missing entries on multiple occasions. Staff interviews confirmed inconsistent documentation practices and uncertainty about whether required care was provided, despite facility policy requiring thorough recordkeeping.
Menus were not followed for 2 reviewed meals. For one meal, the DM substituted pork fritters for the planned beef entrée because brown gravy was unavailable, and residents were served a reduced meal that differed from the posted menu. For another meal, the DM substituted turkey bologna sandwiches and other items for the planned beef dinner because beef roast was too expensive for the budget. The substitution log did not document reasons for these changes, even though facility policy required substitutions to be recorded with the reason.
Food Storage and Handling Deficiencies in Kitchen: The kitchen had an empty paper towel dispenser at the handwashing sink, uncovered food on the stove top and on a shelf above the oven, and a chest freezer with thick frost buildup. In the refrigerator, cooked foods in resealable bags were stored on the same sheet pan as thawing raw pork loin, and multiple items were opened, unlabeled, undated, or not sealed, including sour cream, scrambled eggs, gravy, potato salad, tea, milk, cranberry juice, and peanut butter. The DM stated some items were leftovers, some dates were received dates, and the milk and cranberry juice had been opened that morning.
Failure to Timely Report Alleged Abuse: A resident with dementia, chronic pain, bipolar disorder, schizoaffective disorder, anxiety, diabetes, anemia, and seizures reported that a CNA was rough during care, used profanity, and closed her door after she asked it to stay open. An LPN notified the DON and RN, and the resident repeated the same concerns, but the allegation was not reported to the State Survey Agency right away because staff treated it as a grievance and were unsure whether it met the abuse-reporting threshold.
A resident with CVA, DM2 with CKD, HTN, A-fib, hypothyroidism, GERD, MDD, and an insulin pump had repeated UTI-related hospitalizations, including E. coli UTI resistant to multiple ABX and IV therapy, and later was admitted to Hospice. The comprehensive care plan was not updated to address recurrent/frequent UTIs, urinary incontinence, or Hospice services, and the Significant Change MDS did not select UTI in the infection section. Staff interviews confirmed no care plan was found for the recurrent UTI issues or Hospice services.
The facility failed to pay vendors and maintain essential services, resulting in disconnected phone and internet, an uninsured and unregistered van, and staff purchasing supplies out of pocket. Residents missed medical appointments, and staff had to substitute food and laundry supplies due to insufficient funds. Communication with families and providers was severely impacted, and the absence of an administrator contributed to ongoing operational failures.
The facility operated without a state-licensed administrator for an extended period, resulting in unpaid vendor bills and the loss of essential services such as phone, internet, food, and laundry. Staff, including the DON and maintenance director, used personal funds to purchase supplies for residents. The lack of van insurance and registration led to missed medical appointments for several residents, and communication with families and providers was severely disrupted. These failures led to Immediate Jeopardy due to the widespread impact on resident care and facility operations.
The facility did not ensure proper laundering of resident linens due to a broken hot water heater, lack of required sanitizing chemicals, and inability to service the washing machine, all stemming from unpaid vendor bills. Staff used non-standard cleaning products, and observations confirmed that linens remained stained and odorous after washing. Multiple staff and the DON were aware of the ongoing issue, while the CEO was not informed until interviewed. The facility had 23 residents at the time.
A resident with a history of multiple myeloma and poly osteoarthritis experienced persistent, severe pain and requested hospice care, which was ordered by the facility physician. However, hospice services were delayed for eight days due to a facility policy requiring CEO approval before ancillary services could be initiated, despite repeated requests from the resident, her POA, and staff. The delay was administrative, not clinical, and was contrary to facility policy stating hospice should be made available at end of life.
The facility did not maintain a working telephone for resident use after phone service was disconnected due to non-payment. Residents and their families experienced ongoing difficulties in communication, with staff and the ombudsman confirming repeated complaints and failed attempts to reach the facility. The lack of phone access persisted until a staff member provided a prepaid cell phone at their own expense.
Several residents did not receive timely medical care or hospice services due to the facility's failure to maintain van registration and insurance, which prevented transportation to critical doctor appointments. Additionally, a resident's request for hospice care was delayed for several days because of a requirement for corporate approval, despite a physician's order and ongoing pain.
A resident with a history of bone cancer and poly osteoarthritis experienced ongoing, inadequately controlled pain due to an 8-day delay in arranging hospice services, which was caused by a requirement for CEO approval. During this period, pain assessments and medication administration were inconsistent, scheduled pain medication doses were missed, and communication with the physician regarding breakthrough pain was lacking, resulting in a failure to provide pain management consistent with professional standards and the resident's care plan.
The facility did not ensure RN coverage for at least 8 consecutive hours daily, 7 days a week, for several months. Staffing records and interviews confirmed that there was no RN present on multiple days, especially during the DON's medical leave and on weekends, with only phone availability as backup. A policy on RN coverage was requested but not provided.
Multiple residents did not receive their scheduled medications on time, with some missing entire doses, due to the unavailability of the electronic MAR and lack of a paper backup. Additionally, a CMA administered an initial dose of a narcotic and performed a pain assessment, both outside her permitted scope of practice. Facility staff and physicians were not promptly notified of these medication errors, which affected residents with complex medical needs.
Multiple residents did not receive their scheduled morning medications, including antihypertensives, psychotropics, and cardiac drugs, until several hours late after a CMA delayed administration due to lack of access to the MAR following an internet outage. The delay affected residents with conditions such as dementia, hypertension, stroke, and heart failure, and facility physicians were not notified of the late administration as required by policy.
The facility did not follow its prepared menus for multiple meals due to ongoing food supply shortages and budget constraints, resulting in frequent meal substitutions and staff purchasing food out of pocket. Staff and dietary management reported insufficient funds to order required menu items, and the dietician was not always informed of or able to approve all substitutions. Despite these issues, there was no significant resident weight loss and residents reported satisfaction with the food.
The facility did not follow its Plan of Correction to ensure consistent RN coverage, failing to utilize a pool of RNs, arrange telehealth services, or review RN staffing in SOC meetings. QAPI meetings were not held as required, and RN coverage was not discussed or addressed, resulting in multiple days without RN oversight.
The facility failed to maintain RN coverage for at least 8 consecutive hours a day, 7 days a week, for 34 days over three months. This deficiency was confirmed through staffing data and timecard reports. The CNO acknowledged the policy requirement for daily RN coverage, but the facility did not meet this standard, potentially risking resident care.
The facility failed to prevent infection spread by transporting clean laundry in an uncovered cart through common areas. A housekeeping staff member and the LVN in charge were unaware of the requirement for covering laundry during transport, and the facility lacked a policy for clean laundry delivery.
The facility failed to provide adequate incontinent care for four residents, resulting in skin issues and discomfort. A resident with severe cognitive impairment was found with reddened skin and dried feces, while another with no cognitive impairment had a reddened scrotum and urine odor in his room. A third resident, dependent on total assistance, had dried feces and an open area on her coccyx. A fourth resident experienced burning sensations and stained bed sheets. Staff interviews revealed issues with training and access to care information.
The facility failed to conduct and document a comprehensive facility-wide assessment to determine necessary resources for resident care during routine operations and emergencies. The Administrator and DON acknowledged that the available assessment was outdated and inaccurate, with discrepancies in resident census and needs. Despite requests, no policy regarding the assessment was provided, potentially risking resident care.
The facility failed to implement policies to prevent abuse, neglect, and exploitation, as pre-employment screenings for several staff members were incomplete. Observations showed a CNA working without completed paperwork, and interviews revealed misunderstandings about screening responsibilities. The facility's policies were not followed, risking resident safety.
The facility failed to provide required training on abuse, neglect, and exploitation to its staff, including the DON, an LVN, and three CNAs. Personnel files lacked documentation of training for 2023 and 2024, and pre-hire training completions were missing for the CNAs. Interviews revealed awareness of the issue, but no additional documentation was available to demonstrate compliance with training policies.
A resident with severe cognitive impairment experienced mismanagement of personal funds by the facility, resulting in a negative balance. The facility failed to accurately track transactions during a staff transition, leading to overdrawn funds. The administrator acknowledged the issue and the facility's policy on managing funds was not followed.
A resident requiring maximum assistance for transfers was at risk due to a malfunctioning sit-to-stand mechanical lift with a broken wheel lock. Despite staff awareness of the issue, it was not reported, and the maintenance supervisor was unaware until informed by surveyors. The facility's policy mandates equipment readiness, but the lift was not promptly repaired, leading to a deficiency.
A resident with severe cognitive impairment experienced a burn incident after spilling coffee on herself. The facility failed to notify the resident's physician and representative promptly, with delays of several days. The facility's policy requires immediate notification of significant changes in a resident's condition, which was not followed in this case.
A resident with severe cognitive impairment experienced a coffee burn incident, but the LTC facility failed to document the incident and subsequent care accurately and promptly. The DON and an LVN assessed the resident's skin, noting it was pink with no blisters, but did not document these observations until four days later, leading to inaccuracies in the records.
The facility failed to employ a qualified Dietary Supervisor, as the individual did not complete the required dietary manager training course. Interviews and record reviews revealed that the Dietary Supervisor only had a food handler's certificate and not the necessary manager's safe food handling training or certification as a dietary manager.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards. Various food items in the refrigerator and dry storage were found without proper labeling or sealing, as confirmed by Cook A and the Dietary Supervisor. This was in violation of the facility's food storage policies.
A facility failed to provide appropriate urinary catheter care for a resident with neuromuscular dysfunction of the bladder and prostatic hyperplasia. The facility did not document the catheter type and size, did not irrigate the catheter as ordered, and failed to complete catheter care and output documentation every shift. The resident reported discomfort, and the family expressed concerns about inconsistent catheter care.
The facility failed to ensure RN coverage for at least 8 consecutive hours a day, seven days a week, during October and November 2023. Specifically, there was no RN coverage on three specific days. The DON and Administrator, both of whom were not employed during the deficiency period, confirmed the expectation for seven-day-a-week RN coverage.
A resident with diabetes and a pressure ulcer did not receive a carbohydrate-controlled diet with added protein powder as ordered by the physician. The dietary supervisor admitted to not following the specific dietary orders, and the resident was unaware of the need for protein powder in his meals.
The facility failed to ensure that a resident's indwelling urinary catheter bag was covered, compromising the resident's right to a dignified existence. Observations revealed the catheter bag was viewable from the hall, and interviews confirmed that the staff did not adhere to the care plan requiring the bag to be covered.
A facility failed to secure signed consents for the use of a security camera in a resident's room, violating privacy policies. The resident, with moderate cognitive impairment, expressed a desire for privacy and had not agreed to the camera's presence. The DON admitted the oversight, and the facility's policy requirements for electronic monitoring were not met.
The facility failed to provide proper respiratory care for two residents, including not changing oxygen tubing weekly and not properly storing nebulizer masks, potentially placing residents at risk for infections.
The facility failed to administer insulin on time for a resident with Type 2 Diabetes and Diabetic Chronic Kidney Disease. The insulin was administered late on multiple occasions, with delays ranging from over an hour to more than three hours past the scheduled time. This was confirmed through observations and interviews with the nursing staff and the DON.
The facility failed to secure medications on one of two medication carts and in the medication storage room. An LVN left Medication Cart A unlocked inside an unlocked medication room with the door propped open on two separate occasions. The DON confirmed that medications should be locked up anytime a nurse walks away from them, and the facility's policy states that medication carts should never be left open or unattended.
A facility failed to maintain accurate clinical records for a resident, including documentation of catheter care and medication administration. The DON confirmed the absence of required documentation despite staff training.
The facility failed to maintain an effective training program, resulting in several staff members missing critical training in areas such as communication, QAPI, behavioral health, HIV, restraint reduction, and falls. Interviews revealed systemic issues in the training process, with responsibilities divided between HR and department heads, leading to gaps in training compliance.
The facility failed to post the actual hours worked by licensed and unlicensed nursing staff (RNs, LVNs, and CNAs) per shift daily. Observations on multiple dates showed incomplete postings, which was confirmed by the DON and Administrator. The facility's policy requires posting of actual hours worked and census at the start of each shift.
The facility failed to maintain a training program to ensure staff were trained in effective communication. Two staff members, an RN and a CNA, did not receive the required communication training. The HR representative and DON admitted that some staff did not attend the in-service training meetings, and the facility did not adhere to its own policies on mandatory training.
The facility failed to ensure that all staff received training in Quality Assurance and Performance Improvement (QAPI), specifically RN B and CNA D. Record reviews and interviews revealed that the HR and department heads did not adequately ensure training compliance, placing residents at risk of receiving care from untrained staff.
The facility failed to ensure that three staff members received required behavioral health training, as revealed by record reviews and interviews. This failure could place residents at risk of receiving care from untrained staff. The HR and DON admitted to gaps in the training process, indicating a systemic issue in ensuring compliance with training requirements.
Improper Disposal and Overflow of Facility Garbage Dumpsters
Penalty
Summary
The facility failed to dispose of garbage and refuse properly for two outdoor dumpsters located at the back of the property. During an observation, both dumpsters were seen with lids open and unable to close because bagged garbage was stacked above the rim. Additionally, 11 bags of trash and 5 cardboard boxes were observed on the ground outside the dumpsters. The facility did not provide an Environmental Policy when requested by surveyors. In interviews, a CNA reported that staff had to pile trash bags on top of already full dumpsters and sometimes leave trash bags on the ground beside them, and stated that the dumpsters had not been emptied in weeks. The CNA also stated she had voiced concerns to the Administrator but nothing had been done. The Maintenance Director acknowledged responsibility for the trash on the ground and stated the dumpsters were overflowing because sanitation had not collected them due to lack of payment, and that he had not recently hauled trash to the landfill as he sometimes did. Both the Maintenance Director and the Administrator acknowledged that overflowing dumpsters and open lids could attract pests to the facility grounds and possibly into the facility.
Incomplete Documentation of Insulin Administration and Blood Glucose Monitoring
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for four residents with diabetes who required blood glucose monitoring and insulin administration. Specifically, the Medication Administration Records (MARs) and related documentation for these residents were found to be incomplete, with multiple instances where nurses did not initial or record insulin administration, blood glucose monitoring results, or meal announcements as ordered. These omissions were identified across several dates and affected both residents using insulin pumps and those receiving insulin injections. For example, one resident with type 1 and type 2 diabetes and an insulin pump had missing nurse initials for insulin administration, meal announcements, and blood glucose checks on several occasions. Another resident with similar diagnoses had missing documentation for both insulin and Ozempic administration, as well as for meal announcements and blood sugar checks. Two additional residents with type 2 diabetes, one of whom also had chronic kidney disease, had incomplete records for insulin injections, sliding scale insulin coverage, and fasting blood glucose checks. In several cases, the amount of insulin administered and the corresponding blood sugar levels were not documented as required. Interviews with staff revealed inconsistencies in the documentation process and uncertainty about whether medications and monitoring were performed as ordered. The DON acknowledged that there was no way to confirm if insulin was administered when documentation was missing. Staff interviews also indicated that the responsibility for blood glucose checks and insulin administration sometimes shifted between night and day shift nurses, and that documentation was not always completed in the electronic MAR. The facility's policy required detailed documentation of insulin administration and blood glucose monitoring, but this was not consistently followed for the residents reviewed.
Menus Not Followed for Planned Lunch and Dinner Meals
Penalty
Summary
The facility failed to ensure menus were followed for 2 of 2 meals reviewed for Food and Nutrition Services. The weekly planned menus were issued by the food vendor and were signed by the vendor's Registered Dietitian on 3/08/2025, with validity through 3/31/2026. The resident roster showed a census of 18, and the diet order list showed all residents received oral nutrition and none received feeding tubes. For the planned lunch menu on 7/27/25, the menu called for chopped steak with mushroom gravy, mashed potato casserole, multi-color cauliflower, wheat dinner roll, margarine, marbled cheesecake, 2% milk, and coffee. During observation, whole kernel corn was being heated and breaded meat patties were in the oven. The DM stated the breaded meat patties were pork fritters being substituted for Salisbury steak because brown gravy was unavailable, and she said she would order brown gravy the next day. At lunch service, residents were served pork fritters, mashed potatoes, and corn, and the white board in the dining room listed that meal as pork fritters, mashed potatoes, and corn. For the planned dinner menu on 7/28/25, the menu called for Italian beef sandwich, mixed waffle fries, sauteed peppers and onions, rocky road pudding, 2% milk, and coffee. The DM stated turkey bologna sandwiches with lettuce and sliced tomato were being substituted for the beef sandwiches because beef roast was too expensive for the budget. She also stated she kept a substitution log and had taken pictures of substitutions for the RD Consultant, but the notebook did not document a reason for the substitutions. Observation showed turkey bologna and cheese sandwiches, regular French fries, Italian blend vegetables, zucchini and yellow squash for pureed diets, and carnival chocolate chip cookies were prepared instead of the planned items. The facility policy required menus to be reviewed and approved by the Dietician and required substitutions to be documented with the reason for the substitution, but the substitution notebook contained no documented reasons for the 7/27/25 lunch or 7/28/25 dinner substitutions.
Food Storage and Handling Deficiencies in Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the kitchen. During the initial kitchen tour, the paper towel dispenser at the handwashing sink was empty, and the Director of Maintenance used paper towels from a roll at the 2-compartment sink after washing hands. At the same time, a stainless-steel pan of whole kernel corn with butter was uncovered on the stove top, and a baking sheet with 11 pieces of raw dough was uncovered on a shelf above the gas oven and grill. The DM stated the facility had not been able to get towels for that type of dispenser for a while. The refrigerator and freezer observations showed multiple food storage issues. A residential-style chest freezer contained thick frost buildup on the interior side surfaces. In the refrigerator, a baking sheet with sealed raw pork loin was stored on the bottom shelf, and the same sheet also held resealable bags of cooked foods including honey mustard pork loin, sweet potatoes, sliced sausage, breaded chicken patties, sliced turkey in gravy, sliced ham, and sausage patties. The DM stated the bags were cooked leftovers and were dated when placed in the bags, but the dates did not include use-by dates. The DM later stated the bags had been contaminated with blood from the pork loin and that two bags were outdated. Additional refrigerator and dry storage observations showed opened or stored food items that were not properly labeled, dated, or sealed. These included an opened container of sour cream dated 6/17/25 with a manufacturer best-by date of 7/20/2025, a container labeled scrambled eggs dated 7/23/25, a container that appeared to contain white/cream gravy but was not labeled, an opened carton of potato salad left open to the air, pitchers of tea dated 7/20/25, an open half-full gallon of milk dated 7/20/25, an open bottle of cranberry juice dated 7/22/25, and an open container of creamy peanut butter in dry storage with the lid not securely replaced. The DM stated the milk and cranberry juice were opened that morning, and stated the peanut butter date was the received date. The scrambled eggs remained in the refrigerator, and the DM stated they were used to make pureed eggs for breakfast and still had a day to use them.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving a resident was reported immediately to the administrator and to the State Survey Agency. Resident #2, a female with diagnoses including dementia, chronic pain, anemia, diabetes, schizoaffective disorder, bipolar disorder, anxiety, and seizures, was documented as cognitively intact on the quarterly MDS with a BIMS score of 13. Her care plan identified needs related to ADLs, pain, communication, hearing deficit, osteoporosis, medications, depression-related behaviors, vision deficit, weakness, and injury risk. On 7/25/2025, Resident #2 told an LVN that CNA B had been rude, used profanity, was rough during brief changes, and hurt her by “throwing” her around like a rag doll. The resident also said CNA B closed her door after the resident asked that it remain open because she was claustrophobic, and the resident stated she did not want CNA B to care for her anymore. The LVN told the resident she would report the concern to the DON, and later notified the DON and RN C. The resident repeated the same concerns when the DON, RN C, and the LVN met with her at bedside. The allegation was not reported to the State Survey Agency until 7/29/2025, after the facility had already treated the matter as a grievance and investigated it internally. Interviews showed staff disagreed about whether the complaint was abuse or a grievance, and the DON stated she did not perceive it as abuse at the time. The facility’s own policies stated suspected abuse must be reported immediately, and the mandatory reporting policy stated external reports must be made within required timeframes, including 24 hours for other allegations and 2 hours for serious bodily injury. The report also noted the facility called in a facility-reported incident regarding the resident’s allegations on 7/29/2025.
Failure to Update Care Plan for Recurrent UTI and Hospice Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #18 that included measurable objectives and timeframes to meet the resident’s identified medical, nursing, mental, and psychosocial needs. Resident #18 was an [AGE]-year-old female with diagnoses including cerebral infarction due to thrombosis of the middle cerebral artery, type 2 diabetes mellitus with chronic kidney disease, hypertension, atrial fibrillation, hypothyroidism, gastro-esophageal reflux disease, major depressive disorder, and presence of an insulin pump. Her record showed multiple hospitalizations related to UTI, including admissions for UTI with E. coli resistant to multiple antibiotics and IV antibiotic therapy. The resident’s record also showed an order to admit her to Hospice services with a diagnosis of cerebral infarction due to thrombosis of the unspecified middle cerebral artery. Review of the comprehensive care plan showed it was dated 10/27/2023 and revised 10/18/2024, but it was not updated after the resident’s significant change in condition. The care plan did not include interventions for frequent or recurrent UTIs, urinary incontinence, or Hospice care services, despite the resident’s documented hospitalizations and hospice admission. The Significant Change MDS assessment dated 7/11/25 showed the resident received antibiotic medication and Hospice care services, but the UTI diagnosis was not selected in the infection diagnosis section. During interview, the RN Corporate Nurse stated she did not locate a care plan addressing recurrent/frequent UTIs and did not find a care plan for Hospice services. The LVN Care Plan Nurse stated she completed comprehensive care plans and reviewed them every 3 months, and the Corporate RN stated the expectation was for the DON to enter acute care plans and/or care plans addressing new issues as needed between comprehensive reviews.
Failure to Maintain Essential Services and Timely Vendor Payments
Penalty
Summary
The facility failed to administer its operations in a manner that enabled effective and efficient use of resources, resulting in widespread unpaid debts and disruption of essential services. Key services such as phone and internet were disconnected due to non-payment, forcing staff to use personal cell phones and prepaid devices to conduct facility business and allow residents to communicate with their families. The facility van lacked insurance and current registration, preventing residents from attending medical appointments. Staff members purchased essential supplies such as milk, coffee, laundry soap, bleach, and incontinent briefs out of their own pockets because the facility did not provide adequate funds or pay vendors. Maintenance and laundry services were also compromised, with the hot water heater for laundry out of service for over a month and washing machines lacking proper chemicals and servicing due to unpaid bills. Multiple interviews with staff, including the DON, dietary manager, maintenance director, and housekeeper, confirmed that the facility was unable to purchase necessary supplies or maintain equipment due to outstanding vendor balances. The dietary manager reported substituting menu items because the food budget was insufficient, and staff had to buy food items themselves. The maintenance director and laundry supervisor stated that they could not obtain needed repairs or chemicals for laundry sanitation, and staff had to use cold water and inadequate cleaning agents. The lack of phone and internet service also hindered communication with families, physicians, and pharmacies, impacting the ability to send or receive critical information and documentation. Residents were directly affected by these deficiencies. Several residents missed important medical appointments because the facility van was uninsured and unregistered. One resident's family had to transport her to the ER, and the facility used the uninsured van to pick her up. Residents and their families expressed concerns about communication barriers and missed care opportunities. Staff and department heads repeatedly reported the lack of response from facility leadership regarding supply needs and unpaid bills, and the absence of an administrator further exacerbated the situation. The cumulative effect of these failures resulted in an Immediate Jeopardy situation, as essential care and services required for residents' well-being were not reliably provided.
Removal Plan
- The CEO and Managing Partner re-educated the COO on the governing board responsibility to ensure management and operation of the facility, emphasizing oversight of facility care and services and vendor payments.
- The CEO and COO will review and make payments or payment arrangements for outstanding vendor invoices, including telephone/internet, van insurance, van registration, fire and security vendor, and others. Emergency plans for communication and documentation (hot spots, paper MARs/TARs) will be implemented as needed.
- The DON will complete a Medication Error Form for each of the identified residents with medication errors, including communication with providers, responsible parties, management, and pharmacist consultant, and corrective actions.
- The DON will re-educate nurses and certified medication aides on policies for administering medications and medication errors, using one-on-one meetings and memos, and will conduct Medication Pass Observations.
- The CEO and COO will post the facility administrator's vacant position and continue active recruitment, with a sign-on bonus. Until filled, supply needs will be communicated to the DON and HR Director, with conference calls to ensure vendor payments and resident services.
- Staff will be reimbursed for out-of-pocket expenses per usual procedures, and HR will instruct staff not to purchase items for the facility in the absence of the administrator; all purchases will be made by the administrator and/or HR Director after the conference call.
- Annual van registration and insurance will be added to the annual maintenance checklist, with the administrator reviewing the checklist during QAPI to ensure renewal.
- An ad-hoc QAPI meeting will be held, and the Medical Director will be notified of the deficient practice and removal plan. Action items will be reviewed during QAPI meetings, with meeting minutes maintained.
Failure to Appoint Administrator and Maintain Essential Services
Penalty
Summary
The facility failed to ensure that a governing body appointed a state-licensed administrator responsible for managing the facility, resulting in a prolonged period without an administrator. During this time, the only administrative staff present were the DON and Human Resource Director, who reported that the facility had not been paying vendors, leading to the disconnection of essential services such as telephone, internet, and food deliveries. Staff members were forced to use their personal funds to purchase basic supplies for residents, including food, hygiene products, and laundry supplies, as the facility was unable to maintain regular operations due to unpaid bills. Multiple interviews with staff, including the DON, maintenance director, dietary manager, and others, revealed that the lack of an administrator and insufficient financial support from the governing body resulted in significant operational disruptions. The facility's phone and internet services were disconnected, making communication with families and healthcare providers difficult. The van used for resident transportation lacked insurance and current registration, causing residents to miss important medical appointments. Essential services such as laundry and food preparation were compromised, with staff reporting the use of cold water for laundry due to a broken hot water heater and the need to substitute menu items because of insufficient food supplies. Residents and their representatives expressed concerns about the absence of an administrator and the impact on care, including delays in hospice placement and missed medical appointments. The facility's inability to pay vendors also affected maintenance, with necessary repairs and services being delayed or denied. The cumulative effect of these failures led to the identification of Immediate Jeopardy, as the lack of oversight and resources placed residents at risk of decreased quality of life and care.
Removal Plan
- Re-educate the Chief Operating Officer (COO) on the governing board responsibility to ensure management and operation of the facility, with emphasis on oversight of facility care and services and vendor payments.
- Meet to review and make payments or payment arrangements for outstanding vendor invoices, including telephone/internet, van insurance, van registration, and fire/security services.
- If the internet is out, staff will use Hot spots for internet access; if Hot spots are not working, the DON will obtain paper-printed MARs and TARs from the pharmacy.
- The Social Worker will call each family to share the mobile phone number if/when needed.
- The Activity Director will complete resident interviews to identify residents affected by phone interruption and share with them the availability of mobile phone if needed.
- The Human Resource Director will contact the facility's vendors to share the phone number if/when required.
- Meet to review the facility's outstanding invoices and ensure vendor payments.
- The Director of Nursing (DON) will complete a Medication Error Form for each of the identified residents with medication errors, including communication with providers and corrective actions.
- The Chief Nursing Officer (CNO) will confirm completion of Medication Error Forms.
- The DON will re-educate nurses and certified medication aides on policies for administering medications and medication errors, using one-on-one meetings and memos, and will complete Medication Pass Observations.
- Provide education regarding obtaining MARs and TARs from the pharmacy if no internet is available, and Hot spots will be available for use.
- Post the facility administrator's vacant position and continue active recruitment, with a sign-on bonus.
- Communicate all items needed for resident care to the DON and HR Director, who will participate in conference calls with the CEO and COO to ensure vendor payments and supply needs.
- Continue conference calls with the new administrator once onboarded, and review minutes during QAPI to determine supply needs.
- Educate staff to communicate supply needs to HR, who will ensure supply is replenished before items run out.
- Educate laundry staff to notify HR when chemical supply is low.
- The Maintenance Director will monitor supply levels and communicate needs to HR.
- Department heads will monitor supplies and communicate needs to HR.
- Reimburse staff for out-of-pocket expenses per usual procedures, and HR will instruct staff not to purchase items for the facility in the absence of the administrator; all purchases will be made by the administrator and/or HR Director after the conference call.
- Add annual van registration and insurance to the annual maintenance checklist, and the administrator will review the checklist during QAPI.
- Hold an ad-hoc QAPI meeting, and notify the Medical Director of the deficient practice and removal plan; review action items during QAPI, with meeting minutes maintained.
Failure to Maintain Hygienic Laundry Practices Due to Lack of Hot Water and Sanitizing Chemicals
Penalty
Summary
The facility failed to properly handle, store, process, and transport linens in accordance with accepted national standards, resulting in unsanitary laundry conditions. The washing machine used for resident linens did not have hot water due to a broken hot water heater, and the machine itself displayed an error code and required servicing. The facility was unable to obtain necessary repairs or order the required sanitizing chemicals because of unpaid bills to vendors. As a result, staff resorted to purchasing bleach and laundry detergent themselves, which were not the required chemicals for proper sanitization. Multiple staff, including the Maintenance Director, Housekeeper, Laundry Supervisor, and DON, confirmed the lack of hot water, absence of proper chemicals, and inability to service the equipment. The CEO was unaware of the situation until interviewed. Observations revealed that linens stored in the facility were stained, had dark spots, and emitted a musty or urine odor, indicating inadequate cleaning. The laundry supervisor reported that the issue had persisted for over a month, and the problem had been reported to maintenance and corporate, but no resolution had occurred. The facility's census at the time was 23 residents. There were no reports of residents having skin issues or infections related to the laundry at the time of the survey.
Failure to Facilitate Timely Hospice Care per Resident Request
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not facilitating timely access to hospice care as requested by the resident. The resident, an elderly female with a history of multiple myeloma in remission and poly osteoarthritis, was cognitively intact and her own responsible party. She began experiencing significant, persistent pain and requested hospice services to help manage her symptoms. The facility physician promptly wrote an order for hospice care and increased pain medication, but the initiation of hospice services was delayed due to facility policy requiring CEO approval before ancillary services could be provided. Despite the resident's ongoing pain and repeated requests for hospice, as well as communication from the DON to the CEO requesting approval, no timely action was taken. The DON provided documentation of her request to the CEO, but did not receive a response. The resident, her POA, and facility staff all confirmed that the delay was due to the need for corporate approval, and the CEO later stated that hospice contracts had to be reviewed on a case-by-case basis. The resident continued to experience high levels of pain during this period, with pain scores consistently between 6 and 8 out of 10, and only partial relief from pain medications. Interviews with facility staff, the resident, and her POA confirmed that the delay in hospice initiation was not due to clinical reasons but rather administrative requirements. The facility's own policies stated that hospice services are available to residents at the end of life and that the DON or designee should contact the hospice agency to determine the resident's wishes. However, these policies were not followed, resulting in an eight-day delay before hospice services were finally initiated for the resident.
Failure to Provide Working Telephone for Resident Communication
Penalty
Summary
The facility failed to provide residents with a working telephone, resulting in a lack of access to communication with family members and representatives. The phone service was terminated after the facility did not pay the phone vendor, and the service was not restored. From the date of disconnection, residents were without access to a facility phone for several days until a staff member purchased a prepaid cell phone with personal funds. Multiple interviews with staff, family members, and the ombudsman confirmed ongoing difficulties in contacting the facility and residents, with reports of unanswered calls and busy signals when attempting to reach the facility number. Family members expressed frustration and concern over their inability to communicate with loved ones, and staff reported receiving personal calls from families seeking updates. Residents also reported being unable to contact their families due to the non-functioning phones. Observations by the investigator confirmed that the facility phone line remained inaccessible, consistently giving a busy signal. Review of the facility's Resident Rights policy indicated that residents are entitled to access to a telephone, which was not provided during this period.
Failure to Provide Timely Medical Appointments and Hospice Services Due to Transportation and Administrative Delays
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards, the comprehensive person-centered care plan, and residents' choices for several residents. Specifically, three residents did not attend their scheduled doctor appointments for follow-up and other medical needs due to the facility van being unavailable. The van was not used because its registration had expired and the insurance policy had been canceled, as confirmed by interviews with the Human Resource Director, DON, CNA, and the insurance company. Staff reported that the lack of van insurance prevented them from transporting residents to critical medical appointments, and there was no log of van usage during this period. One resident with multiple chronic conditions, including heart failure, diabetes, and kidney disease, missed nephrology and cardiology appointments that were not rescheduled in a timely manner. Another resident experiencing light vaginal bleeding was unable to be transported to her physician as requested, and although the physician offered to come to the facility, this did not occur. The resident was eventually transferred to the emergency room by ambulance. A third resident missed a primary care appointment for the same reason. Documentation and interviews confirmed that these missed appointments were directly related to the facility's inability to provide transportation due to the lack of van insurance and registration. Additionally, the facility failed to provide hospice services to a resident who requested them for uncontrolled pain, despite a physician's order and the resident's expressed preferences. The process was delayed because corporate approval was required before ancillary services could be initiated, resulting in an eight-day delay before hospice services were arranged. The resident, her POA, and the facility physician all expressed concern about the delay, and documentation showed that the resident continued to experience pain while waiting for hospice care. The facility's policy required communication with and access to services, but this was not followed in these cases.
Delay in Hospice Services and Inadequate Pain Management
Penalty
Summary
The facility failed to provide timely and appropriate pain management for a resident with a history of multiple myeloma in remission and poly osteoarthritis, who experienced frequent and significant pain. Despite the resident's request for hospice services due to uncontrolled pain, there was an 8-day delay in arranging hospice care, attributed to the facility's requirement for CEO approval before initiating such services. During this period, the resident continued to report pain levels that were not adequately controlled by the prescribed medications, and her care plan interventions were not fully effective in managing her discomfort. Documentation revealed that the resident's pain was assessed and pain medications were administered, but scheduled doses were missed on at least two occasions without the knowledge of the DON. The facility also failed to consistently document pain monitoring as ordered by the physician, and there was a lack of communication with the physician regarding the resident's breakthrough pain. The resident and her POA both expressed concerns about the delay in hospice services and ongoing pain, while the physician indicated that she expected her orders for hospice and pain management to be carried out promptly due to the critical nature of the situation. Interviews with facility staff and review of facility policy indicated that pain assessments and interventions were not always conducted or documented according to professional standards and the facility's own procedures. The CEO stated that the delay in hospice initiation was due to the need for contract approval, and considered the response time adequate, despite the resident's ongoing pain. The failure to promptly arrange hospice services and to consistently monitor and manage the resident's pain as ordered resulted in a deficiency in providing safe, appropriate pain management consistent with the resident's care plan and preferences.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week, as required. Record review and interviews confirmed that for 3 of 12 months reviewed, there was no RN coverage for multiple days, specifically 28 out of 47 days. The Human Resource Director and the Director of Nursing (DON) both confirmed that there was no RN coverage during the DON's medical leave and that, even after her return, RN coverage was only provided Monday through Friday. There was no RN present in the facility on weekends, although staff could contact the DON by phone if needed. The CEO also confirmed that the DON works only Monday through Friday and that no one had applied for the RN position to cover weekends. The DON acknowledged that during her absence, there was no RN coverage in the building. A facility policy regarding RN coverage was requested but was not provided by the time of exit. The lack of RN coverage was verified through staffing records and staff interviews.
Failure to Provide Timely and Accurate Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration of all drugs and biologicals to meet the needs of each resident. During a medication pass, twelve residents did not receive their scheduled medications as ordered. Specifically, two residents did not receive any of their 8:00 am medications, and multiple residents received their morning medications more than one hour after the scheduled administration time. The delay was attributed to the unavailability of the electronic Medication Administration Record (MAR) due to an internet outage, and the lack of a paper backup MAR until later in the morning. As a result, all morning medications were administered after 11:00 am on the affected day. Additionally, a Certified Medication Aide (CMA) operated outside her scope of practice by administering an initial dose of a narcotic medication and performing a pain assessment for a resident. According to state regulations and facility policy, CMAs are not permitted to administer the initial dose of a medication that has not been previously given to a resident, nor are they allowed to conduct physical, psychological, or social assessments that require professional nursing judgment. The CMA confirmed in interviews that she administered the first dose of morphine and assessed the resident's pain, actions which were not permitted under her certification. Interviews with facility staff, including the DON and facility physicians, revealed that the physicians were not notified of the late or missed medication administration. The DON was unaware that two residents did not receive their medications at all, and both physicians expressed concern upon learning of the delays and omissions. The facility's own policies and state regulations were not followed, resulting in medication errors including omissions and wrong-time administration for multiple residents with significant medical conditions such as heart failure, hypertension, diabetes, and cognitive impairments.
Significant Medication Administration Delays Due to MAR Unavailability
Penalty
Summary
Surveyors identified that the facility failed to ensure residents were free from significant medication errors, specifically for seven out of eleven residents reviewed. On a specific morning, a Certified Medication Aide (CMA) did not administer scheduled morning medications, including antihypertensives, psychotropics, and cardiac medications, at their prescribed times. Instead, these medications, which were ordered to be given between 7:00 am and 8:00 am, were not administered until after 11:00 am. This delay was confirmed through Medication Administration Record (MAR) reviews and interviews with staff and residents. The affected residents had various diagnoses, including Alzheimer's disease, hypertension, stroke, dementia, anxiety disorder, bipolar disorder, congestive heart failure, schizophrenia, and chronic kidney disease. Many of these residents were severely cognitively impaired, as indicated by low BIMS scores, while others were cognitively intact. Interviews with residents revealed that most were unaware of the late administration or could not recall if their medications were given late. The MARs for each resident confirmed the late administration of multiple critical medications, such as amlodipine, lisinopril, metoprolol, carvedilol, hydralazine, clonidine, depakote, buspirone, quetiapine, and amiodarone. The delay in medication administration was attributed to the unavailability of the electronic MAR and physician orders due to an internet outage. The CMA reported not feeling comfortable administering medications without access to the MAR and waited until a paper copy was provided, which did not occur until after 11:00 am. The Director of Nursing (DON) and facility physicians were not notified of the delay at the time it occurred. The facility's policy on medication errors defines omissions and wrong-time administration as errors and requires prompt physician notification of significant errors, which did not happen in this instance.
Failure to Follow Prepared Menus Due to Food Supply and Budget Issues
Penalty
Summary
The facility failed to follow menus that were prepared in advance for a period covering 11 meals, resulting in multiple substitutions due to insufficient food supplies. Staff interviews revealed that the facility experienced ongoing shortages of essential food items such as milk, bread, coffee, and sweeteners, with staff members and the dietary manager purchasing food out of their own pockets to supplement the supplies. The dietary manager reported that the allocated budget was insufficient to purchase the food required to follow the planned menus, leading to frequent substitutions and menu changes. The dietician was not always aware of or able to approve all substitutions, and the facility did not provide a dietary policy when requested by the investigator. Observations confirmed that food supplies in the pantry and storage areas were low, with only nonperishable items available for seven days and a lack of posted menus in the dining room. Staff interviews indicated that residents were not always informed about what was being served, and that menu substitutions were made based on what could be purchased within the limited budget. The dietary manager provided a detailed substitution log showing numerous instances where planned meals were replaced with alternative items due to cost or availability constraints. Despite these deficiencies, record reviews indicated that there was no significant weight loss among residents during the period in question, and residents reported that the food was good. However, the facility's failure to follow the prepared menus and ensure adequate food supplies was attributed to budgetary limitations and issues with vendor payments, as confirmed by the DON, Human Resource Director, and dietician. The dietician also expressed concerns about the food budget and acknowledged that she was not always informed of all menu changes.
Failure to Implement and Monitor RN Coverage and Quality Assurance Processes
Penalty
Summary
The facility failed to implement and maintain appropriate plans of action to address previously identified quality deficiencies, specifically regarding RN coverage. Despite a Plan of Correction (POC) that outlined the use of a pool of RNs from neighboring or sister communities to ensure at least 8 consecutive hours of RN coverage per day, 7 days a week, the facility did not follow through with these arrangements. Record reviews and interviews revealed that there was no RN coverage on multiple dates, particularly during the DON's medical leave and on weekends, as the DON only worked Monday through Friday. The facility also did not utilize telehealth RN services as previously planned, and staff were reportedly not trained or encouraged to use telehealth options. Additionally, the facility failed to conduct weekly reviews of RN coverage in Standard of Care (SOC) meetings as required by their POC, due to the absence of an Administrator and the discontinuation of regular SOC meetings. The facility also did not discuss these quality deficiencies in monthly QAPI meetings for three months, with only one QAPI meeting held during the period in question and no discussion of RN coverage documented. Job postings for RN positions were not provided, and there was no evidence of active recruitment for RNs. These failures resulted in periods without RN oversight, as confirmed by staffing records and interviews with facility staff.
Failure to Maintain RN Coverage 8 Hours Daily
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for at least 8 consecutive hours a day, 7 days a week, for 34 out of 92 days during the months of October, November, and December 2024. This deficiency was identified through a review of the PBJ Staffing Data Report, which showed no RN coverage on specific dates within this period. The absence of RN coverage was confirmed by the Human Resources department, which provided timecard reports indicating the lack of RN presence on the specified days. The Chief Nursing Officer (CNO) acknowledged the facility's policy requiring an RN to be on staff for 8 hours daily and stated that weekend coverage was available, with the CNO being reachable by phone 24/7 if needed. However, the facility's failure to maintain consistent RN coverage could potentially place residents at risk, as decisions requiring an RN's expertise in managing healthcare needs and monitoring direct care staff might not be made. The policy statement provided by the facility reiterated the requirement for RN services to be available for at least eight consecutive hours every day of the week.
Failure to Properly Transport Clean Laundry
Penalty
Summary
The facility failed to handle, store, process, and transport linens in a manner that prevents the spread of infection. During an observation, a housekeeping staff member was seen delivering clean laundry using an uncovered cart. The staff member transported the laundry to various rooms, moving the uncovered cart through common areas such as the lobby and dining room. Upon interview, the housekeeping staff member stated she was unaware that a cover was required for the cart during transport. Additionally, the Licensed Vocational Nurse (LVN) in charge at the time of the survey was also unaware of the requirement for covering clean laundry during transport and confirmed that the facility did not have a policy in place for the delivery of clean laundry. This lack of proper procedure and awareness could potentially place residents at risk for healthcare-associated cross-contamination and infections.
Inadequate Incontinent Care Leads to Resident Discomfort
Penalty
Summary
The facility failed to provide necessary bowel and bladder incontinent care for four residents, resulting in skin issues and discomfort. Resident #2, a female with severe cognitive impairment and chronic kidney disease, was observed with reddened skin and dried feces on her buttocks. Her care plan required prompt assistance, but no skin assessments were completed during the review period. Resident #3, a male with no cognitive impairment but requiring maximum assistance for ADLs, was found with a reddened scrotum and a strong urine odor in his room. His care plan included regular checks for incontinence, but similar to Resident #2, no skin assessments were documented. Resident #4, a female dependent on total assistance, was observed with dried feces and an open area on her coccyx, indicating a lack of proper incontinent care. Resident #7, a male with moderate cognitive impairment, experienced burning sensations and had dark red skin in the groin area. Observations revealed stained bed sheets and inadequate care. Interviews with staff highlighted issues with training and access to care information, as a new CNA was not properly set up to access resident care plans. The facility's failure to adhere to its policy on resident rights and dignity was evident, as no specific policy on maintaining hygiene was provided by the administration.
Failure to Conduct and Document Facility-Wide Assessment
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. This deficiency was identified during interviews and record reviews, revealing that the facility had not updated its assessment to reflect current resident needs and census. The Administrator admitted that the only available assessment was outdated and inaccurate, and it was found in the emergency preparedness book. Additionally, the Director of Nursing (DON) was unaware of who was responsible for maintaining the assessment and confirmed that it was not up to date with the current resident census. The facility's emergency preparedness book contained outdated acuity levels for evacuation purposes, with discrepancies in the total resident census and specific resident needs. The document titled Facility Assessment, found by the Administrator, was also outdated and lacked accuracy. Despite multiple requests for the facility's policy regarding the assessment, the Administrator was unable to provide any additional documentation or policy. This lack of a current and accurate facility-wide assessment could potentially place residents at risk of not receiving the necessary care and services required.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to develop and implement written policies and procedures to prevent abuse, neglect, exploitation of residents, and misappropriation of resident property. This deficiency was identified in the files of four employees, including three CNAs and one LVN, where pre-employment screenings such as criminal background checks, EMR, and NAR checks were not completed before their employment dates. The absence of these checks could place residents at risk for abuse, neglect, and exploitation. Observations revealed that one CNA was in possession of blank new hire paperwork on her first day of work, and she was instructed to work the floor before completing her paperwork. Interviews with the ADM indicated a lack of awareness regarding the incomplete pre-employment screenings and a misunderstanding of the requirements for completing these checks before allowing staff to provide care. The ADM believed that the responsibility for these checks lay with the Human Resources department, which was shared between three facilities. The facility's policies on abuse prevention and employee screening were not adhered to, as evidenced by the lack of documentation in the employee files. The ADM and Human Resources acknowledged the deficiencies in the files and the ongoing efforts to rectify them, but at the time of the survey, the necessary pre-employment checks had not been completed for the employees in question.
Lack of Staff Training on Abuse and Neglect
Penalty
Summary
The facility failed to provide necessary training to its staff on critical areas such as abuse, neglect, exploitation, and misappropriation of resident property. This deficiency was identified during interviews and record reviews, which revealed that the Director of Nursing (DON), a Licensed Vocational Nurse (LVN A), and three Certified Nursing Assistants (CNA E, CNA F, and CNA G) had not received the required training for 2023 or 2024. The personnel files lacked documentation of pre-hire training completions for the CNAs, and the DON and LVN A had no records of training for the past two years. Interviews with the Administrator (ADM) and Human Resources indicated awareness of the missing training documentation and acknowledged the disorganized state of the files. The facility's policies, including the Abuse Prevention Program, mandate that all new employees receive in-service training on abuse prohibition before working a shift, and current employees must receive annual training. However, the facility did not adhere to these policies, as evidenced by the lack of training records. The ADM confirmed that there was no additional documentation available to demonstrate compliance with the training requirements. This oversight could potentially impact resident care and increase the risk of abuse due to insufficient staff training.
Mismanagement of Resident's Personal Funds
Penalty
Summary
The facility failed to properly manage the personal funds of a resident, leading to a negative balance in the resident's trust account. The resident, who has severe cognitive impairment and is her own responsible party, was found to have a negative balance of $369.63 in her trust account. This occurred after a series of transactions, including a credit from Social Security and debits for room and board and cash disbursements, which were not accurately tracked by the facility. The facility's administrator admitted to not having answers regarding the resident's trust funds and acknowledged that the facility was not keeping accurate records during a transition of staff. The administrator explained that the business office manager (BOM) position was shared among three facilities, which contributed to the mismanagement of funds. The facility had taken out more money than the resident had in her account, leading to the negative balance. The administrator also mentioned that the facility gave the resident additional money despite knowing her account was overdrawn. The facility's policy on managing residents' personal funds states that they should act as a fiduciary and inform residents in advance of any charges, which was not adhered to in this case.
Inadequate Supervision and Equipment Maintenance
Penalty
Summary
The facility failed to provide adequate supervision and assistance devices to prevent accidents for a resident who required maximum assistance with transfers using a mechanical lift. The resident, a male with a history of type 2 diabetes, chronic kidney disease, cerebral infarction, and muscle weakness, was observed using a sit-to-stand mechanical lift with a broken wheel lock. This malfunction was noted during an observation where the lift moved during a transfer, despite staff attempts to steady it. Interviews with staff revealed that they were aware of the broken lock but had not reported it, and the maintenance supervisor was also unaware of the issue until informed by the surveyors. The facility's policy requires equipment to be ready for use at all times, but the broken lift was not addressed promptly, posing a risk to residents. The maintenance supervisor later contacted the company responsible for inspections to fix the lift, but there was no expected arrival date for the necessary part. The facility's failure to maintain the mechanical lift in proper working condition and ensure staff awareness and reporting of equipment issues led to the deficiency.
Failure to Notify Physician and Representative of Resident's Burn Incident
Penalty
Summary
The facility failed to promptly notify a resident's physician and representative of a significant change in the resident's condition following a burn incident. The incident occurred when the resident spilled coffee on herself, resulting in burns to her lower extremities. Despite the incident occurring on May 10, 2024, the physician was not notified until May 13, 2024, and the resident's representative was informed on May 14, 2024. This delay in communication was contrary to the facility's policy, which mandates immediate notification of the physician and representative in the event of a significant change in a resident's condition. The resident involved was an elderly female with a history of lung cancer, Alzheimer's Disease, and cognitive deficits. Her cognitive impairment was severe, as indicated by a BIMS score of 03. The facility's records showed that the resident's skin was initially intact and pink with no blisters, but by May 13, 2024, the skin on her thighs was peeling. The facility's policy requires that any significant change in a resident's condition, which impacts their health status and requires intervention, should be promptly communicated to the physician and the resident's representative. The failure to adhere to this policy could result in care issues, as acknowledged by the Director of Nursing during an interview.
Failure to Document Resident Incident and Care
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident who experienced a coffee burn incident. The resident, a female with severe cognitive impairment due to Alzheimer's Disease and other conditions, spilled coffee on herself, resulting in burns on her lower extremities. Despite the incident occurring on May 10, 2024, there were no nursing notes, incident notes, or progress notes documented until May 14, 2024. The Director of Nursing (DON) and a Licensed Vocational Nurse (LVN) assessed the resident's skin on the day of the incident, noting it was pink with no blisters, and changed her clothes. However, this assessment and subsequent observations were not documented until four days later, leading to inaccuracies in the records. The DON admitted to failing to document the immediate treatment provided, such as applying cool rags, and acknowledged that the documentation entered later was incorrect. The facility's policy requires documentation of resident care upon admission and as needed, but this was not adhered to in this case. The lack of timely and accurate documentation could result in improper documentation, as noted by the DON. The facility's failure to document the incident and the resident's condition accurately and promptly was a significant deficiency in maintaining clinical records according to professional standards.
Failure to Employ Qualified Dietary Supervisor
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition services. Specifically, the Dietary Supervisor did not complete an approved dietary manager training course. This deficiency was identified through interviews and record reviews, which revealed that the Dietary Supervisor only had a food handler's certificate and not a manager's safe food handling training. Additionally, there was no documented evidence that the Dietary Supervisor had completed a certified dietary manager course, despite being employed in this position since February 2023 and starting the dietary manager course in July 2023. Interviews with the Business Office Manager (BOM) and the Dietary Supervisor confirmed that the necessary training and certifications had not been completed. The Dietary Supervisor's job description required her to be a graduate of an accredited course in diabetic training approved by the American Diabetic Association and to be registered as a Food Service Director in the state. The facility's Professional Staffing policy also stipulated that a qualified director of food and nutrition services must be a certified dietary manager or a certified food service manager. The U.S. Food and Drug Administration's 2022 Food Code further specified that the person in charge must be a certified food protection manager who has shown proficiency through passing a test that is part of an accredited program.
Failure to Properly Store and Label Food Items
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an observation of the facility kitchen, it was found that various food items in the refrigerator were not labeled with an open date or identifier. Items such as Sweet N Sour sauce, a gallon jar of an unknown substance, a bag with a sliced lemon, a bottle of ketchup, a bag with sliced sandwich turkey, ground hamburger meat, containers of donuts, and apple fritters were all found without proper labeling. Cook A confirmed that any opened food item needed to be labeled with an identifier and date, which was not done in these instances. In the dry storage area, similar issues were observed. Items such as a bag of brown sugar, a bag of small marshmallows, a 50-pound bag of rice, a loaf of bread, and a bag of dinner rolls were found without open dates or proper sealing. The Dietary Supervisor confirmed that the expectation was for all food to be labeled and dated upon opening and stored in sealed containers. The facility's policies for food storage, both for dry goods and cold foods, were reviewed and indicated that all foods should be properly sealed, labeled, and dated, which was not adhered to in these instances.
Failure to Provide Appropriate Urinary Catheter Care
Penalty
Summary
The facility failed to ensure that a resident who was incontinent of bladder received appropriate treatment and services. Specifically, the facility did not document the urinary catheter type and size in the physician's order for a resident with neuromuscular dysfunction of the bladder and prostatic hyperplasia. Additionally, the facility did not irrigate the resident's urinary catheter as ordered and failed to complete urinary catheter care and output documentation every shift as required by the physician's orders. The resident, who had a moderate cognitive impairment, reported discomfort and pressure from the catheter, which was not being flushed or cleaned regularly. The resident's family member also expressed concerns about the catheter care not being performed consistently and attempted to discuss these issues with the facility's administrator. The resident's attending physician's assistant confirmed that the catheter size ordered was incorrect and that the catheter care instructions were not being followed accurately. The Director of Nursing acknowledged that the orders were not documented correctly and that the catheter care, irrigation, size, and output should have been completed and documented accurately. The facility's policy on bowel and bladder continence management was not adhered to, leading to potential risks for the resident, including urinary tract infections and catheter-related trauma.
Failure to Provide RN Coverage 7 Days a Week
Penalty
Summary
The facility failed to ensure the use of the services of a registered nurse (RN) for at least 8 consecutive hours a day, seven days a week for two of the three months reviewed (October and November 2023). Specifically, there was no RN coverage on October 1, October 15, and November 19, 2023. The Director of Nurses (DON), who started on November 8, 2023, confirmed that she was not employed by the facility in October 2023 and stated that her expectation was for the facility to have seven-day-a-week RN coverage. The Administrator, who was also not employed during the deficiency period, echoed this expectation. The lack of RN coverage on the specified dates could place residents at risk of not having their healthcare needs managed properly.
Failure to Follow Physician-Ordered Diet
Penalty
Summary
The facility failed to ensure that a resident received a carbohydrate-controlled diet with added protein powder as ordered by the physician. The resident, a male with type 2 diabetes mellitus, chronic kidney disease, and an unstageable pressure ulcer, was observed eating a meal that did not comply with his dietary restrictions. The resident was unaware of the need for protein powder in his meals and reported never having received it. The dietary supervisor admitted to not using protein powder in the resident's food and stated that for carbohydrate-controlled diets, she would simply remove the bread, which is not in accordance with the physician's orders. Interviews with the Director of Nursing (DON), the Administrator, the registered dietician, and the resident's physician all confirmed that the expectation was for physician-ordered diets to be followed precisely. The failure to adhere to these dietary orders was acknowledged as a liability and a potential cause for poor clinical outcomes, such as delayed wound healing and increased blood sugar levels. The facility's policy on therapeutic diets mandates that all diet orders be prepared according to the guidelines in the approved diet manual and the individualized plan of care, which was not followed in this case.
Failure to Cover Catheter Bag Compromises Resident Dignity
Penalty
Summary
The facility failed to ensure that Resident #16's indwelling urinary catheter bag was covered, compromising the resident's right to a dignified existence, self-determination, and communication. Observations revealed that the catheter bag was hanging from the resident's chair without a privacy bag, and it was viewable from the hall due to the open door. The resident expressed a desire for the bag to be covered but did not want to make a fuss about it. Despite having a privacy bag available, it was not used, and the staff failed to adhere to the care plan that required the catheter bag to be covered. Interviews with the LVN and the DON confirmed that the catheter bag should have been covered according to the care plan. The LVN was unsure why the bag was not covered, and the DON acknowledged that the failure to cover the catheter bag could place residents at risk for dignity issues. The facility's policy and procedures on dignity and catheter bag covers were requested but not provided at the time of the survey exit.
Failure to Secure Consent for Security Camera Use
Penalty
Summary
The facility failed to ensure personal privacy by not securing signed consents for the use of security cameras for a resident. Specifically, a security camera was operational in a resident's room without obtaining consent from the resident who occupied the room. The resident, who had moderate cognitive impairment and was independent in her activities of daily living, expressed her desire for privacy and stated that the camera was from a previous occupant. The camera was not pointed at her bed but towards the other side of the room, which was unoccupied. There was no sign indicating that the room was being electronically monitored, and the resident had not agreed to the camera's presence. The Director of Nursing (DON) revealed that the camera was initially placed for a previous resident and had not been removed. The DON admitted that the facility did not realize the current resident had not consented to the camera's presence. The facility's policy required a completed request form for authorized electronic monitoring, consent from any roommates, and a conspicuous notice at the room's entrance. None of these requirements were met in this case, leading to a violation of the resident's privacy rights.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to ensure that respiratory care for two residents was provided in accordance with professional standards and the residents' care plans. For Resident #5, who has chronic combined systolic and diastolic heart failure and chronic pulmonary disease, the facility did not change the oxygen tubing weekly as required. Observations revealed that the oxygen tubing was dated 3/18/2024, and the humidifier bottle was not dated, despite the resident receiving oxygen therapy. The resident was unable to recall when the tubing was last changed, indicating a lapse in the facility's adherence to the care plan and infection control protocols. For Resident #30, who has obstructive pulmonary disease and severe cognitive impairment, the facility failed to properly store the nebulizer mask and date the tubing. The nebulizer mask was observed on the nightstand without being stored in a bag, and the tubing was not dated. The resident was unable to provide information about the mask, and the Director of Nursing confirmed that nebulizer masks should be stored in plastic bags when not in use to prevent cross-contamination and infection. These deficiencies highlight the facility's failure to follow its own policies and procedures for respiratory care, potentially placing residents at risk for infections and communicable diseases.
Failure to Administer Insulin on Time
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically in the administration of insulin for Resident #14. The resident, a 76-year-old female with Type 2 Diabetes and Diabetic Chronic Kidney Disease, had specific physician orders for insulin administration at 7:00 AM. However, the insulin was administered late on multiple occasions in April 2024, with delays ranging from over an hour to more than three hours past the scheduled time. This failure was observed and confirmed through interviews with the nursing staff and the Director of Nursing (DON), who acknowledged that nurses often got behind on medication passes due to assisting other staff members, leading to the late administration of insulin. On April 29, 2024, it was observed that LVN B was running behind on the medication pass and had not administered the insulin to Resident #14 at the scheduled time of 7:00 AM. The insulin was eventually administered at 8:44 AM, well past the ordered time. The DON confirmed that the expectation was for medications, including insulin, to be administered as per physician orders and acknowledged that the staff had been trained on the importance of timely medication administration. The facility's policy on medication administration emphasized the importance of administering medications at the right time, dose, and route, but this was not adhered to in the case of Resident #14.
Failure to Secure Medication Cart and Room
Penalty
Summary
The facility failed to ensure medications were secured on one of two medication carts and in the medication storage room. During an observation and interview, a Licensed Vocational Nurse (LVN) left Medication Cart A unlocked inside an unlocked medication room with the door propped open. The LVN admitted that this was accidental and acknowledged that it could allow residents to access the medications. This incident was observed on two separate occasions, with the LVN stating that she thought the medication room door was closed and that she was responsible for the medications in the cart. The Director of Nursing (DON) confirmed that the expectation is for medications to be locked up anytime a nurse walks away from them and that staff are trained on these expectations. The Administrator was observed putting up a new sign on the medication room door to remind staff that the door should be closed and locked at all times when unattended. The facility's policy and procedure on Medication Administration, dated January 2013, clearly states that medication carts should never be left open or unattended. Despite this policy, the failure to secure the medication cart and room was observed, indicating a lapse in adherence to established protocols. This deficiency could potentially allow residents to gain access to medications, posing a risk of drug diversion.
Failure to Maintain Accurate Clinical Records
Penalty
Summary
The facility failed to maintain accurate and current clinical records for a resident, specifically in relation to catheter care and medication administration. The resident, a male with multiple diagnoses including congestive heart failure, neuromuscular dysfunction of the bladder, hypertension, and prostatic hyperplasia, had an indwelling catheter. The facility's records indicated that the catheter was changed as per the order, but there was no corresponding nursing note documenting this change as required by the facility's policy. Additionally, the facility did not maintain accurate medication records for the resident. There were multiple instances where medications were not documented as given, refused, or held. The medications in question included treatments for hypertension, constipation, neuromuscular dysfunction of the bladder, chronic idiopathic constipation, reflux, dry eyes, major depressive disorder, intestinal obstruction, hypothyroidism, moderate pain, and anemia. The lack of documentation spanned several dates and times, and the nursing notes did not reflect any reasons for the missed documentation, such as the resident being absent from the facility. In an interview, the DON confirmed the absence of documentation for the catheter change and the medication administration. She acknowledged that all nursing staff had been trained on documentation and following orders, and she was responsible for ensuring that documentation was entered. The facility's policy on documentation was reviewed, but a copy of the policy covering documentation and medication administration was not provided at the time of the exit interview.
Failure to Maintain Effective Staff Training Program
Penalty
Summary
The facility failed to maintain an effective general training program for its staff, resulting in several deficiencies. Specifically, the facility did not ensure that RN B, LVN C, CNA D, and CNA E received necessary training in areas such as communication, QAPI, behavioral health, HIV, restraint reduction, and falls. Personnel files revealed that these staff members were missing critical training components, which are essential for providing competent care to residents. The HR department was responsible for orientation training, while department heads were tasked with ensuring ongoing training. However, this division of responsibilities led to gaps in training compliance, as evidenced by the missing training records for the staff members reviewed. Interviews with the HR and DON highlighted systemic issues in the training process. The HR indicated that while she conducted monthly in-service training sessions, it was up to the department heads to ensure their staff received the necessary training. The DON admitted that some staff members did not attend the in-service meetings and were too busy to review the training materials later. This lack of follow-through and accountability resulted in staff members not being adequately trained, as required by the facility's policies and handbook. The facility's failure to ensure comprehensive training for all staff could place residents at risk of receiving care from untrained or incompetent staff members.
Failure to Post Actual Nursing Hours Worked
Penalty
Summary
The facility failed to post the actual hours worked by licensed and unlicensed nursing staff (RNs, LVNs, and CNAs) directly responsible for resident care per shift daily. Observations on multiple dates revealed that the daily nursing staffing information was posted but did not include the total numbers of actual hours worked for each direct care staffing type. This omission was confirmed by the Director of Nursing (DON), who acknowledged that the form was incomplete and did not meet the facility's policy requirements. In an interview, the Administrator confirmed that the policy was not followed, as the total numbers of actual hours worked for RNs, LVNs, and CNAs, as well as the census at the beginning of each shift, were missing from the posting. The facility's policy, revised in September 2014 and reviewed in November 2019, mandates that facility census and nursing staff information be posted on each shift, including the actual number of hours of direct care provided. The failure to comply with this policy could affect residents and visitors who may want to know the staffing levels and actual hours worked per shift daily.
Failure to Maintain Effective Communication Training for Staff
Penalty
Summary
The facility failed to maintain a training program to ensure staff were trained in effective communication. Specifically, two staff members, RN B and CNA E, did not receive the required communication training. RN B was hired on 08/22/2022, and CNA E was rehired on 12/15/2023. The HR representative stated that while she was responsible for orientation training, each department head was responsible for subsequent trainings. The Director of Nursing (DON) admitted that some staff did not attend the in-service training meetings and that she would inform them to read the material and sign the sheets later, which often did not happen due to their busy schedules. The facility's policy on training compliance and the employee handbook both emphasize the importance of attending orientation and mandatory in-service training sessions. However, the record review revealed that the facility did not adhere to these policies, as evidenced by the lack of communication training for RN B and CNA E. This failure to ensure all direct care staff were trained on communication could place residents at risk of receiving care from untrained staff.
Failure to Ensure Staff Training in QAPI
Penalty
Summary
The facility failed to maintain a training program to ensure staff were trained in Quality Assurance and Performance Improvement (QAPI) for two staff members, RN B and CNA D. Record reviews revealed that RN B, hired on 08/22/2022, and CNA D, hired on 03/15/2024, did not receive the required QAPI training. Interviews with the HR representative and the Director of Nursing (DON) indicated that while the HR was responsible for orientation training, department heads were responsible for subsequent trainings. The HR representative mentioned that in-service training sheets were signed by attendees, but it was the responsibility of each department head to ensure their staff received the trainings. The DON admitted that some staff did not attend the meetings and were too busy to complete the training materials later, leading to gaps in training compliance. The facility's policy on training compliance and the employee handbook both emphasized the importance of mandatory training and attendance at designated meetings. However, the failure to ensure that all staff, including RN B and CNA D, received QAPI training placed residents at risk of receiving care from untrained or incompetent staff. The deficiency was identified through record reviews and interviews, highlighting a lapse in the facility's training program and oversight by department heads.
Failure to Ensure Behavioral Health Training for Staff
Penalty
Summary
The facility failed to maintain a training program to ensure staff were trained in behavioral health, affecting three out of ten reviewed staff members (RN B, CNA D, CNA E). Record reviews revealed that these staff members did not receive the required behavioral health training. RN B was hired on 08/22/2022, CNA D was hired on 03/15/2024, and CNA E was rehired on 12/15/2023. This lack of training could place residents at risk of receiving care from incompetent or untrained staff. The facility's policy mandates that all newly hired employees attend orientation within the first five days of employment and participate in compliance training within 30 days of employment, which was not adhered to in these cases. Interviews with the HR representative and the Director of Nursing (DON) revealed gaps in the training process. The HR representative stated that while she was responsible for orientation training, each department head was responsible for ensuring their staff received ongoing training. The DON admitted that some staff did not attend the in-service training meetings and were too busy to review the training materials later. This indicates a failure in the facility's system to ensure that all staff members receive the necessary behavioral health training, as required by their policies and federal law.
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 20 citations issued within 25 miles in the last 12 months — 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 Henrietta
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Midwestern Healthcare Center | 16.6 mi | ★★★★★ | 19 | 0 |
| Senior Care Health & Rehabilitation Center - Wichi | 16.6 mi | ★★★★★ | 0 | 0 |
| Swan Health At Wichita Falls | 18.1 mi | ★★★★★ | 0 | 0 |
| Courtyard Gardens | 18.4 mi | — | 0 | 0 |
| Advanced Rehabilitation And Healthcare Of Wichita | 19.3 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.