Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Greenville Health & Rehabilitation Center during CMS and state inspections, most recent first.
Incomplete care planning for wandering, splint use, and activities: A resident with dementia and wandering behaviors was found attempting to exit and later near the exit door, yet the physician’s recommendation for a secure unit was not implemented and no interventions were added for his bathroom-seeking behavior. Another resident with dementia and right-hand contractures had an order for a resting hand splint, but the splint was missing and no care plan addressed it. A third resident with multiple chronic conditions had stated activity preferences, but no activity care plan was in place and he reported having no current activity calendar.
Activities Program Not Directed by Qualified Professional: The facility did not have a qualified Activity Director in place, and residents reported not receiving the July activity calendar. A resident and a confidential resident group stated there was no longer an activity director, and the Administrator had to sit in at resident council because the role was vacant. The DON confirmed resident council was affected, and record review found no documentation that the facility had an Activity Director with the required certification, approved training, licensure, or other qualifying documentation.
The facility failed to keep the resident environment free of accident hazards and to provide adequate supervision for three residents. A resident with dementia and wandering behaviors attempted to elope, but her risk was not reassessed after the incident. In another room, insect spray was left on a resident’s dresser, and in a third room, purple top disinfectant wipes were found in a resident’s bathroom. Staff and leadership stated these items should not have been left in resident areas.
Expired and undated medications were found on multiple med carts, including OTC meds, insulin, and nasal and suspension medications. Staff interviews showed nurses and medication aides were expected to date opened meds, remove expired items, and pass meds as ordered, but there was no system in place to check the carts.
Medication storage was not maintained as required when a resident’s Nystatin powder was found in a bedside dresser and another resident had Nystop fungal powder on a dresser and sore throat spray on top of a personal refrigerator. Both residents were cognitively intact and had active medication orders for topical Nystatin. Staff, including the DON and Administrator, stated that meds were not to be left in resident rooms and were to be locked in the medication cart or medication room.
Food was not consistently palatable or served at an appetizing temperature for two residents and during a lunch tray observation. One resident said meals were cold and needed more seasoning, another said the food could be more seasoned and served hotter, and the sampled tray had lukewarm, dry pork loin, lukewarm bland broccoli, and sticky rice. Staff reported resident complaints about cold and poorly seasoned food, and the Administrator stated the facility did not have a policy for palatable food.
Unsafe food storage and poor kitchen sanitation were observed in the dietary area. Undated, unsealed food items were found in the walk-in cooler, and the ice scoop holder, can opener blade, microwave, blender, and deep fryer all had visible buildup or debris. Staff were also observed with hair restraints not fully covering the head, and a dietary staff member stirred pureed chicken with a spoon taken from the prep sink before washing it.
Infection Control and PPE Use Failures During Resident Care and Isolation Room Entry: Staff did not consistently follow PPE, hand hygiene, and perineal care practices during observed care for a resident with a urinary catheter and enhanced barrier precautions, a resident who was incontinent and required extensive assistance, and a resident on contact isolation for a UTI. An OT entered a resident’s room without a gown, a CNA performed incontinent care without changing gloves or completing hand hygiene between tasks, and a floor tech entered an isolation room without PPE before handling the sanitizer dispenser.
Failure to communicate with a resident in his preferred language. A resident with dementia and severe cognitive impairment was identified as Spanish-speaking, but staff did not consistently provide Spanish communication or translation assistance. Interviews showed limited Spanish fluency among staff, use of Google Translate or family members for interpretation, and the resident indicated that staff did not speak Spanish and that only some people understood him.
Missed Scheduled Showers and Hygiene Care: A resident who required maximal assistance for bathing and other ADLs did not receive showers as scheduled, and shower records did not show bathing over several days. The resident was observed with oily hair and reported she had not been showered in over a week and felt unclean. CNAs said showers were sometimes missed because of time and other duties, and the DON and Administrator stated showers were expected per schedule and refusals should be documented.
Failure to Complete Ordered Wound Care for Toe Wound: A resident with DM and cellulitis to the right great toe did not receive ordered daily wound care, and the treatment record had blanks showing missed care. The toe was observed red, open, and without a bandage, and the LVN stated she was unaware of the wound care order and did not complete the care on multiple days. The ADON and DON were unaware the scheduled wound care was not being completed.
Improperly Secured Indwelling Catheter: A cognitively intact male resident with an indwelling urinary catheter was observed multiple times with no catheter strap or securement device in place, and he stated it had been missing for about 2 weeks. An OT later found the securement device hanging on the drainage line instead of attached to the resident’s leg, and an LVN replaced it. The DON and Administrator stated the strap should always be secured and that nursing staff and CNAs were responsible for ensuring it was in place.
A resident with COPD and another resident requiring continuous oxygen were observed with oxygen set above the ordered rate, and the first resident’s HHN tubing was also found unbagged on the nightstand. Records showed both residents had physician orders for specific oxygen settings, and staff later verified the oxygen was not set as ordered and that the nebulizer tubing should have been bagged when not in use.
Surveyors found a medication error rate above the allowed threshold after observing two medication administration errors involving two residents. An LVN administered insulin that appeared to be expired to a resident with DM, and a medication aide gave the wrong dose of Slow-Mag and did not administer ordered Potassium to another resident with CHF, COPD, hypoxia, dementia, and DM. The DON stated staff were expected to read the MAR and give medications as ordered.
Expired insulin was administered to a resident with diabetes when an LVN checked the resident’s blood sugar, prepared Novolog, and gave 2 units before noticing the vial appeared to be expired. The resident was cognitively intact and had orders for sliding scale insulin. The DON and Administrator stated nurses were expected not to give expired insulin, and facility policy required medication to be administered per order and opened vials to be dated and discarded within the required timeframe.
Expired Food Handler Permit for Dietary Aide: The facility failed to ensure a dietary aide had a current food handler permit. Record review showed the aide’s certificate had expired, and the aide stated she was not aware it had expired. The Dietary Manager said she was responsible for tracking the 2-year training requirement but overlooked the expiration date, and the Administrator stated dietary staff were expected to have certificates before they expired.
A resident with protein-calorie malnutrition, dementia, anxiety, and dysphagia was ordered fortified foods with every meal, but the Dietary Manager prepared fortified pudding with condensed milk instead of the regular milk called for in the recipe. The tray card identified the item as fortified pudding, and the dietician, DON, and Administrator all stated the kitchen was expected to follow the recipe and physician orders.
Failure to Honor a Resident Food Preference: A resident with a hx of cerebral infarction due to embolism of the right cerebellar artery was observed with apples on her lunch tray even though she stated she did not like apples and had requested a substitution. The Dietary Manager said she should have substituted the fruit but forgot, while the RD, DON, and Administrator stated the resident should have received her preference or a substitute and that alternative foods were expected to be available.
Therapeutic Diet Not Provided as Ordered: A resident with severe cognitive impairment, malnutrition risk, and adult failure to thrive did not receive ordered nutritional supplements at lunch. The meal ticket showed a magic cup, fortified pudding, and a plate guard were to be served, but observation found the resident without the supplements and eating only about half of his meal. A NA reported the resident had missed the prescribed shake and pudding on multiple occasions, while the RD, Dietary Manager, LVN, DON, and Administrator all confirmed the supplements were ordered and should have been provided.
Failure to provide an ordered plate guard: A resident with severe cognitive impairment, malnutrition risk, and an eating setup/clean-up care plan did not receive his physician-ordered plate guard at a meal, and food was observed falling off his plate until surveyor intervention. Staff, including NA, LVN, RD, Dietary Manager, and DON, acknowledged the plate guard was needed to assist him with eating and that it was not provided as ordered.
Incomplete PASRR Service Documentation: A resident with bipolar disorder, seizures, rhabdomyolysis, and state level II PASRR-identified ID had a care plan and PCSP recommending habilitation coordination and behavior support services, but the EMR contained no notes documenting those services. The Habilitation Supervisor said the agents visited monthly but left no documentation at the facility, while the SW, DON, and Administrator acknowledged there was no system to track PASRR services or ensure documentation after visits.
Missing Hospice IDG Documentation and Care Coordination: The facility failed to coordinate hospice care and maintain current hospice binder documentation for two residents receiving hospice services. One resident's binder lacked the updated hospice IDG notes, medication list, and plan of care, and the medication list did not include an ordered PRN Ativan. The other resident's binder had no IDG documentation. Interviews showed confusion between hospice and facility staff about who was responsible for updating and reviewing the binders, while the DON and Administrator acknowledged the binders were incomplete.
Loose Flooring, Wallpaper, and Baseboard in Resident Areas: The facility failed to maintain a safe, functional, sanitary, and comfortable environment when loose flooring was observed under a resident’s bed, wallpaper behind the headboard was coming loose, and a baseboard on 300 hall was peeling away from the wall. The resident, who had AFib, HF, dementia, and required extensive ADL assistance, said the floor and wallpaper had been deteriorating for an unknown period. A CNA reported the tile had been coming up for months and the wallpaper issue had been recurring, while the Maintenance Supervisor said he was not aware of the issues when asked.
Failure to complete quarterly smoking evaluation for a dependent smoker. A resident with dementia was identified as needing direct supervision to smoke, but the record showed no updated smoking evaluation after the initial assessment. Staff stated smoking assessments were to be completed on admission and quarterly, and an observation found the resident smoking with difficulty holding the cigarette.
A resident with moderate intellectual disabilities, dementia, severe cognitive impairment, and major functional limitations was identified as PASRR positive and the IDT determined he would benefit from a customized wheelchair. However, the facility did not submit the request for the CMWC in the LTC online process, and staff gave conflicting accounts about whether it had been ordered. The PASSR Representative confirmed the request had not been submitted, while the DOR acknowledged he did not follow up and later learned the resident was not eligible for Medicaid wheelchair coverage because he had no applied income.
The facility failed to ensure that several residents received scheduled bathing and hygiene care as outlined in their care plans and the shower schedule. Three residents with varying cognitive and physical statuses required supervision or assistance with bathing, yet multiple scheduled shower days lacked completed shower sheets, and the electronic record did not indicate whether showers or bed baths were actually provided. When interviewed, residents reported not receiving showers as scheduled and could not recall recent bathing, while observations showed matted or disheveled hair, unshaved appearance, and unclean odor. CNAs and LVNs confirmed there was a shower schedule and a process for completing shower sheets and reporting refusals and skin concerns, but they could not explain missing documentation or confirm that showers occurred. Leadership stated expectations that showers be completed and monitored, but the missing records, staff statements, and resident conditions demonstrated that routine bathing and grooming needs were not consistently met.
Four residents did not receive scheduled showers or adequate hygiene care due to missed or incomplete documentation, lack of staff availability, and inconsistent adherence to the shower schedule. Residents reported not being offered showers or only receiving bed baths, and staff interviews confirmed challenges in completing all scheduled showers and confusion about documentation procedures.
A resident with moderate cognitive impairment was denied access to his personal funds and had a pre-need funeral plan purchased against his wishes by the administrator, despite previously expressing he did not want such a plan. The resident's debit card was not functional for daily use, and unauthorized withdrawals were made from his account. Staff concerns about misuse of the resident's funds were not addressed, resulting in a deficiency related to resident rights and self-determination.
Two residents were involved in the unauthorized use of another resident's debit card, with staff also participating in attempted ATM withdrawals and other transactions without proper authorization. The affected resident, who had dementia and moderate cognitive impairment, was unaware of multiple unauthorized withdrawals and did not give permission for staff or other residents to use his card beyond a single instance. Facility staff failed to report or act on these incidents in a timely manner, and administration did not recognize the extent of the misappropriation, resulting in financial loss and emotional distress for the resident.
A resident with moderate cognitive impairment and multiple medical conditions was subjected to unauthorized use of his debit card by staff and other residents, with staff failing to follow abuse prevention policies or conduct a timely investigation into the misappropriation of funds, despite being aware of repeated incidents.
Staff failed to promptly report incidents of alleged abuse, neglect, and misappropriation, including an attempted unauthorized ATM transaction using a resident's debit card and a resident-to-resident altercation. In both cases, required notifications to the administrator and state authorities were delayed, and staff did not follow established reporting procedures.
A resident with moderate cognitive impairment was not adequately protected from misappropriation of personal funds when staff and other residents accessed or attempted to access the resident's debit card without proper authorization. Multiple unauthorized withdrawals occurred, and staff failed to thoroughly investigate or report the incidents as required by facility policy.
Two residents did not receive their prescribed therapeutic diets and fortified foods as ordered by their physicians. One resident with severe cognitive impairment and dysphagia was not given fortified food, Ensure Clear, or water as indicated on her tray card, while another resident with diabetes and anemia did not receive fortified mashed potatoes at lunch. Staff interviews confirmed that dietary staff did not prepare or serve the required fortified foods, and the dietary manager and DON acknowledged the oversight.
Staff failed to consistently follow infection control protocols, including proper use of PPE and hand hygiene, when caring for residents on COVID-19 isolation. Communication breakdowns led to staff being unaware of which residents were COVID-positive, and PPE was not always available outside isolation rooms. These lapses resulted in improper implementation of isolation precautions and noncompliance with facility policy.
The facility failed to maintain resident dignity during dining services. Staff referred to residents needing assistance as 'feeders,' and an LVN was observed standing while feeding a resident, contrary to expected practices. Both actions were recognized as dignity issues by the staff and administration.
Several residents in the facility experienced abuse due to ineffective management of known behavior problems. A resident was shoved by another in the dining room, and another was hit on the head by a different resident. Additionally, a resident was struck with silverware, and another was slapped for reaching into a Christmas bag. Despite care plans addressing behavior issues, these incidents highlight a failure to protect residents from abuse.
The facility failed to implement its policies on reporting abuse, as evidenced by two resident-to-resident altercations that were not reported to the state agency within the required timeframe. One incident involved two male residents with cognitive impairments, leading to a physical confrontation over a wheelchair. The second incident involved two female residents, one with heart failure and the other with dementia, resulting in a physical altercation over seating. Both incidents were witnessed by staff, but reporting was delayed, violating the facility's policies and potentially placing residents at risk.
The facility failed to report two resident-to-resident altercations within the required 2-hour timeframe. In one incident, two male residents with cognitive impairments were involved in a physical altercation over a wheelchair. In another, two female residents had a disagreement in the dining room, leading to one hitting the other with a silverware packet. Both incidents were witnessed by staff, but delays in reporting to the state agency were noted, indicating lapses in communication and adherence to reporting protocols.
A resident with a history of vascular disease and diabetes was reported to have skin issues on her buttocks, but the LVN did not assess or document the condition. Despite the CNA reporting the issue to a charge nurse, no further action was taken, and the facility's Skin Management Policy was not followed.
The facility failed to provide Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) forms to three residents when their Medicare Part A services ended. Staff interviews revealed a lack of awareness and training regarding the SNF ABN forms, leading to the failure to inform residents about their financial responsibilities.
The facility failed to accurately code the use of anticoagulant medications for four residents, leading to discrepancies in their MDS assessments. The residents were incorrectly coded as taking anticoagulants when they were actually prescribed antiplatelet medications like aspirin and Plavix. This error was identified through interviews and record reviews.
The facility failed to develop and implement comprehensive care plans for four residents, leading to deficiencies in addressing their medical, nursing, and psychosocial needs. This included missing care plans for critical medications, fall interventions, and palliative care, highlighting a lack of oversight and coordination among staff.
The facility failed to provide prescribed nutritional supplements to three residents, leading to potential risks of malnourishment and weight loss. The kitchen was out of stock, and staff did not notify the administration or physicians about the shortages.
The facility failed to provide appropriate respiratory care for several residents, including not having proper oxygen orders, not cleaning oxygen concentrator filters, and not storing respiratory equipment properly. These deficiencies could lead to respiratory complications for the residents.
The facility failed to ensure all drugs were stored in locked compartments and labeled in accordance with professional standards. Unsecured medication carts and improperly labeled or expired medications were found, posing risks to resident safety and medication efficacy.
The facility failed to follow menus and recipes for residents on a pureed diet, leading to incorrect scoop sizes and preparation methods. Staff did not use the recipe book, and there was a lack of oversight and training on proper procedures.
The facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for four residents. Observations and interviews revealed that the food served was either bland, over-seasoned, or too spicy, leading to dissatisfaction among the residents. A test tray review indicated that the macaroni and cheese was cold and bland, although other items were satisfactory. The Dietary Manager admitted to not tasting the food daily and acknowledged difficulties with staff finding recipes in a new program book.
The facility failed to properly label, date, and dispose of food items in the refrigerator and freezer, and did not repair a leak in the kitchen ceiling, posing risks of food contamination and foodborne illness. These deficiencies were confirmed by staff interviews and observations.
The facility failed to ensure proper infection prevention and control practices, including hand hygiene, glove changes, and proper disposal of PPE and trash, leading to multiple deficiencies and potential infection risks for residents.
A CNA entered a resident's room without knocking or identifying herself, making the resident feel uncomfortable and unsafe. The resident, who was cognitively intact and required moderate assistance, reported that staff regularly entered his room without knocking. Interviews with facility leadership confirmed that staff were expected to knock and introduce themselves before entering, as per the facility's policy on maintaining resident dignity.
Incomplete care planning for wandering, splint use, and activities
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #13, Resident #11, and Resident #1. The report states that these failures involved missing or incomplete care planning for a physician-recommended secure unit placement, a right-hand splint, and activities, respectively. The facility policy required a comprehensive person-centered care plan with measurable objectives and timeframes to meet each resident’s medical, nursing, mental, and psychosocial needs. Resident #13 was a female with diagnoses including encephalopathy and dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Her care plan identified her as at risk for wandering/elopement and injury related to dementia and poor safety awareness, and noted that she often attempted to leave through double doors and required a wheelchair for assistance. On 06/09/26, staff documented that she opened a door at the end of the hall and made it about halfway through before being pulled back inside, and later that day she was found standing behind her wheelchair in the grass near the exit door. A physician later suggested transfer to a lock down unit, but the record review and interviews showed the recommendation was not implemented and no interventions were put in place related to her repeated bathroom-seeking and wandering behaviors. Resident #11 was a male with dementia, right hand contractures, muscle weakness, and depressive disorder, with severe cognitive impairment and extensive assistance needs. His physician ordered a right resting hand splint to be worn as tolerated during waking hours every day shift related to muscle wasting. At the time of observation, he was sitting in his chair without anything on his right hand. Interviews showed the splint had been missing, staff knew it was missing, and therapy was aware, but his comprehensive care plan did not include the splint. Resident #1 was a cognitively intact male with kidney failure, heart failure, COPD, and hypertension. His MDS indicated that activity preferences were very important to him, but his comprehensive care plan did not include activities. During observation, he stated he did not have a current activity calendar for July and did not have an activity director, and the calendar on his refrigerator was from the prior month.
Activities Program Not Directed by Qualified Professional
Penalty
Summary
The activities program was not directed by a qualified professional because the facility did not have a qualified Activity Director in place. During interview, an anonymous resident stated that he did not receive an activity calendar. A confidential group of residents stated they were aware there was no longer an activity director in the facility, that they had not received the July 2026 activity calendar, and that the Administrator had to sit in at their monthly resident council meeting because there was no Activity Director. The DON stated she knew there was no activity director and that resident council was affected because there was no one to keep minutes or help assemble the meeting, and residents missed discussion of resident rights. The Administrator stated the facility did not have an activity director and that the Activity Director was responsible for activities and resident council. Record review showed no documentation that the facility had an Activity Director with certification, completion of an approved training course, qualifying licensure, or other documentation showing the required qualifications. The facility policy stated each facility would have a director responsible for recreation services who was qualified according to state requirements.
Accident Hazards and Supervision Failures
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards and that residents received adequate supervision to prevent accidents for three residents reviewed. The report identified failures involving elopement risk reassessment for one resident, insect spray left in another resident’s room, and purple top microdot disinfectant wipes left in a third resident’s bathroom. Resident #13 had diagnoses including encephalopathy and dementia, with a BIMS score of 3 indicating severely impaired cognition. Her care plan identified her as at risk for wandering and elopement, and records noted she had exit wandering behaviors and often attempted to leave through double doors. After an incident on 06/09/26 in which she opened a door and made it halfway through before a CNA pulled her back inside, the DON stated she was not aware of the first incident at the time and did not follow up to ensure the elopement/wandering risk was updated. The Social Worker stated she had never been asked to complete an elopement assessment, and RN P stated she was instructed to reassess the resident but got distracted and forgot to complete it. Resident #7 had COPD and intact cognition with a BIMS score of 15. During observation, a bottle labeled Hot Shot Flying Insect spray was found sitting on her dresser. The resident stated her family member brought it because she had gnats and said she was unsure whether the facility knew she had it. Staff interviews reflected that the spray should not have been in the building, that all staff were responsible for ensuring items were stored properly and securely, and that one CNA had seen the spray and tried to remove it but did not report it to the charge nurse, DON, or Administrator. Resident #2 had diagnoses including type 2 diabetes mellitus, anxiety, and major depressive disorder, and her MDS indicated she was cognitively intact with a BIMS score of 15. During observation, a container of purple top microdot disinfectant wipes was found in her bathroom on the back of the toilet. The resident stated she did not place them there and did not use the bathroom. The DON and Administrator stated the wipes should not be available to residents or left in resident rooms and should be kept secured for staff use, but the wipes were found in the resident’s room at the time of observation.
Expired and Undated Medications Found on Multiple Medication Carts
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure accurate dispensing and administration of medications on 3 of 6 medication carts reviewed. On Hall 100, an observation found undated eye drops, Geri-Tussin expired 5/26, and Calcium 600 with vitamin D expired 5/26/26. On Hall 300, Resident #17’s Novolog R insulin was observed on the nurse’s cart with a date of 05/30/26. On Hall 400, Resident #30’s Calcitonin Salmon nasal solution was expired 07/05/26, and Resident #4’s Budesonide suspension was open and not dated. During interviews, LVN D stated medications should be dated when opened and that all nurses were accountable for ensuring medications were dated. MA E said expired medications or medications without open dates should not be on the cart and that there was no system in place to check the carts. The physician said staff were expected to pass medications as ordered and not give expired medications. LVN A stated insulin is only good for 28 days and that multipacket medications should be dated. The DON said nurses were expected to give medications as ordered, remove expired medications from carts, and date insulin and inhalers when opened. The Administrator said nurses and medication aides were responsible for giving medications as ordered and removing expired medications, and that the DON was responsible for monitoring and overseeing by rounding.
Medication Left Unsecured in Resident Rooms
Penalty
Summary
Drugs and biologicals were not stored in accordance with accepted professional principles when medication was left in residents’ rooms. Resident #47, a female with diagnoses including dementia, depression, and muscle weakness, had a physician order for Nystatin External Powder to be applied topically as needed for a yeast rash. During review and interviews, staff reported that medication was found in her bedside dresser, and multiple staff members stated that medications were not supposed to be left in resident rooms because of safety concerns. The DON and Administrator stated that nurses were responsible for removing products brought into rooms and storing them in the medication cart or medication room. Resident #2, a female with diagnoses including type 2 diabetes mellitus, anxiety, and major depressive disorder, had an order for nystatin external powder to be applied to skin folds as needed for yeast rash. During observation, she was found lying in bed with a bottle of Nystop fungal powder on her dresser beside her personal refrigerator and a bottle of sore throat spray on top of the refrigerator. Resident #2 stated that the nurse applied the powder regularly and that she used the sore throat spray as needed, and she acknowledged that other residents sometimes wandered into her room. The facility’s medication storage policy stated that all drugs and biologicals were to be stored in locked compartments such as medication carts, cabinets, drawers, refrigerators, or medication rooms under proper temperature controls. Interviews with the DON and Administrator confirmed the expectation that medications were not to be left at bedside or in resident rooms and were to be locked in the medication cart or medication room. The report also stated that the failure placed residents at risk of medications being taken by other residents, Resident #2 not using medications appropriately, and other residents getting the medications and using them inappropriately or drinking them.
Food Served Cold and Bland
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for two residents and during one lunch meal observation. Resident #38 stated during an interview that the food could be more seasoned and served hotter. Resident #27 stated the food was served cold and could be more seasoned, and he ate in his room during meal service. During a lunch tray observation, the sample tray reviewed by the Administrator and surveyors included pork loin that was lukewarm and dry, broccoli that was lukewarm and bland, and rice with a sticky texture. The Administrator stated the pork loin could have been warmer and more tender, the broccoli could have been warmer and more salted, and the rice should have had the texture of steamed rice and could have been warmer. Staff interviews reflected ongoing complaints about food quality and temperature. A CNA stated residents had complained that the food was "slopped" and that she had reported the complaints to the charge nurse, DON, and Administrator. An RN stated she had not received complaints about cold or bland food, while the Dietician stated she had not heard complaints and reported that a test tray in June 2026 had passed. The Dietary Manager stated she had complaints about food being cold, and the DON and Administrator both stated they had received complaints that food was cold and not seasoned. The Administrator stated the facility did not have a policy for palatable food.
Unsafe food storage and poor kitchen sanitation
Penalty
Summary
Food items were found improperly stored and kitchen equipment was found unclean during an initial tour of the dietary area. In the walk-in cooler, surveyors observed a bag of garlic bread that was undated and unsealed, a bag of puffy pastries that was undated and unsealed, and a box containing 14 unsalted margarines that was undated. The ice machine scoop holder had several brown and white pieces floating in the bottom, the can opener blade had a black substance buildup, the microwave had a brown buildup inside, the exterior of the blender had a tan buildup, and the deep fryer had golden food crumbs on the inside surfaces. Surveyors also observed dietary staff not following hair restraint and food handling practices. The Dietary Manager's hair net covered only half of her head, and another dietary staff member had loose hair sticking out. During a later observation, a dietary staff member removed a spoon from the prep sink and stirred pureed chicken before washing the spoon. The Dietary Manager stated the spoon should have been washed first and had the chicken discarded. The Dietician and Dietary Manager both stated that food should be dated and sealed, hair nets should cover the entire head, and the equipment observed should be cleaned on the expected schedule. During interviews, the Dietician stated she had monitored the kitchen by monthly observations and had not had issues since April 2026, though she recalled a prior May 2026 issue involving a staff member not washing a spoon before use and a verbal in-service being done. The Dietary Manager stated she was responsible for ensuring the kitchen was cleaned appropriately and that staff were responsible for labeling food, cleaning the ice scoop holder, and cleaning the can opener blade, microwave, blender, and fryer. The Administrator stated she expected food to be dated and sealed, hair nets to cover the entire head, and the kitchen equipment to be cleaned daily.
Infection Control and PPE Use Failures During Resident Care and Isolation Room Entry
Penalty
Summary
The facility failed to maintain its infection prevention and control program for three residents during observed care and room-entry activities. Resident #1 was a re-admitted male with kidney failure, heart failure, COPD, high blood pressure, an indwelling urinary catheter, and a BIMS score of 15. His care plan required enhanced barrier precautions with gown and gloves during high-contact care. During an observation, OT Q was fastening Resident #1’s brief while wearing gloves but no gown, despite the enhanced barrier precaution sign and PPE being present on the door. OT Q stated he probably should have had on his gown and gloves but was not really providing catheter care, only placing a new brief on. Resident #2 was a re-admitted female with type 2 diabetes, anxiety, major depressive disorder, urinary incontinence, and a BIMS score of 15. She required maximal assistance with toileting, dressing, and bed mobility, and total assistance with transfers. During incontinent care, CNA C and LVN F changed the resident’s brief and provided perineal care. CNA C wiped the perineal area from front to back, then wiped the buttocks without changing gloves, and then wiped the back side from back to front with the same wipe. CNA C removed her gloves and did not perform hand hygiene before new gloves were applied, and later changed gloves again without hand hygiene. CNA C stated she should have changed gloves after providing incontinent care from front to back and should not have wiped on the buttocks. Resident #55 was a male with dementia, anxiety, high blood pressure, and benign prostatic hyperplasia, with a BIMS score of 10 and a care plan indicating a urinary tract infection requiring contact isolation precautions. During an observation, the room had a contact precautions sign and isolation PPE supplies on the door. The Floor Tech entered the room to check the sanitizer dispenser, removed the old dispenser, and went to the environmental door to change it out without PPE on. He stated he was in his own little world and said he did not touch anything but the hand dispenser. The DON and Administrator stated they expected proper PPE use for contact isolation and that the failure placed a risk for infection and spread of disease.
Failure to Communicate with Resident in Preferred Language
Penalty
Summary
The facility failed to ensure Resident #39 was fully informed in a language he could understand about his total health status, including his medical condition. Resident #39 was admitted with dementia, had a BIMs score of 05 indicating severe cognitive impairment, and his MDS identified him as of Spanish origin with Spanish as his preferred language. His care plan noted he was dependent on staff for cognitive stimulation, activity attendance, and social interaction related to cognitive impairment and was at risk for isolation. Observation and interviews showed Resident #39 speaking Spanish with speech therapy staff, but no observation of other employees speaking Spanish or using translation assistance. The speech therapist stated the resident chose to speak Spanish most of the time and often asked for repetition because she was not fluent. During interview, communication with the resident was limited and a translation app was needed; he indicated staff did not speak Spanish and only some people understood him. Staff reported using Google Translate, calling family members to translate, or knowing only limited Spanish, while the DON and Administrator stated staff were expected to address him in his preferred language of Spanish.
Missed Scheduled Showers and Hygiene Care
Penalty
Summary
The facility failed to ensure a resident who was unable to perform activities of daily living received the necessary services to maintain grooming and personal and oral hygiene. Resident #5, a female re-admitted with diagnoses including atrial fibrillation, heart failure, dementia, and lack of coordination, had a quarterly MDS showing she required maximal assistance for bathing, bed mobility, dressing, and transferring, and her care plan directed staff to provide shower, shave, oral care, hair care, and nail care per schedule and as needed. Review of shower sheets from 06/30/26 through 07/06/26 did not show that she received a shower. During observation on 07/06/26, Resident #5 was in bed with oily hair and stated she was not getting showers 3 times a week on Tuesday, Thursday, and Saturday, and that she had not had a shower since 06/27/26. She said she was "stinky." CNAs reported that residents complained about not receiving baths from the 2 p.m. to 10 p.m. shift, that showers were not always given because of time and other duties, and that Resident #5 sometimes refused showers, though one CNA was unsure whether she had given her a shower the prior week. The DON stated showers were expected according to the schedule and should be documented if refused, and the Administrator stated residents were expected to receive baths and that staff should document if they did not.
Failure to Complete Ordered Wound Care for Toe Wound
Penalty
Summary
The facility failed to ensure that Resident #12 received wound care in accordance with the physician order for a right great toe wound with cellulitis. The resident, a female with type 2 diabetes mellitus and a BIMS score of 15, had a care plan addressing risk for impaired circulation and pressure ulcers. A wound care order was started for the right great toe to cleanse with normal saline, pat dry, apply calcium alginate, and cover with a band aid daily during the day shift. A progress note documented that the resident reported a toe wound on 06/30/2026, and the toe was described as blistered, inflamed, and warm to the touch. A skin assessment on 07/04/2026 documented a new in-house skin issue with measurements of 0.2 cm by 0.2 cm by 0.1 cm, with no undermining or tunneling. The treatment record contained blanks for 07/04 and 07/05, indicating wound care was not documented as completed, and on 07/06 the resident’s right great toe was observed to be red, open, and sore without a bandage. The resident stated staff had not put a bandage on the toe and that no wound care had been done. On 07/07, the toe still had no bandage and wound care had not been done. The LVN stated she was unaware of the wound care order and acknowledged she did not complete wound care on 07/04, 07/05, and 07/06. The ADON and DON stated they were unaware the scheduled wound care was not being completed, and the Administrator stated wound care orders were expected to be followed.
Improperly Secured Indwelling Catheter
Penalty
Summary
Resident #1, a cognitively intact male with diagnoses including kidney failure, heart failure, COPD, and hypertension, was assessed as having an indwelling urinary catheter and requiring maximal assistance with toileting. His care plan identified the catheter and noted risk for urinary tract infections and injury, with interventions to provide catheter care per facility policy. However, during observations on 07/06/2026 and 07/07/2026, his catheter drainage bag was seen without a strap or securement device in place, and the resident stated he had not had a catheter strap in place for about 2 weeks. On 07/08/2026, an OT observed the catheter securement device hanging on the drainage line rather than attached to the resident’s leg, and stated it should have been secured to the leg because the failure could have pulled the catheter. An LVN then replaced the securement device and stated it should always be in place to prevent pain and discomfort. The DON and Administrator later stated their expectation was that the catheter strap or securement device should always be in place, and that nurses and CNAs were responsible for ensuring it was secured or reporting it if not.
Oxygen and Nebulizer Equipment Not Provided as Ordered
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for two residents who had orders for oxygen therapy and, for one resident, nebulizer treatment equipment. Resident #4 had diagnoses including COPD, hypoxia, dementia, and diabetes, and her care plan identified impaired respiratory status with oxygen therapy ordered. Her physician order required oxygen at 3 liters per nasal cannula every shift for COPD, and she also had an order for Budesonide inhalation every shift. During observation on 07/07/26, her oxygen was set at 2.5 liters and her hand-held nebulizer tubing was on the nightstand and not bagged. Resident #4 stated she had a breathing treatment the prior night. A nurse later verified the nebulizer tubing was not bagged and that the oxygen was not set at the ordered rate. Resident #8 had diagnoses including dependence on supplemental oxygen, CHF, and anxiety, and her care plan directed staff to apply oxygen as ordered. Her physician order required oxygen at 2 liters per minute via nasal cannula continuously for COPD. During observation on 07/06/26, her oxygen was applied at 2.5 liters. During another observation on 07/07/26, her oxygen was again at 2.5 liters, and the resident stated her oxygen should be set at 2 liters. A nurse later verified the oxygen was set at 2.5 liters, checked the order, and confirmed it should have been at 2 liters. The DON and Administrator stated that nurses were responsible for ensuring oxygen was set as ordered and that HHN tubing was bagged when not in use. The report also noted the facility policy on oxygen administration required verification of the physician order. The deficiency was based on observations, interviews, and record review showing that the ordered oxygen settings were not followed for both residents and that the nebulizer tubing for Resident #4 was left unbagged.
Medication administration errors with expired insulin and missed ordered medications
Penalty
Summary
The facility failed to ensure its medication error rate remained below 5 percent. Surveyors determined the medication error rate was 7.14 percent, based on 3 errors out of 28 opportunities, involving 2 of 5 residents reviewed for medication administration. The deficiencies involved expired insulin being administered to one resident and ordered medications not being given correctly to another resident. Resident #59 was a male with diagnoses including type 2 diabetes mellitus, stroke, and high blood pressure. His quarterly MDS indicated he could make himself understood and understood others, and his BIMS score was 15. He had a physician order for Novolin R insulin to be given by sliding scale before meals and at bedtime. During observation and interview, an LVN checked his blood sugar, prepared insulin, and administered 2 units after a reading of 208. The LVN then reviewed the insulin vial and stated she could not read the date on the bottle but it looked like it may have expired, and said expired medication may not be effective. Resident #4 was a female with diagnoses including CHF, COPD, hypoxia, dementia, and diabetes. Her quarterly MDS showed a BIMS score of 05 and that she required assistance with multiple activities of daily living. She had physician orders for Potassium Chloride ER 20 mEq in the morning for CHF and Slow-Mag every 12 hours for supplement. During observation, a medication aide gave one tablet of Slow-Mag, but the aide later stated it was the wrong dose based on the order. The aide also checked the MAR and did not give Potassium as ordered, later stating she thought she had given it but found none on the cart. The DON stated she did not pull Potassium from the emergency kit and that she expected staff to read the MAR and give medications as ordered.
Expired Insulin Administered to Resident with Diabetes
Penalty
Summary
The facility failed to ensure that a resident with Type 2 diabetes mellitus, stroke, and high blood pressure was free from a significant medication error when an LVN administered expired Novolog insulin. The resident’s record showed he was cognitively intact, with a BIMS score of 15, and that he received insulin during the 7-day look-back period. During an observation and interview, the LVN checked the resident’s blood sugar, obtained a reading of 208, prepared Novolog, and administered 2 units to the resident’s left arm. While administering the insulin, the LVN reviewed the vial and stated she could not read the date on the bottle but that it looked like it was 05/05/26; she said that if so, the insulin had expired and that expired medication may not be effective. She then disposed of the Novolog and obtained a new vial. The resident’s physician order directed sliding scale insulin before meals and at bedtime, and the facility’s policies required medication administration according to physician orders and that opened multi-dose vials be dated and discarded within 28 days unless otherwise specified. The DON and Administrator stated they expected nurses not to give expired insulin and that expired medication should be discarded.
Expired Food Handler Permit for Dietary Aide
Penalty
Summary
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service was not met when the facility failed to ensure Dietary Aide B had a current food handler permit. Record review of the food handler certificates provided by the facility showed that Dietary Aide B’s food handler certificate expired on 07/15/25. During an interview, Dietary Aide B stated she was not aware her food handler permit had expired and stated it was important to have a food handler certificate to know how to handle food and prevent cross contamination or infection. During an interview, the Dietary Manager stated she was responsible for ensuring staff completed their food handler certificate training every 2 years and that she reviewed the certificates weekly but overlooked the actual day it expired. The Dietary Manager stated this failure could potentially put residents at risk for food borne illness and cross contamination. The Administrator stated she expected the Dietary Manager to ensure dietary staff had their food handler certificates before they expired and stated this failure could potentially put residents at risk for food borne illness and cross contamination. The facility policy titled Certified Food Protection Professional and Food Safety Training stated the food establishment shall maintain on premises a certificate of completion of the food handlers training course for each employee.
Fortified pudding prepared incorrectly
Penalty
Summary
The facility failed to ensure the lunch meal met the nutritional needs of residents when the Dietary Manager did not follow the recipe for fortified pudding served to a resident. Resident #58 was a male re-admitted to the facility with diagnoses including protein-calorie malnutrition, dementia, anxiety, and dysphagia. His quarterly MDS indicated he was cognitively intact, required assistance with several activities of daily living, and was independent with eating. His physician’s order directed a regular diet with fortified foods added to every meal related to protein-calorie malnutrition, and his care plan identified nutritional problems related to malnutrition and impaired cognition with the intervention to serve the diet as ordered. During observation, Resident #58 was eating pudding in the dining room and his tray card identified it as fortified pudding. On interview, the Dietary Manager stated the pudding had been made with condensed milk instead of regular milk and acknowledged the recipe was not followed. The dietician stated dietary staff should follow the recipe when making fortified pudding, and the DON and Administrator both stated they expected the kitchen to follow the recipe. The facility policy stated meals were to be provided according to physician orders, the Facility Diet Manual, and the menu spread sheet.
Failure to Honor Resident Food Preference
Penalty
Summary
The facility failed to accommodate Resident #17’s food preference when apples were served with the lunch meal and no substitution was provided. Resident #17 was a [AGE]-year-old female admitted on [DATE] with diagnoses including cerebral infarction due to embolism of the right cerebellar artery. On 07/06/2026 at 12:25 p.m., she was observed with apples on her tray, and at 12:30 p.m. she stated that she did not like apples, had requested a substitution, and had not received one. During interview, the Dietary Manager stated that she should have substituted the apples for Resident #17 but did not because she forgot, and she also stated that she was the dietary aide for the day and did not realize the resident had not been supplied. The Registered Dietitian stated that Dietary was expected to substitute the apples with another available fruit and have substitutes on hand for Resident #17. The DON and Administrator both stated that Resident #17 should have received her preference or a substitution, and the Administrator stated that nurses were responsible for checking trays while Dietary was responsible for providing the substitution. Record review showed meal choice forms should be followed according to the meal ticket and that alternative/substitute foods would be kept on hand for quick preparation and service if a resident refused all foods served.
Therapeutic Diet Not Provided as Ordered
Penalty
Summary
The facility failed to ensure Resident #54 received therapeutic foods ordered by the physician. Resident #54 was a [AGE]-year-old male admitted with major depressive disorder, had a BIMS of 03 indicating severe cognitive impairment, and was care planned for nutritional risk related to adult failure to thrive and malnutrition risk. His care plan included providing and serving supplements as ordered, and the order summary showed a regular diet with fortified foods at all meals, along with magic cup with meals. On 07/06/2026 at lunch, the meal ticket indicated Resident #54 was to receive a magic cup, fortified pudding, and a plate guard. Observation at 12:20 p.m. showed him sitting in the assisted dining room without the magic shake and fortified pudding, and he ate about 50% of his plate. During interview, the resident stated he was supposed to get a magic shake and fortified pudding. A NA stated that on multiple occasions Resident #54 had not received his prescribed magic shake and fortified pudding, and the LVN stated she was not aware he had not received them. The Registered Dietitian stated the supplements were ordered for malnutrition and high risk of weight loss and expected the facility to provide them according to the order. The Dietary Manager stated the resident was supposed to receive the magic shake and fortified pudding and that she was responsible for placing them on the tray. The DON stated she was not aware the resident was not offered or provided the shake or pudding, and the Administrator stated the resident should have received his therapeutic diet according to physician order and that dietary was responsible for providing it.
Failure to Provide Ordered Plate Guard
Penalty
Summary
The facility failed to provide Resident #54 with his physician-ordered plate guard during the lunch meal, even though the order summary listed a regular diet with a plate guard and fortified foods at all meals. Resident #54 was a [AGE]-year-old male admitted with major depressive disorder, had a BIMS score of 03 indicating severe cognitive impairment, and was assessed as needing setup or clean-up assistance for eating. His care plan addressed ADL self-care deficits and nutritional risk related to adult failure to thrive, with interventions for eating setup and clean-up assistance and for providing diet and supplements as ordered. On 07/06/2026, the meal ticket indicated that Resident #54 was supposed to receive a plate guard, but during the lunch meal he did not receive it until surveyor intervention. Observation showed food falling off his plate. Resident #54 stated that sometimes he did not receive the plate guard and that it helped him eat his food. NA G stated she had told Dietary staff multiple times that he needed the plate guard and that he frequently did not receive it. The LVN, Registered Dietitian, Dietary Manager, and DON all stated that the plate guard was intended to assist him with eating, and the Dietary Manager stated the plate guard was not given on accident during the lunch meal.
Incomplete PASRR Service Documentation
Penalty
Summary
The facility failed to ensure the medical record was complete and accurately documented for one resident who was reviewed for resident records. The resident’s face sheet showed he was a male admitted with diagnoses including bipolar disorder, seizures, and rhabdomyolysis. His annual MDS indicated he was considered by the state level II PASRR process to have intellectual disability, and his BIMS score was 15, indicating he was cognitively intact. His comprehensive care plan, revised 06/10/26, identified that he needed specialized services due to a history of intellectual disabilities and epilepsy, and the care plan stated that an IDT meeting would be conducted with the designated LIDDA and LMHA representative annually and as needed, with specialized services initiated as determined necessary by the IDT. The PCSP meeting dated 03/20/26 reflected that Habilitation Coordination and Behavior Support Coordinator services were recommended for the resident. However, the EMR dated 07/07/26 contained no documentation of Habilitation Coordination or Behavior Support Coordinator notes. During interviews, the Habilitation Supervisor stated the habilitation agent and behavior support agent visited monthly and that the resident had a quarterly meeting on 06/24/26, but she also stated they did not leave documentation of the monthly visits at the facility. The Social Worker stated she was responsible for ensuring the visits were conducted, was not aware of when the last behavior coordinator visit occurred, believed the habilitation coordinator came every 1-2 months, and said staff did not coordinate with habilitation after visits. The DON and Administrator both stated they expected documentation after each visit and acknowledged there was no system in place to monitor PASRR services or the Social Worker’s oversight of the resident’s PASRR needs.
Missing Hospice IDG Documentation and Care Coordination
Penalty
Summary
The facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for 2 residents receiving hospice services, including communication with the hospice medical director, the residents' attending physicians, and others involved in care. Surveyors found that Resident #8's hospice binder did not contain the most recent updated hospice IDG meeting notes, hospice medication list, or hospice plan of care. The binder's medication list was last updated 05/19/26 and did not include Ativan, even though a physician order dated 05/25/25 directed Ativan 0.5 mg by mouth every 8 hours as needed for anxiety. The plan of care in the binder was also last updated 05/19/26, and no IDG meetings were present in the binder. Resident #8's record showed diagnoses of CHF, essential hypertension, and anxiety, and the quarterly MDS reflected a BIMS score of 4, indicating severely impaired cognition. The resident's care plan stated she had a terminal illness and was receiving hospice services or palliative care. During interviews, the Hospice Director stated IDG meetings were held weekly and that updated information was usually provided to the facility within the next week, with the business development staff responsible for bringing the information to the facility and placing it in the hospice binder. The DON and Administrator stated the hospice plan of care, medications, and IDG meetings should be in the binder, but both acknowledged missing or incomplete information. For Resident #9, the hospice binder did not contain any interdisciplinary group meeting documentation. The resident's record showed a diagnosis of Huntington's disease, and the care plan identified a terminal prognosis related to Huntington disease with hospice care and an intervention to coordinate with hospice so the resident's spiritual, emotional, intellectual, physical, and social needs were met. The quarterly MDS indicated the resident received hospice care and had a BIMS score of 15. During interviews, the RN stated she was unsure who reviewed the hospice binders and that it was not her responsibility to check them, while the Hospice RN stated she was responsible for bringing the IDG meeting notes to the facility but had not done so. The DON stated she was responsible for reviewing the hospice binders but was unsure what documents were required, and the Administrator stated the binders were expected to be updated according to the care plan and IDG meeting.
Loose Flooring, Wallpaper, and Baseboard in Resident Areas
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in Resident #5’s room and on 300 hall. Resident #5 was a re-admitted female with diagnoses including atrial fibrillation, heart failure, dementia, and lack of coordination. Her quarterly MDS indicated she made herself understood and was understood by others, with a BIMs score of 13, and she required maximal assistance for bathing, bed mobility, dressing, and transferring. Her care plan identified an ADL self-care performance deficit requiring total assistance with bathing. During observation and interview, Resident #5 stated her floor had been coming apart for an unknown period and pointed to wallpaper behind the headboard that had been coming down as well. Surveyors observed loose flooring under her bed and loose wallpaper in her room. A CNA stated the floor tile had been coming up for months and the wallpaper issue had been on and off, and that the Maintenance Supervisor had fixed the wallpaper before but it kept coming down. Surveyors also observed a loose baseboard by a room on 300 hall. The Maintenance Supervisor stated he was not aware of the loose flooring, wallpaper, or baseboard when asked, and later said he fixed the baseboard and wallpaper in Resident #5’s room and would need to order tile for the floor. The facility policy stated residents have a right to a safe, clean, comfortable, and homelike environment and that maintenance opportunities are to be corrected immediately.
Failure to Complete Quarterly Smoking Evaluation
Penalty
Summary
The facility failed to follow its smoking policy for Resident #40 by not ensuring a safe smoking evaluation was completed quarterly. Resident #40 was admitted with a diagnosis of dementia and was identified in the care plan as a smoker at risk for injury who required direct supervision to smoke. The care plan also directed staff to perform smoking assessments according to facility policy. A Smoking Evaluation dated 03/09/2026 identified the resident as a dependent smoker who required assistance and supervision to smoke, but the record review found no updated Smoking Evaluation after that date. During observation on 07/06/2026 at 1:45 p.m., Resident #40 was seen smoking and had difficulty holding the cigarette in his hand. In interviews, staff stated smoking assessments were to be completed on admission, with change of condition, and quarterly, and that Resident #40 should have had a safe smoking assessment at least quarterly. The smoking policy dated 7/14/2024 stated the facility must evaluate patients who smoke using the Smoking Evaluation/Smokeless Tobacco Tool upon admission, quarterly, when a non-smoking patient takes up smoking or smokeless tobacco, and if unsafe smoking practices are observed.
Failure to Submit PASRR Specialized Service Request for Customized Wheelchair
Penalty
Summary
The facility failed to ensure that a resident identified as PASRR positive received specialized equipment in accordance with the PASRR Comprehensive Service Plan and failed to submit a request for specialized services in the LTC Online Portal. The resident was an older male with diagnoses including moderate intellectual disabilities, dementia, anxiety, major depressive disorder, delusional disorders, dysphagia, hypertension, and osteoarthritis. His quarterly MDS showed severe cognitive impairment with a BIMS score of 02, communication deficits, impaired vision and hearing, and significant functional dependence, including the need for a wheelchair for mobility and extensive assistance with transfers, toileting, bathing, dressing, and wheelchair mobility. Record review showed that the resident’s care plan identified him as PASRR positive and stated that specialized services determined necessary by the IDT would be initiated and a request submitted within 20 business days after the IDT meeting. The PASRR Comprehensive Service Plan documented that the IDT reviewed the plan of care and determined that he would benefit from a customized wheelchair. During interview, the PASSR Representative stated that the meeting had been held and that the facility still had not submitted the request for authorization of the customized wheelchair. Facility staff gave conflicting accounts about the wheelchair request. The Social Worker stated she believed the wheelchair had been ordered but had not followed up with therapy. The DOR stated he thought it had been ordered, but he was unsure how it was processed and acknowledged he did not follow up with the medical equipment supplier; he also stated he later learned the resident did not have applied income, which was why the wheelchair was not ordered through Medicaid and that the request should have been submitted through the PASSR program. The BOM confirmed the resident did not have applied income, and the DON and Administrator stated the resident was currently using a standard wheelchair and that staff had a knowledge deficit regarding the PASSR program. The facility policy stated that if a resident is positive, specialized services are to be initiated by submitting a request within 20 days of the PCSP meeting.
Failure to Provide and Monitor Scheduled Bathing and Hygiene Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents who were unable to fully perform activities of daily living received necessary services to maintain good nutrition, grooming, and personal and oral hygiene, specifically related to routine bathing and showers. For Resident #1, records showed she was cognitively intact with a BIMS score of 12, had no range of motion impairment, and required supervision with bathing. Her care plan directed staff to provide shower care per schedule and as needed, with no indication of routine refusals. She was scheduled for showers on the day shift three times weekly, yet multiple dates over several weeks had no completed shower sheets, and the electronic medical record bathing task did not indicate whether she received a bed bath or shower. On observation and interview, she reported not receiving a shower that day, could not recall her shower schedule or last shower, and her hair appeared matted and greasy. Resident #2 had severe cognitive impairment with a BIMS score of 6, required moderate assistance with bathing, and had a care plan directing staff to provide showers per schedule and as needed. His care plan also included a behavioral focus for rejection of care, with a goal that he would remain clean and well-groomed. He was scheduled for showers three times weekly on the day shift. The shower assignment sheets showed only two documented showers and one refusal over the review period, with multiple scheduled days lacking any completed shower sheet. The electronic medical record bathing task again did not specify whether a bed bath or shower was provided. During interview, he stated he did not get a shower that day, believed his last shower was the previous day, and reported taking showers regularly with no specific schedule preference. Observation noted he was unshaved, had an unkempt appearance, matted hair, and an unclean odor. Resident #3 was cognitively intact with a BIMS score of 12, had no extremity impairment, and required supervision or substantial/maximal assistance with bathing according to the MDS and care plan. Her care plan required staff to provide showers per schedule and as needed, with no indication of bathing refusals. She was also scheduled for showers three times weekly on the day shift. The shower sheets showed one documented shower and two refusals, with numerous scheduled days lacking any completed shower sheet. As with the other residents, the electronic medical record bathing task did not indicate whether a bed bath or shower was actually given. In interview, she stated she did not receive or was not offered a shower that day and believed her last shower had been a couple of weeks earlier; observation showed her hair was disheveled and unclean in appearance. Staff interviews revealed systemic issues with the shower documentation and monitoring process. Multiple CNAs stated there was a shower schedule posted at the nurses’ station and that they were to complete shower sheets after each shower and turn them in to the nurse, including documenting refusals and skin concerns. Several CNAs acknowledged that sometimes they were not able to complete all scheduled showers and did not know if showers were completed on subsequent shifts, and none could explain why multiple shower sheets were missing for the three residents or confirm that showers had been provided. LVNs reported that shower sheets were important for proof of completion and for identifying skin changes, and that they were responsible for reviewing the sheets and being notified of refusals, but they also could not explain the missing documentation or confirm that showers occurred. The DON and Administrator stated their expectation that showers be completed per schedule, refusals reported to nursing, and shower sheets completed and monitored by nursing and management, but the missing shower sheets and resident reports and observations demonstrated that these expectations were not met for the three residents. The facility’s own Clinical Practice Guidelines for Activities of Daily Living Care stated that residents will receive essential services for ADLs to maintain grooming and personal and oral hygiene, and that bathing includes grooming activities such as shaving and brushing teeth and hair. Despite these guidelines and the established shower schedules and care plans, the lack of completed shower sheets on multiple scheduled days, the absence of clear documentation in the electronic medical record regarding whether showers or bed baths were provided, and the residents’ own statements and observed unkempt conditions show that the facility did not ensure that these three residents were routinely showered or bathed as planned. This combination of incomplete documentation, staff inability to verify that showers were given, and observed poor hygiene constituted the deficiency in providing necessary ADL care for bathing and grooming.
Failure to Provide Scheduled Showers and Hygiene Care
Penalty
Summary
The facility failed to provide necessary care and services to ensure that four residents who were unable to carry out activities of daily living received the required assistance to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, the facility did not provide scheduled showers for these residents during the month of November, as evidenced by observation, interviews, and record reviews. Documentation inconsistencies and missing shower sheets were noted, and residents reported not receiving showers as scheduled or not being offered them at all. Resident interviews revealed that some residents did not receive showers on their scheduled days, with one resident stating she was not even asked or informed about her shower. Another resident reported not receiving a shower due to the absence of a shower aide, and a third resident indicated she was only given bed baths because staff did not want to use the Hoyer lift for showers, despite her preference for a shower. A fourth resident stated she received showers only about once a week and noted inconsistency in staff providing showers. In several cases, shower sheets were missing or incomplete, and staff were unable to verify whether showers or bed baths had been provided as scheduled. Staff interviews confirmed that there were challenges in completing all scheduled showers, with some nurse aides reporting insufficient time to complete showers and passing the responsibility to the next shift. There was also confusion among staff regarding the shower schedule and documentation procedures. Nursing staff and administration acknowledged the expectation for showers to be completed per schedule and for staff to notify supervisors if showers could not be completed, but records and interviews indicated this process was not consistently followed.
Failure to Uphold Resident Self-Determination and Financial Rights
Penalty
Summary
The facility failed to ensure a resident's right to self-determination and choice regarding personal finances and significant life decisions. A male resident with dementia, anxiety, heart failure, hypertension, and impaired coordination, who had a moderate cognitive impairment (BIMS score of 8), was not provided access to a working debit card attached to his personal funds for daily use. The resident's care plan indicated a goal of maintaining dignity and meeting his needs in a timely manner, but the facility did not uphold these standards. The resident was unable to use his debit card for purchases, as observed when a transaction was denied at a vending machine. Additionally, the facility failed to prevent the administrator from purchasing a pre-need funeral plan for the resident, despite the resident having previously expressed to his family that he did not want such a plan. The administrator withdrew over $13,000 from the resident's account to purchase the funeral plan and start a trust fund, without the resident's informed consent. Interviews revealed that the administrator acted on the suggestion of a family member who was not the resident's POA or guardian, and that the resident had not authorized these financial decisions. There were also concerns raised by staff about other residents and staff accessing the resident's debit card without proper authorization, resulting in unexplained withdrawals from his account. The facility's inaction in addressing repeated staff concerns about unauthorized use of the resident's funds, as well as the administrator's decision to proceed with significant financial transactions against the resident's wishes, led to the identification of Immediate Jeopardy. The facility did not ensure the resident's right to make choices about aspects of his life that were significant to him, particularly regarding his finances and end-of-life arrangements.
Failure to Prevent Misappropriation of Resident Funds by Staff and Peers
Penalty
Summary
The facility failed to protect a resident from misappropriation of personal funds and belongings, resulting in unauthorized use of the resident's debit card by both staff and another resident. The resident, who had dementia and moderate cognitive impairment as indicated by a BIMS score of 8, was at risk for further cognitive decline. Despite the care plan interventions to maintain routine and monitor cognitive changes, the resident's debit card was used for multiple unauthorized ATM withdrawals and purchases over several dates. The resident was unaware of these transactions and did not authorize the use of his card by others, except for a single instance where he permitted another resident to use it for a small amount. Staff interviews revealed that certified nurse aides (CNAs) and another resident were involved in attempting to withdraw funds from the resident's account without proper authorization. One CNA admitted to attempting an ATM withdrawal after being given the card and PIN by another resident, only realizing the card did not belong to that resident when a fraud alert appeared. The CNA returned the card but did not immediately report the incident. Further interviews indicated a pattern of staff and residents accessing the resident's funds, with reports of other staff and family members of residents charging the resident for errands and transportation, sometimes for significant amounts. These incidents were not consistently reported to administration, and there was confusion and lack of clarity among staff and administration regarding what constituted misappropriation. The administrator was aware that the resident had given his card to another resident but was not aware of the extent of unauthorized use by staff. The administrator believed that if the resident gave his card to another resident, it did not constitute misappropriation, and was unaware of the attempted $200 withdrawal by staff. The administrator and other staff had been informed of suspicious withdrawals and concerns by the resident's family, but the issue was not promptly or thoroughly investigated. The facility's policy required protection against misappropriation, but the lack of timely action and oversight allowed unauthorized transactions to occur, resulting in financial loss and emotional distress for the resident.
Failure to Prevent and Investigate Misappropriation of Resident Funds
Penalty
Summary
The facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. Specifically, the facility did not follow its own abuse policy for a resident with moderate cognitive impairment, who had diagnoses including dementia, anxiety, heart failure, high blood pressure, and lack of coordination. The resident was at risk for further cognitive decline and had a care plan aimed at maintaining his dignity and current level of functioning. Staff members, including CNAs, were involved in unauthorized attempts to use the resident's debit card for ATM withdrawals. One CNA admitted to attempting a transaction after being given the card and PIN by another resident, only to discover the card belonged to the affected resident. The CNA did not report the incident immediately and later revealed knowledge of multiple occasions where the resident's funds were accessed or used by other residents, staff, and even family members of other residents. The administrator was reportedly aware of these incidents but did not take appropriate action or conduct a thorough investigation into the misappropriation of the resident's funds and unauthorized transactions. Interviews and record reviews indicated that the resident was unaware of the extent of unauthorized use of his debit card and did not authorize others to use it beyond a single instance. Bank statements revealed multiple large withdrawals that the resident could not recall, causing him emotional distress. Despite staff and other residents being aware of the ongoing misuse of the resident's funds, the facility failed to protect the resident, did not follow its abuse policy, and did not initiate a timely or adequate investigation into the misappropriation of property.
Removal Plan
- The DON completed an assessment on Resident #9 to determine if resident was having any emotional distress related to this incident.
- The DON completed a Comprehensive Trauma screen on the resident, and resident will be referred to psychology services for further evaluation.
- The V.A. Social Worker was contacted by the facility regarding the need of the resident needing a psychology evaluation related to this incident.
- The Regional Director of Operations provided 1:1 in-service with the Regional Nurse Consultant on the facility's abuse, Neglect, and Misappropriations policy.
- The Regional Nurse Consultant provided 1:1 education to the facility DON on the Abuse, Neglect, and Misappropriations policy.
- The DON started in-service education with all staff on the facility's Abuse, Neglect, Misappropriations policy, including post-test. No staff will be allowed to work until they have completed their education.
- The Administrator was suspended by the Regional Director of Operations pending investigation.
- The resident will be taken to his bank by the Maintenance Director and Social Services to obtain a new debit card. Residents' family will be encouraged to go as well. Resident does have an active Trust fund in the facility and has access to immediate funds if he chooses.
- The Misappropriation incident was reported to HHSC by the DON.
- The Misappropriation incident was also reported to the local law enforcement agency.
- The incident was reported to HHSC by the DON regarding Resident #63 not being authorized to use Resident #9's debit card.
- Resident #63 was discharged from the facility and did not have access to resident #9's debit card.
- The facility started an investigation into the incident; the investigation was completed.
- C.N.A. E was suspended by the DON related to the incident.
- C.N.A. D was suspended and never returned to work.
- The Social Worker/designee will complete alert resident interviews 3 x week for 3 weeks, then weekly x 6 weeks to validate that all residents are allowed to make choices about aspects of his/her life in the facility, including financial choices. This will be reviewed after each interview is completed by the DON and Social Services so any issues, if applicable, can be addressed immediately.
- The Regional Nurse Consultant will oversee this process weekly x 6 weeks.
- The facility's DON notified the Medical Director regarding the Immediate Jeopardy the facility received related to failure to implement the abuse policy.
- The facility conducted an Ad Hoc QAPI meeting to discuss Misappropriation, and implementation of the abuse policy and sustaining compliance.
Failure to Timely Report Alleged Abuse, Neglect, and Misappropriation
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment—including injuries of unknown source and misappropriation of resident property—were reported immediately, or within the required timeframes, to the administrator and appropriate authorities. Specifically, there were delays in reporting incidents involving three residents. In one case, two CNAs attempted to use a resident's debit card at an ATM after receiving it from another resident, but the incident was not reported to the administrator or state agency in a timely manner. The resident whose card was used had moderate cognitive impairment and was unaware that his card was being given to others or used for unauthorized transactions. Interviews revealed that staff and other residents were aware of ongoing issues with the resident's finances, but these concerns were not promptly reported as required. In another incident, a resident-to-resident altercation occurred in which one resident with severe cognitive impairment was struck in the head multiple times by another resident known to have aggressive behaviors. The CNA who witnessed the event reported it to two nurses, but neither nurse reported the incident to the administrator immediately. The administrator only became aware of the altercation several days later, after which the required assessments and reporting were initiated. Interviews with staff indicated confusion or lack of knowledge regarding the proper reporting procedures, with some staff assuming others had reported the incident or not understanding the steps required. Record reviews and staff interviews confirmed that the facility's policies required immediate reporting of abuse, neglect, exploitation, and misappropriation of property, but these procedures were not followed in the cited incidents. The failure to report these events in a timely manner resulted in delayed investigations and assessments, and the facility did not meet regulatory requirements for prompt notification to the administrator and state authorities.
Failure to Investigate and Protect Resident from Misappropriation of Funds
Penalty
Summary
The facility failed to thoroughly investigate and protect a resident from misappropriation of personal funds, as evidenced by multiple staff and resident interviews and record reviews. The resident, who had moderate cognitive impairment with a BIMS score of 8 and diagnoses including dementia, anxiety, heart failure, high blood pressure, and lack of coordination, was at risk for further decline. The care plan indicated the resident required support to maintain dignity and current functioning. Despite this, there were several incidents where the resident's debit card was used or attempted to be used by others without proper authorization or oversight. On one occasion, two CNAs attempted to withdraw money from an ATM using the resident's debit card, which had been given to them by another resident. The CNAs were unaware the card belonged to the resident until a fraud alert appeared. The incident was not immediately reported to the administrator, and the CNAs were only suspended after the fact. Interviews revealed that the resident had given his card to another resident for a single use but was unaware that it was being given to staff or used for multiple unauthorized withdrawals. Bank statements showed several large withdrawals that the resident did not recognize or authorize, causing him distress when reviewed. Further interviews with staff indicated that there were ongoing concerns about the resident's funds being accessed by other residents, staff, and even family members of other residents. These concerns were reported to the administrator, who claimed to have investigated but did not take comprehensive action to protect the resident or thoroughly investigate the allegations. The facility's own policy required immediate and thorough investigation and reporting of all allegations of abuse, neglect, exploitation, and misappropriation of resident property, but these procedures were not followed in this case.
Failure to Provide Prescribed Therapeutic Diets and Fortified Foods
Penalty
Summary
The facility failed to ensure that two residents received therapeutic diets as prescribed by their attending physicians. For one resident, who had diagnoses including dementia, heart failure, dysphagia, and high blood pressure, the care plan required a mechanical soft diet without dairy and the provision of fortified foods and Ensure Clear at all meals. On the observed date, this resident did not receive fortified food, Ensure Clear, or water as indicated on her tray card. Staff interviews revealed that the cook did not add fortified ingredients to the mechanically soft meal and did not serve any fortified food for lunch. The CNA assisting the resident was unaware of what should have been fortified on the tray, and the dietary manager confirmed that the cook was responsible for ensuring the correct diet and supplements were provided. Another resident, with diagnoses including diabetes, anorexia, anemia, and a history of stroke, was also not provided with the required fortified foods during a lunch meal. The resident's care plan and meal ticket specified a regular diet with consistent carbohydrates, no added salt, and fortified foods at all meals, including a specific order for fortified mashed potatoes at lunch. Observation showed that the resident did not receive the fortified mashed potatoes as indicated. The cook stated she was unaware that the resident required fortified foods and did not prepare them. The dietary manager and DON both acknowledged that the resident should have received fortified foods as ordered, and the DON noted a typo on the meal ticket but confirmed the expectation for fortified foods to be provided. Facility policy required that all residents receive foods in the appropriate form and nutritive content as prescribed by the physician, with all diet orders communicated to the dietary department and validated by the dietary manager. Despite these policies, the failures in communication and execution led to residents not receiving their prescribed therapeutic diets and supplements as ordered.
Failure to Implement and Maintain Effective Infection Control Program
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple instances where staff did not follow established policies and procedures for COVID-19 isolation and use of personal protective equipment (PPE). Observations revealed that staff members entered and exited rooms of residents on isolation precautions without donning appropriate PPE or performing hand hygiene. For example, a nursing assistant was seen entering the shared room of two COVID-positive residents without gloves, gown, or N95 mask, and did not wash or sanitize her hands before or after contact. Another staff member was observed pushing a COVID-positive resident in a wheelchair in the hallway without ensuring the resident wore PPE, and did not perform hand hygiene between resident contacts. There was a lack of clear communication and awareness among staff regarding which residents were COVID-positive and required isolation. Several staff members, including nursing assistants and medication aides, reported that they were not informed about the COVID status of residents on their assigned halls, relying instead on visual cues such as PPE boxes or red floor tape, which were inconsistently used or removed. Charge nurses and the infection preventionist indicated that it was the responsibility of the charge nurses to inform staff about positive cases, but this process was not reliably followed. Documentation and lists of COVID-positive residents were incomplete or outdated, leading to confusion and improper implementation of isolation protocols. Additionally, the facility did not ensure that PPE was consistently available outside the rooms of all residents on isolation precautions. In one instance, a resident listed as COVID-positive did not have a PPE box outside her room, and both the infection preventionist and DON were unaware of this omission. The facility's own policies required that all COVID-positive residents have PPE available for staff use before entering their rooms, and that residents remain in isolation for the required period. However, these policies were not consistently implemented, as evidenced by staff interviews, observations, and record reviews.
Failure to Maintain Resident Dignity During Dining
Penalty
Summary
The facility failed to treat residents with respect and dignity during dining services, as observed in two specific instances. Firstly, a CNA and an MA referred to residents needing assistance with eating as 'feeders,' which was acknowledged by both staff members as a dignity issue. The CNA admitted to using the term out of habit and recognized the need to use more respectful language, such as 'assisted dining room.' This inappropriate terminology was used in close proximity to residents, potentially impacting their dignity and self-esteem. Secondly, an LVN was observed standing while feeding a resident, which is not the correct method for assisting residents with meals. The LVN admitted to not being taught to sit at eye level with residents during feeding, which is the expected practice to ensure residents do not feel rushed or intimidated. The Director of Nursing and the Administrator both confirmed that the staff should refer to residents needing assistance as 'assisted diners' and should sit at eye level when feeding residents. These practices are part of the facility's policy to promote and maintain resident dignity.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect several residents from abuse, resulting in multiple incidents of resident-to-resident aggression. Resident #3 was involved in two separate incidents where he was physically assaulted by other residents. On one occasion, Resident #9 shoved Resident #3 in the dining room, and on another occasion, Resident #4 hit Resident #3 on the back of the head. Both Resident #9 and Resident #4 had documented behavior problems, and their care plans included interventions to manage these behaviors, but these measures were not effective in preventing the incidents. Resident #6 was also a victim of abuse when Resident #5 hit her with a silverware packet during breakfast. Despite Resident #5's severely impaired cognition, her care plan did not prevent the aggressive behavior. Similarly, Resident #7 was struck on the head by Resident #8 after repeatedly reaching into Resident #8's Christmas bag. Resident #8 had a history of aggressive behaviors, and his care plan included interventions to manage agitation, but these were not sufficient to prevent the incident. The facility's failure to prevent these incidents of abuse indicates a lack of effective implementation of care plan interventions and monitoring of residents with known behavior problems. The incidents were witnessed by staff members, and immediate actions were taken to separate the residents involved, but the repeated occurrences suggest systemic issues in managing resident behaviors and ensuring a safe environment.
Failure to Report Resident-to-Resident Altercations Timely
Penalty
Summary
The facility failed to implement its written policies and procedures prohibiting mistreatment, neglect, and abuse of residents, as evidenced by two incidents of resident-to-resident altercations that were not reported to the state agency within the required timeframe. The first incident involved two residents, one with supraventricular tachycardia and moderate cognitive impairment, and the other with dementia and severe cognitive impairment. The altercation occurred when one resident moved the other's wheelchair, leading to a physical confrontation. Although the incident was witnessed by staff, it was not reported to the state agency until several hours later. The second incident involved two female residents, one with heart failure and severe cognitive impairment, and the other with dementia but intact cognition. During breakfast, one resident hit the other with a silverware packet after a disagreement over seating. This incident was also witnessed by staff, but the report to the state agency was delayed. The facility's policy required immediate reporting of such incidents, but this was not adhered to in both cases. Interviews with staff, including an LVN and the Administrator, revealed that the facility's abuse prevention coordinator, who was also the Administrator, was responsible for reporting these incidents. However, the Administrator admitted to delays in reporting and acknowledged the importance of timely reporting for resident safety. The failure to report these incidents promptly was a clear violation of the facility's policies and procedures, potentially placing residents at risk for further abuse and neglect.
Failure to Timely Report Resident-to-Resident Altercations
Penalty
Summary
The facility failed to report alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, within the required timeframe of 2 hours after the allegation was made. This deficiency was identified for four residents involved in two separate incidents of resident-to-resident altercations. The first incident involved two male residents, one with a diagnosis of supraventricular tachycardia and moderate cognitive impairment, and the other with dementia and severe cognitive impairment. The altercation occurred when one resident moved the other's wheelchair, leading to a physical confrontation. Although the incident was witnessed by staff, it was not reported to the State Survey Agency within the required 2-hour timeframe. The second incident involved two female residents, one with severe cognitive impairment and a history of paranoid personality disorder and depression, and the other with intact cognition but a diagnosis of dementia. The altercation occurred in the dining room when one resident hit the other with a silverware packet after a disagreement over seating. This incident was also witnessed by staff, but the report to the state agency was delayed beyond the 2-hour requirement. The facility's policy mandates immediate reporting of such incidents to ensure resident safety and compliance with state regulations. Interviews with facility staff, including an LVN and the Administrator, revealed that there were communication lapses and delays in reporting the incidents. The Administrator, who is the abuse coordinator, acknowledged the importance of timely reporting and the expectation that staff should notify her immediately of any allegations. Despite being aware of the incidents, the Administrator did not ensure that the reports were made within the required timeframe, highlighting a failure in the facility's internal processes for handling and reporting abuse allegations.
Failure to Assess and Document Skin Issues
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. A resident, who was at risk for developing pressure ulcers, was reported to have skin issues on her buttocks by a CNA. However, the LVN did not assess the resident's buttocks after the report was made. This lack of assessment and documentation could lead to the resident not receiving appropriate care and treatment. The resident, a female with a history of peripheral vascular disease, Type 2 diabetes mellitus, congestive heart failure, and protein calorie malnutrition, was frequently incontinent of urine and always incontinent of bowel. Her care plan included weekly skin checks and reporting any new skin conditions to the physician. Despite these measures, there was no documentation of skin issues in the resident's progress notes or treatment administration record for the month of May 2024. Interviews with staff revealed that the CNA reported the skin issues to a charge nurse, who instructed the CNA to apply cream, but no further action was taken. The ADON acknowledged that the skin breakdown should have been documented and monitored. The facility's Skin Management Policy requires that any change in skin condition be documented and communicated to the physician, wound team, and family, which was not done in this case.
Failure to Provide SNF ABN Forms to Residents
Penalty
Summary
The facility failed to ensure that residents were informed about Medicaid/Medicare coverage and potential liability for services not covered. Specifically, the facility did not provide a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) to three residents (Residents #30, #183, and #185) when they were discharged from skilled services before their covered days were exhausted. This notice is essential to inform residents that Medicare will no longer pay for skilled services and to provide them with the option to continue services at their own expense. Resident #30, a male with severe cognitive impairment, was admitted with diagnoses including gastroenteritis, anxiety, and depression. He was receiving Medicare Part A services, but no SNF ABN was completed when his coverage ended. Similarly, Resident #183, a female with moderate cognitive impairment and diagnoses including dementia, kidney failure, and atrial fibrillation, did not receive an SNF ABN when her Medicare Part A services ended. Resident #185, a female with moderate cognitive impairment and diagnoses including respiratory failure, congestive heart failure, and stroke, also did not receive an SNF ABN when her Medicare Part A services ended. Interviews with facility staff revealed a lack of awareness and training regarding the SNF ABN forms. The MDS Coordinators and the Business Office Manager (BOM) were unaware of their responsibilities related to the SNF ABN forms. The Director of Nursing (DON) and the Administrator also did not know about the SNF ABN forms or the process for completing them. This lack of knowledge and training led to the failure to provide the necessary notifications to the residents, potentially placing them at financial risk.
Inaccurate MDS Coding for Anticoagulant Use
Penalty
Summary
The facility failed to ensure that assessments accurately reflected the resident status for four residents reviewed for MDS assessment accuracy. Specifically, the facility did not accurately code the use of anticoagulant medications for these residents. This discrepancy was identified through interviews and record reviews, which revealed that the residents were not actually taking anticoagulant medications, despite being coded as such in their MDS assessments. The medications in question were aspirin and Plavix, which are antiplatelet medications and should not have been coded as anticoagulants according to the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual. Resident #17, a female with multiple diagnoses including chronic obstructive pulmonary disease and Parkinson's, was incorrectly coded as taking an anticoagulant medication. However, her medication review report indicated she was only prescribed aspirin. Similarly, Resident #38, a male with diagnoses including deep vein thrombosis and stroke, was also incorrectly coded as taking an anticoagulant. His physician's orders indicated he was prescribed aspirin and Plavix, both of which are antiplatelet medications. Residents #49 and #53 were also affected by this coding error. Resident #49, with diagnoses including chronic respiratory failure and congestive heart failure, was coded as taking an anticoagulant, but her records only showed an order for aspirin. Resident #53, with chronic respiratory failure and type 2 diabetes, was similarly misrepresented in the MDS assessment. Interviews with the MDS Coordinators revealed that they mistakenly believed aspirin could be coded as an anticoagulant, leading to these inaccuracies. The Administrator and other staff members acknowledged the importance of accurate MDS coding for proper resident care and facility reimbursement.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for four residents, leading to deficiencies in addressing their medical, nursing, and psychosocial needs. Resident #44, a cognitively intact female with anxiety, diabetes, COPD, and stroke, had a physician's order for Lorazepam to manage anxiety. However, her care plan did not include this medication or any related interventions. Similarly, Resident #51, a cognitively intact female with PVD, COPD, high blood pressure, and bipolar disorder, was prescribed Eliquis, an anticoagulant, but her care plan lacked any mention of this medication or necessary interventions. Interviews with the MDS Coordinators and DON revealed a lack of awareness and oversight in updating care plans to reflect these critical medications, which are essential for proper resident care and staff guidance. Resident #5, a severely cognitively impaired male with anxiety, dementia, dysphagia, and a history of stroke, experienced a fall that was documented in his progress notes. Despite this incident, his care plan was not updated to include the fall or any new interventions to prevent future falls. Interviews with the MDS Coordinators, DON, and ADON highlighted a breakdown in communication and responsibility for updating care plans following incidents like falls. This oversight could lead to missed care and increased risk of further incidents. Resident #47, a severely cognitively impaired male with multiple diagnoses including pneumonia, heart failure, and diabetes, had an active order for palliative care. However, his care plan did not reflect this significant change in his care needs. The MDS Coordinators and DON acknowledged the oversight, attributing it to a lack of timely updates and coordination among staff. The failure to include palliative care in the resident's care plan could result in inadequate comfort measures and support for the resident's end-of-life care needs.
Failure to Provide Prescribed Nutritional Supplements
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for three residents, leading to potential risks of malnourishment, weight loss, and decreased quality of life. Resident #1, who had moderate cognitive impairment and was on hospice care, did not receive his prescribed magic cup with meals on multiple occasions. Despite the dietary orders, the kitchen did not provide the magic cup, and the charge nurses failed to ensure its delivery. The Assistant Director of Nursing (ADON) acknowledged the risk of weight loss due to this oversight. Resident #34, who was severely cognitively impaired and required total assistance with daily activities, did not receive his prescribed health shake with meals. The kitchen was out of stock, and the staff did not notify the physician or the administration about the shortage. The Dietary Manager (DM) admitted to not informing the Administrator about the lack of health shakes and magic cups, which were essential for maintaining the residents' weight and nutritional status. Resident #49, who had multiple chronic conditions and a recent history of significant weight loss, did not receive her Nutritious Shake for several days. The staff informed her that the shakes were out of stock, and the DM confirmed the shortage. The Nurse Practitioner (NP) and Registered Nurse (RN) were not notified about the unavailability of the nutritional supplements, which could lead to further weight loss. The facility's policy on diets, nutrition, and hydration was not followed, resulting in the residents not receiving the necessary supplements to maintain their health.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to ensure that residents requiring respiratory care were provided such care consistent with professional standards of practice. For Resident #44, there was no oxygen order in place until after surveyor intervention, despite the resident requiring oxygen therapy for chronic obstructive pulmonary disease (COPD). The resident's oxygen was initially set at an incorrect level, and the charge nurse was unaware of the missing order until questioned by the surveyor. This oversight could have led to respiratory issues for the resident due to improper oxygen levels. Resident #51's oxygen concentrator filter was found to be dirty, and the night shift staff responsible for cleaning it had not done so. The resident's care plan indicated the need for clean filters to prevent respiratory issues, but this was not adhered to. Similarly, Resident #17's oxygen filter was also dirty, and the oxygen tubing was not stored in a bag when not in use, which could lead to contamination and respiratory complications. The staff were not following the protocol for weekly cleaning and proper storage of respiratory equipment. Resident #60's oxygen concentrator filter was observed to be dirty, indicating a failure to follow the weekly cleaning schedule. Resident #47's nebulizer mask was not stored in a bag after use, increasing the risk of cross-contamination. Lastly, Resident #53's BiPAP mask was not functioning properly, and the resident had not used it for 2-3 months due to a broken strap. The staff had not contacted respiratory therapy to address the issue, and the mask was not stored in a bag, exposing it to potential contamination. These failures in providing appropriate respiratory care could lead to significant respiratory complications for the residents involved.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure all drugs were stored in locked compartments and labeled in accordance with professional standards. Specifically, the Treatment Cart and the 400 Hall Nurse cart were found unsecured and accessible to unauthorized personnel. Additionally, medications on the 100 Hall Nurse cart, including an insulin pen and inhalers for three residents, were not labeled with open dates. A multidose vial of Lidocaine on the 300 Hall Nurse cart also lacked an open date. These lapses were observed during various checks and interviews with staff, who acknowledged the importance of securing and properly labeling medications but failed to adhere to these protocols. The facility also failed to discard expired medications in the medication storage room. A vial of Influenza Vaccine and a vial of Tuberculin Purified Protein Derivative were found in the medication fridge, both of which had been opened for more than 30 days and should have been discarded. Staff interviews revealed a lack of awareness regarding the expiration timelines for these medications, and the Assistant Director of Nursing (ADON) admitted to not checking the medication fridge as frequently as required due to other work demands. Interviews with the Director of Nursing (DON) and other staff confirmed that the facility's policy required all medications to be stored in locked compartments and labeled with open dates. The DON and ADON acknowledged the importance of these practices for maintaining medication efficacy and resident safety. However, the facility's failure to consistently follow these protocols resulted in multiple deficiencies, including unsecured medication carts and improperly labeled or expired medications.
Failure to Follow Pureed Diet Menus and Recipes
Penalty
Summary
The facility failed to ensure that menus were followed for residents on a pureed food consistency diet, leading to deficiencies in the nutritional needs of these residents. Specifically, the facility served the wrong scoop size servings of macaroni and cheese during the lunch meal on 3/25/24, and failed to serve pureed bread to residents on the same day. Cook S used a #12 scoop instead of the required #6 scoop and did not provide a second scoop to compensate. Additionally, Cook S forgot to serve the pureed bread, which was prepared but not served to the residents. The Dietary Manager confirmed these errors and acknowledged that the correct scoop size and pureed bread should have been used and served, respectively. On 3/26/24, the facility again failed to follow the puree recipe for the lunch meal. Cook T did not use the recipe book while preparing the meal, instead relying on personal methods for preparing chili, collard greens, and rice. This resulted in the incorrect preparation of these items, as Cook T added ingredients and thickener without following the specified recipe. Similarly, Cook S did not use the recipe book while preparing pureed cinnamon apple slices, instead relying on her memory. Both cooks acknowledged the importance of following the recipe book to ensure residents receive the correct food, especially for those with dietary restrictions such as diabetes. Interviews with the Dietary Manager and Regional Director revealed a lack of oversight and training regarding the use of correct scoop sizes and adherence to recipe books. The Dietary Manager admitted that staff had not been trained on scoop sizes and recipe book usage in the current year and that test trays were not conducted regularly. The Regional Director was unaware of the issues with scoop sizes and had only recently taken over the facility's account. The Administrator also admitted to not inspecting the kitchen recently and was unaware of any recent in-services on scoop sizes or recipe book usage. This lack of oversight and training contributed to the deficiencies observed in the preparation and serving of pureed meals.
Failure to Provide Palatable and Appetizing Food
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for four residents. Observations and interviews revealed that the food served was either bland, over-seasoned, or too spicy, leading to dissatisfaction among the residents. Specifically, Resident #23 found the food bland, Resident #49 found it over-seasoned, Resident #47 described it as terrible, and Resident #17 found it too spicy. Additionally, a test tray review indicated that the macaroni and cheese was cold and bland, although other items were found to be satisfactory in temperature and taste by both the Dietary Manager and State Surveyors. The Dietary Manager admitted to not tasting the food daily and acknowledged difficulties with staff finding recipes in a new program book. She also mentioned that in-services had not been conducted this year, although staff had been trained in the past. The Regional Director, who had been in the position for only a few weeks, confirmed that food complaints were handled through grievances and necessary adjustments were made. The Administrator, who had been in her role since March 2023, also confirmed that she had not conducted a test tray for March 2024 yet, although she had received both complaints and compliments about the new menu. Record reviews indicated that the menus were planned to meet the average resident's nutritional needs and were reviewed by a Registered Dietitian. However, the policy did not include information on palatability. The facility's failure to ensure the food was palatable, attractive, and at an appetizing temperature could place residents at risk of decreased food intake, hunger, and unwanted weight loss.
Deficiencies in Food Storage and Kitchen Maintenance
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 Refrigerator #1, it was found that a 5-pound block of sliced cheese, 5 slices of cheese in saran wrap, 8 quarts of lettuce, and 5 slices of bologna were not properly labeled with open dates, received dates, or expiration dates. Additionally, 6.5 pounds of sliced strawberries in Freezer #2 were also found without received or expiration dates. These deficiencies were confirmed by interviews with the Dishwasher, Certified Dietary Manager (CDM), and the Dietary Manager, who acknowledged the lack of proper labeling and dating of food items in the refrigerator and freezer. The CDM also admitted that there had been no recent in-services on labeling, dating, and resealing food items for the dietary staff. Furthermore, a leak in the kitchen ceiling above the food preparation area was observed, which had been reported but not yet repaired, posing a potential fall hazard and risk of contamination. During interviews, the Dietary Manager and Regional Director both confirmed the importance of labeling, dating, and disposing of expired food items according to the facility's policy. The Regional Director stated that labeling and dating were on her to-do list for the dietary staff, but she was unsure if any in-services had been conducted in the past. The Administrator, who had been employed at the facility since March 2023, also confirmed the need for proper labeling and dating of food items and acknowledged the leak in the kitchen ceiling. The Administrator stated that the leak had been reported and repaired previously but was still occurring, and she was unsure when it would be repaired again. The facility's policy on frozen and refrigerated food storage requires proper labeling of cooked foods with the date placed in the refrigerator and an expiration or use-by date. The policy also mandates that refrigerated products be labeled with an opened-on date and a use-by date, which is 7 days from when the product was opened unless there is a manufacturer's use-by, expiration, or sell-by date. The FDA Food Code for 2022 also emphasizes the importance of maintaining physical facilities in good repair. The facility's failure to adhere to these policies and standards could place residents at risk for food contamination and foodborne illness.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices, leading to multiple deficiencies. CNA X did not perform hand hygiene or change gloves while providing incontinent care to a resident, which could spread infection. The CNA admitted to not realizing the importance of hand hygiene and glove changes, despite being trained on these procedures. The Director of Nursing (DON) and the Administrator both acknowledged the expectation for proper hand hygiene and the risks associated with failing to follow these protocols. In another instance, facility staff improperly disposed of used personal protective equipment (PPE) in a resident's personal trash can instead of the biohazard bin. The charge nurse and Assistant Director of Nursing (ADON) confirmed that biohazard materials should be disposed of in designated bins to prevent contamination. The DON admitted that staff needed reeducation on proper disposal practices, and the Administrator was unaware of the improper disposal but recognized the infection control risks. Additionally, a CNA left trash and a sheet in a resident's room after providing care, and a treatment nurse failed to perform hand hygiene after glove removal and did not change gloves properly while providing wound care. Both the ADON and DON emphasized the importance of proper disposal of trash and linens and the need for hand hygiene to prevent cross-contamination and infection. The facility's policies on hand hygiene, infection control, and transmission-based precautions were not followed, leading to these deficiencies.
Failure to Knock on Resident's Door Before Entering
Penalty
Summary
The facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for one resident. Specifically, a CNA entered a resident's room without knocking or identifying herself, which made the resident feel uncomfortable and unsafe. The resident, who was cognitively intact and required moderate assistance for transfers and toileting, expressed that staff regularly entered his room without knocking, which he found distressing. The CNA acknowledged that she should have knocked and introduced herself before entering the room, recognizing that the facility was the residents' home and they deserved dignity and privacy. Interviews with the ADON, DON, and Administrator confirmed that staff were expected to knock on residents' doors and introduce themselves before entering to ensure no patient care was taking place and to respect residents' rights. The facility's policy on promoting and maintaining resident dignity also required staff to explain care or procedures before initiating them and to maintain resident privacy. Despite annual and as-needed in-services on dignity, the failure to knock on the resident's door before entering was identified as a violation of the resident's rights and dignity.
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Illustrative
What surveyors actually found near you
We read the 114 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Greenville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Briarcliff Health Center Of Greenville | 0.4 mi | ★★★★★ | 15 | 1 |
| Greenville Gardens | 0.8 mi | ★★★★★ | 0 | 0 |
| Legend Healthcare And Rehabilitation - Greenville | 2.2 mi | ★★★★★ | 0 | 0 |
| Royse City Medical Lodge | 10.8 mi | ★★★★★ | 6 | 0 |
| Farmersville Health And Rehabilitation | 13.6 mi | ★★★★★ | 15 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.