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 Matlock Place Health & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with quadriplegia, COPD, epilepsy, cognitive impairment, and dependence on 2 staff for incontinent care fell during a CNA’s attempt to provide care. The CNA stated he was new, PRN, and did not have access to the electronic care plan system, and he turned the resident on his side when the resident tipped over and fell to the floor. The resident was later found with bleeding and a head injury that required staples in the ED, and staff confirmed the resident required 2-person assistance and that fall protocol called for immediate nurse assessment before moving the resident.
A CNA performed incontinent care on a resident who required 2-person assistance, and the resident fell from the bed and sustained a head laceration. The CNA stated he was new, PRN, had not been trained on fall protocol, and did not have access to the electronic care plan system containing the resident’s care needs. Records showed the resident had quadriplegia, moderate cognitive impairment, and was totally dependent on staff for incontinent care.
Failure to provide nail care and personal hygiene assistance left several residents with long, dirty, or chipped fingernails despite documented ADL dependence and requests for help. Residents with conditions including dementia, DM, ESRD, stroke, hemiplegia, and psychiatric diagnoses were observed with nails needing cleaning or trimming, while staff interviews showed inconsistent responsibility for nail care between CNAs, nurses, and other staff.
Broken controlled medication blister packs were found in multiple med carts, including a Nurses' med cart and an MA med cart, with pills still in the blisters and the seals taped on the back. Staff stated they did not know when the seals became broken and said opened packs should be discarded to prevent diversion. The DON stated broken blister pack pills should be discarded and that keeping an opened blister pack was not acceptable.
Food items in the kitchen were found improperly stored and labeled. Surveyors observed chicken tenders in an unlabeled, undated bag stored with frozen fries in the freezer, expired thickened beverages and hot cocoa mix in dry storage, and opened spices without open or use-by dates. The DM and a Cook/Dietary Aide stated food items should be labeled, dated, stored separately, and expired items discarded.
A resident with dementia, anxiety, depression, and recent weight loss had ordered nutritional interventions that were not fully implemented. The MAR/TAR did not reflect the ordered 2 Cal Med Pass or house shakes, resulting in missed supplement doses, and ordered weekly weights were also missed. Staff and the DON acknowledged the orders were entered but did not carry over correctly, and the resident's weight monitoring was not completed as ordered.
Failure to complete ordered pain assessments for a cognitively impaired resident. A resident with Alzheimer’s disease, dementia, and hospice services had standing orders for pain assessment every shift and PRN Tylenol and morphine, but staff did not assess pain on every shift and morphine was never given. Interviews showed the LPN and leadership were aware the resident could not reliably verbalize pain and that PAINAD should be used, yet assessments were still missed.
A resident with ESRD required hemodialysis three times weekly, and the care plan reflected ongoing dialysis-related monitoring and access site care. However, the chart did not contain a current physician order for dialysis even though dialysis communication forms showed regular M/W/F treatments with an early morning chair time. Staff, including an LVN, ADON, and DON, confirmed the order could not be located and that the omission was missed during order review.
Failure to Follow PPE and Hand Hygiene During High-Contact Care: Two residents on EBP for wounds were observed during high-contact care without proper PPE and with missed hand hygiene. A CNA provided incontinent care to one resident without a gown and changed gloves without hand hygiene, and an LVN performed wound care for another resident without a gown and repeatedly changed gloves without hand hygiene. Both staff acknowledged the infection control lapses, and the DON stated staff were expected to use appropriate PPE and perform hand hygiene during these care activities.
A facility failed to keep call lights within reach for two residents with care plans directing staff to ensure access to the device. One resident with intact cognition and impaired physical mobility was found unable to reach her call light while asking for help to use the bathroom, and an LVN found it on the floor. Another resident with dementia and generalized weakness was observed in bed with her special call light on the floor under the head of the bed, and the DON retrieved it and clipped it to her linen.
A resident with severe cognitive impairment and a history of reliving past trauma alleged sexual abuse to her mental health provider, who promptly notified facility staff. Despite facility policy and regulatory requirements, the allegation was not reported to law enforcement or the state agency within the required 2-hour timeframe, as staff believed the claim was related to past trauma. This failure to report constituted a deficiency in abuse reporting procedures.
Staff failed to accurately document respiratory treatments in the MDS assessments for three residents with severe cognitive impairment and complex medical needs. Despite receiving treatments such as nebulizer therapy and oxygen, these interventions were not recorded in the MDS, as confirmed by record reviews, observations, and interviews with facility leadership.
The facility did not include required respiratory treatments in the care plans for several residents with complex medical and cognitive needs, despite physician orders and ongoing administration of these therapies. Care plans addressed other needs but omitted documentation of oxygen therapy, nebulizer treatments, and inhalation medications, as confirmed by record review, staff interviews, and direct observation.
Multiple residents with respiratory needs did not have their care plans updated to include respiratory treatments, and staff failed to consistently clean, bag, and date respiratory equipment such as nebulizer masks and nasal cannula tubing. Observations found unbagged and undated equipment in use, and staff interviews confirmed lapses in following established protocols for respiratory care.
Staff failed to follow infection control protocols, including Enhanced Barrier Precautions and hand hygiene, during care of three residents. CNAs and an LVN did not consistently perform hand hygiene, change gloves between tasks, or wear required PPE during incontinence care, transfers, and wound care, despite facility policies and recent training.
A resident with severe cognitive impairment, total dependence, and multiple chronic wounds did not receive daily physician-ordered wound care, resulting in unchanged, saturated, and foul-smelling dressings. The responsible LVN admitted to missing the treatment and failing to notify the next shift, and the DON was unaware of the lapse until after it occurred. Facility policy required wound care to be provided and documented as ordered, which was not followed in this case.
A CNA transferred a severely cognitively impaired, dependent resident by manually lifting her under the arms instead of using a mechanical lift with two staff as required by her care plan and facility policy. The CNA did not use a gait belt and was unfamiliar with the resident's needs, leading to a deficiency in accident hazard prevention and supervision.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A deficiency was cited when a resident's care plan did not address all identified needs and lacked measurable timetables and specific actions, as observed in the resident's records.
A resident with Alzheimer's disease was prescribed and administered Seroquel, an antipsychotic, without a documented diagnosis to justify its use. The order listed agitation as the indication, but no associating diagnosis was included, and the resident's records did not reflect behaviors warranting antipsychotic therapy. Staff interviews confirmed the omission, and facility policy did not address the need for a diagnosis with psychotropic medication orders.
Two residents did not have comprehensive care plans reflecting their current needs: one receiving hospice services and another dependent on enteral tube feeding. Despite staff awareness and physician orders, the care plans lacked documentation of these services, and staff interviews revealed unclear responsibility for updating care plans. This failure to update care plans as required placed the residents at risk of not receiving appropriate care.
Two residents receiving enteral nutrition experienced deficiencies when staff failed to follow physician orders: one resident was given a substitute tube feeding formula without a documented order, and another did not receive the prescribed downtime between feedings. Nursing staff did not document or communicate these deviations as required by facility policy.
Two residents with end-stage renal disease did not receive dialysis care in accordance with professional standards and their care plans. One resident's post-dialysis vital signs and assessments were not documented, and required communication forms were incomplete or missing. For the other resident, there were no physician orders for dialysis or related monitoring, despite staff awareness of the need. These deficiencies occurred despite facility policy requiring such documentation and orders.
Narcotic counts on multiple medication carts did not match the actual number of pills in the blister packs for three residents. An LVN administered narcotic medications but failed to sign the Narcotic Administration Record log or the MAR as required, resulting in discrepancies between documented and actual medication counts. The DON confirmed that staff are expected to document all narcotic administrations, and no training records on narcotic administration were available when requested.
A nurse failed to flush a resident's gastrostomy tube with the prescribed amount of water between each medication and left residual medication in several cups, resulting in incomplete medication administration. The nurse was aware of the correct procedure but did not follow physician orders or facility policy, and had not attended recent g-tube medication training.
Staff failed to serve correct portion sizes for pureed foods during a lunch meal, using incorrect scoop sizes for pureed broccoli and cauliflower, pizza pasta bake, and garlic bread. The Dietary Manager and a staff member became confused about the required portions, resulting in smaller servings than specified by the menu and recipe card. This was confirmed by a sample tray review and interviews, with eight residents identified as being on a pureed diet.
The facility did not ensure that pureed food served during a lunch meal was smooth and pudding-like, as required for residents on pureed diets. The Dietary Manager prepared and served a pureed pizza pasta bake that remained chunky with pieces of pasta, which was confirmed by surveyors and acknowledged by the DM. Eight residents were identified as requiring a pureed diet, and facility policy assigns responsibility for proper preparation to the food service department.
A resident with a stage 4 pressure ulcer and severe cognitive impairment did not have complete wound care documentation for several days, as required by physician orders and facility policy. Staff interviews revealed that wound care was either not documented due to system limitations or was performed by the Weekend Supervisor but not recorded, resulting in incomplete clinical records.
Staff failed to follow infection control protocols during wound and incontinence care for two residents with pressure ulcers and cognitive impairment. A Wound Care Nurse did not change gloves or perform hand hygiene between steps of wound care, and two CNAs did not consistently perform hand hygiene when changing gloves during incontinence care. These lapses occurred despite prior training and facility policies requiring proper infection prevention practices.
Three residents with pressure ulcers did not receive wound care as ordered, including missed dressing changes and lack of PRN care. Staff interviews and record reviews revealed breakdowns in communication and responsibility among CNAs, nurses, and the wound care nurse, resulting in untreated wounds and unaddressed missing dressings.
A resident with depression and moderate cognitive impairment was temporarily moved to another room without any personal belongings, television, or activities, leaving her in a bare environment. Staff did not provide alternative entertainment or move her items, despite her care plan and facility policy requiring support for a home-like setting. Multiple staff acknowledged the oversight after the fact.
A CNA did not receive required annual dementia management training, as shown by missing documentation in personnel records. Interviews with HR, ADON, and DON confirmed that dementia training was not provided during orientation or annual in-services, and the facility could not produce evidence of such training for staff.
The facility failed to provide adequate PPE for staff entering rooms on droplet precautions, as observed in multiple rooms across three halls. Despite the presence of COVID-19 cases, face shields were missing from PPE bins, leading staff to rely on insufficient protection. Interviews confirmed the absence of necessary PPE, contradicting facility policy and CDC guidelines, thereby risking the spread of infection.
A facility failed to accurately document a resident's medications on their MDS assessments, leading to discrepancies between the resident's actual medication administration and what was recorded. The resident, with multiple complex medical conditions, was prescribed and administered several medications, including antipsychotics and anticonvulsants, which were not accurately reflected in the MDS assessments. The issue was identified through interviews and record reviews, revealing that the staff responsible for the assessments were initially unaware of the inaccuracies.
A resident with dementia was subjected to abuse by a CNA who roughly transferred her from bed to a geri-chair without using a gait belt, resulting in a rough transfer and a slap on the hand. The incident was captured on video by the resident's POA, leading to the CNA's termination. The facility's failure to protect the resident from abuse placed her at risk of harm.
A resident with cognitive impairments was roughly handled during a transfer by a CNA who failed to use a gait belt, as required by facility policy. The CNA attempted to transfer the resident from a bed to a geri-chair without proper equipment, resulting in an unsafe and rough transfer. The incident was captured on video and reported by the resident's POA, leading to the identification of a deficiency in supervision and use of assistance devices.
Two residents in an LTC facility did not receive timely incontinence care, leading to deficiencies in their ADL support. One resident with cognitive impairments was found with a soaked brief, while another resident, who required moderate assistance due to physical limitations, expressed frustration over delayed care. The facility's policy required care every two hours, but lapses in communication and adherence to care plans resulted in extended periods without necessary assistance.
A resident with cirrhosis and hepatic encephalopathy refused her Lactulose medication on three occasions, and the facility failed to notify her physician or document the refusals. This oversight led to a delay in addressing her altered mental status, which was eventually noticed by her family, prompting a hospital evaluation.
A resident with a history of stroke and hemiplegia was left unattended in a shower chair by a CNA, leading to a fall and a right shoulder fracture. The resident's care plan indicated a high risk for falls, and staff were instructed to use a shower bed, but this was not followed. The facility's policy did not address the need for supervision while a resident is in a shower chair, contributing to the incident.
The facility failed to ensure proper labeling and dating of food items stored in the freezer, with multiple bags of food found undated and unlabeled. Additionally, a dark substance from spilled tea was observed frozen at the bottom of the freezer, indicating a lack of immediate cleaning. Interviews confirmed that the facility's food storage policies were not followed.
The facility failed to follow physician orders for weekly weights for a resident, resulting in significant weight fluctuation, and did not obtain necessary physician orders for the use of a hinged knee brace for another resident. These lapses in care and documentation were acknowledged by the DON and ADON.
The facility failed to report a resident's positive urine culture results in a timely manner, leading to a delay in starting antibiotics and implementing contact isolation. The delay was due to a lack of follow-through by the nursing staff, which could have prolonged the resident's infection and increased the risk of spreading the infection to others.
The facility failed to maintain an effective pest control program, resulting in the presence of gnats in multiple resident rooms and a conference room. Despite increased pest control efforts and regular cleaning, the issue persisted, with staff and residents noting ongoing problems. The facility's pest control records indicated multiple visits for various pests, but the program was not effectively implemented.
The facility failed to implement policies and procedures to prevent neglect, as evidenced by an incident where a resident's wheelchair tilted in a van, causing a fall and minor injuries. The incident was not reported to the State Survey Agency as required by the facility's policy.
The facility failed to report an incident where a resident tilted in her wheelchair while being transported in the facility van. The resident sustained a bruise and mild pain, but the incident was not reported to the State Survey Agency within the required 24-hour timeframe. Interviews revealed that the incident was not considered severe enough to report, despite the facility's policy requiring such reporting.
A resident with severe dementia and schizophrenia was admitted without a proper PASARR Level II evaluation due to an error in the screening process, leading to a lack of necessary specialized services.
A facility failed to update a resident's care plan to include the use of a hinged knee brace following a fall that resulted in a fracture. Despite the resident's intact cognition and the necessity of the knee brace for fracture care, the care plan only addressed fall interventions. Interviews with staff confirmed the omission, which placed the resident at risk of not receiving appropriate care.
The facility failed to provide necessary grooming and personal hygiene services to two residents with cognitive impairments. Both residents expressed a desire to have their facial hair removed, but staff did not address this need. Interviews revealed confusion among staff regarding responsibility for facial hair removal, despite facility policy indicating that such care should be provided.
The facility failed to provide adequate supervision and assistance devices for two residents, resulting in one resident's wheelchair tipping over in a van and another resident being stuck outside in the courtyard due to downed phone lines. Both incidents highlight significant lapses in ensuring resident safety.
The facility failed to follow physician orders for water flushes on a feeding pump for a resident with severe cognitive impairment and multiple medical conditions. Observations revealed discrepancies in the settings, which were not corrected over multiple days. Interviews confirmed that the settings were not verified against the orders, leading to incorrect administration.
Fall During Incontinent Care After Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices were used to prevent an accident for Resident #109, who was totally dependent on 2 staff for incontinent care. Resident #109’s record showed diagnoses including quadriplegia, COPD, epilepsy, muscle wasting and atrophy, cognitive communication deficit, and acute and chronic respiratory failure with hypoxia. His quarterly MDS reflected a BIMS score of 09, indicating moderate cognitive impairment, and his care plan identified an ADL self-care deficit related to quadriplegia with an intervention for total dependence on 2 staff for incontinent care. On 6/28/26, while CNA K was changing Resident #109, the resident tipped over and fell to the floor. CNA K stated he turned the resident on his side, the resident fell, and CNA K then picked him up from the floor and placed him back in bed before leaving to get the charge nurse. The witness fall report documented that CNA K reported the resident fell during care and was later observed lying on the bed with a bump and active bleeding to the left side of the forehead. The resident was unable to describe what happened. Hospital records showed the resident had a posterior scalp laceration that was stapled in the ED. During interviews, CNA K stated he was new, PRN, and it was his first day working with Resident #109, and he did not have log-in access to the electronic system to review the resident’s care needs. RN M stated fall protocol required contacting the nurse immediately for assessment before moving the resident and confirmed the resident required 2 staff for incontinent care. The DON and Administrator stated staff were expected to have access to the electronic care plan system and to obtain another direct care staff member when a resident required 2-person assistance.
CNA lacked competency and care plan access before resident fall during incontinent care
Penalty
Summary
The facility failed to ensure that nurse aides had the competencies needed to care for residents according to their assessments and care plans. The deficiency involved CNA K and Resident #109, a male resident with diagnoses including quadriplegia, cognitive communication deficit, epilepsy, COPD, muscle wasting and atrophy, and acute and chronic respiratory failure with hypoxia. His quarterly MDS showed a BIMS score of 09, indicating moderate cognitive impairment, and his care plan identified him as totally dependent on 2 staff for incontinent care because of his quadriplegia. On 6/28/26, CNA K performed incontinent care on Resident #109 independently even though the resident required 2-person assistance. During the care, the resident fell off the bed and sustained a head injury. A witness fall report documented that the CNA reported the resident fell while being changed, and the resident was later observed with a bump and active bleeding to the left side of the forehead. The hospital record documented a posterior scalp laceration that was stapled in the ED. Record review showed CNA K’s orientation packet included general information on falls, fall prevention, and reducing fall risk, but the packet was unsigned and the New Employee Orientation and Competency Checklist did not show competency for fall procedures. During interview, CNA K stated he was new and PRN, had trained for 3 days the prior week, did not have log-in access to the electronic system containing resident care needs, and had not been trained on facility fall protocol before the incident. Staff interviews also confirmed that Resident #109 required 2 staff for incontinent care and that staff were expected to notify a nurse immediately after a fall before moving the resident.
Failure to Provide Nail Care and Personal Hygiene Assistance
Penalty
Summary
The facility failed to provide necessary ADL assistance for grooming and personal hygiene for six residents who were dependent on staff for care. Surveyors observed multiple residents with fingernails that were long, dirty, chipped, or had debris underneath, and several residents stated they wanted their nails trimmed or cleaned but that staff had not done so. The deficiency involved Resident #46, Resident #8, Resident #38, Resident #40, Resident #65, and Resident #100, all of whom had care needs documented in their MDS assessments and care plans related to personal hygiene and ADLs. Resident #46 had diagnoses including hypo-osmolality and hyponatremia and hemiplegia, with intact cognition and moderate assistance needed for toileting and personal hygiene. His care plan did not include interventions for personal hygiene, bathing, or nail care. During observation, he was seen biting the long fingernails on his left hand, and he stated he wanted them trimmed but staff had not offered. Staff interviews reflected that nurses were responsible for nail care, that the resident had refused nail care at times, and that the refusal had not been documented. Resident #100 had hypertension and diabetes mellitus, with moderate cognitive impairment and substantial to maximal assistance needed for personal hygiene. Her care plan called for moderate assistance with personal hygiene. She was observed lying in bed with fingernails about 1/4 inch long and black matter underneath, and she stated she had been asking staff to clean, trim, and polish her nails. A CNA later assessed her nails and confirmed they needed cleaning and trimming. Resident #40, who had hypertension, diabetes mellitus, and non-Alzheimer's dementia with severe cognitive impairment, was dependent for personal hygiene and was observed with fingernails about 0.6 cm long and brown matter underneath on the right hand. Resident #8, who had hypertension, Alzheimer's disease, schizophrenia, and limited mobility, was dependent on staff for personal hygiene and was observed in a wheelchair with fingernails about 1/4 inch long and chipped. She stated she wanted her fingernails trimmed and polished. Resident #38, who had intact cognition and was dependent for oral hygiene, shower/bath, and personal hygiene, was observed with fingernails at least one inch long and said his nails and toenails were too long and he wanted them cut. Resident #65, who had hypertension, high blood sugar, end-stage renal disease, and needed substantial assistance with personal hygiene, was observed with fingernails at least half an inch long with black debris underneath and stated he had asked for nail care that day but was unsure staff would have time to do it. Staff interviews indicated that nail care was expected to be completed by CNAs or nurses during showers or bed baths, but several staff members were unaware of the residents' nail condition or did not complete the care.
Broken Controlled Medication Blister Packs Found in Multiple Medication Carts
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, and administering of medications for three of five medication carts reviewed. During observation and record review, surveyors found controlled medications in multiple carts with blister pack seals broken and taped on the back while pills remained in the blisters. The affected carts included the Nurses' Medication Cart for the 100/300/400 Hall, the Nurses' Medication Cart for the 500 Hall, and the MAs' Medication Cart for the 100/300 Halls. For one resident with metabolic encephalopathy, reduced mobility, muscle weakness, cognitive communication deficit, and severe vascular dementia, the medication cart contained Acetaminophen-codeine 300-30 mg with one blister area seal broken and taped. For another resident with Alzheimer's disease, pain, muscle wasting and atrophy, mood disorder, major depressive disorder, anxiety disorder, and cognitive communication deficit, the medication cart contained Lorazepam 0.5 mg with two blister pill areas broken and taped. For two additional residents on the 500 Hall, each with severe cognitive impairment, diabetes mellitus, dementia, and hypertension, the medication cart contained Lorazepam 0.5 mg with broken and taped blister seals while pills remained in the blisters. In each instance, the controlled medication count sheets were reviewed and reflected that the counts were accurate when compared with the medications in the drawer. The nurses and medication aide interviewed stated they were unaware when the blister pack seals became broken and stated that the seals were easily torn when handled every shift to be counted. They also stated the medication was supposed to be discarded if opened to prevent potential diversion of controlled medications. The DON stated that if a blister pack seal was broken, the pill should be discarded and that it was not acceptable to keep a pill in an opened blister pack. The facility's controlled substances policy stated that controlled substances obtained from a non-automated medication cart or cabinet are to be recorded on the designated usage form.
Food items were not labeled, dated, or properly stored
Penalty
Summary
The facility failed to store food in accordance with professional standards in its only kitchen observed for food service safety. On 07/07/2026 at 10:20 AM, surveyors observed the walk-in freezer with chicken tenders in an unlabeled and undated transparent plastic bag stored inside a box alongside frozen potato fries. In the dry storage room, one box of Sysco Imperial thickened tea had an expired use-by date of 11/06/2020, three boxes of ReadyCare thickened hot cocoa had an expired use-by date of 12/27/2021, and one box of Swiss Miss hot cocoa mix had an expired use-by date of 03/10/2026. The same observation found seven 32-ounce plastic containers of previously opened spices that lacked both open dates and use-by dates. During interviews, the Dietary Manager stated all dietary staff were responsible for ensuring spices were dated, food items were stored in separate boxes in the freezer, and expired food items were discarded. A Cook/Dietary Aide stated it was important to label food items with both the opening date and use-by date and that mixing chicken tenders with potato fries could cause cross-contamination. The facility policy stated all foods must be covered, labeled, and dated upon receipt and after opening, and that expired canned goods must be discarded immediately.
Missed Nutritional Supplements and Weights
Penalty
Summary
The facility failed to ensure Resident #7 maintained acceptable nutritional status when ordered supplements and weekly weights were not carried out as ordered. Resident #7 was an older female with diagnoses including HTN, non-Alzheimer's dementia, anxiety disorder, and depression. Her quarterly MDS reflected significant recent weight loss, and her care plan included regular diet, thin liquids, fortified foods, double portions, Med Pass 90 cc TID, house shakes with meals, and weekly weights to monitor weight loss. Record review showed the physician ordered 2 Cal (Med Pass) three times daily for weight loss, house shakes with meals, and weekly weights. However, the MAR/TAR did not reflect the Med Pass or house shake orders, and staff reported the resident did not receive the Med Pass because the orders were not carried over to the administration record. The DON stated the orders were entered but did not move over, resulting in missed doses from 06/05/26 through 07/09/26, totaling 105 missed doses. The ADON and DON both stated they were responsible for ensuring the orders were entered and implemented correctly. The resident's weekly weights also were not completed as ordered. The record showed weekly weights were missed on 06/17/26 and 07/01/26. The DON stated there was a designated person to complete weekly weights, but when that person was out there was no backup assigned, and she acknowledged she was responsible for ensuring the weights were completed. During observation, the resident was seen eating lunch and consuming about 90 percent of her tray with a house shake, and she told staff she enjoyed the food and had no issues eating. Staff also stated she ate well and snacked throughout the day, but the ordered supplements and weight monitoring were not consistently documented or administered.
Failure to complete ordered pain assessments for a cognitively impaired resident
Penalty
Summary
The facility failed to ensure safe, appropriate pain management for one resident who required pain services. Resident #21 had diagnoses including Alzheimer’s disease, dementia, and muscle wasting and atrophy, was dependent on staff for toileting, personal hygiene, and tub/shower transfers, and had no BIMS score because she was rarely or never understood. Her care plan reflected hospice services for end-stage Alzheimer’s disease and included a goal that her comfort would be maintained, with interventions to observe her closely for signs of pain, administer pain medications as ordered, and notify the physician immediately if there was breakthrough pain. Record review showed standing physician orders for pain assessment every shift, Tylenol 325 mg every 6 hours as needed for pain/headache, and morphine sulfate concentrate every 3 hours as needed for pain. The medication administration record showed Tylenol was given when pain levels of 2 or 3 were documented in May, June, and July 2026, but morphine was not administered during those months. The pain level summary for the prior 90 days reflected only 13 pain assessments, and the documented assessments were not completed on every shift. During observation and interviews, the resident did not respond to questions, and her family member stated staff did not complete a pain assessment every day and that the resident might not tell staff when she was in pain unless asked. An LVN stated she did not assess the resident for pain during every shift or every day, first saying there was no need and later saying she missed the order; she also stated she had not remembered when she last received in-service training on pain management. The ADON initially stated the resident did not require pain assessment every shift, then acknowledged the standing order had been in effect until 07/09/2026 and that nurses were responsible for completing pain assessments during every shift. The DON and RN also stated the resident required pain assessment every shift using PAINAD because she could not verbalize pain, and the facility policy stated pain should be assessed using a standardized instrument appropriate to the resident’s cognitive level.
Missing Physician Order for Scheduled Dialysis
Penalty
Summary
The facility failed to ensure a resident who required hemodialysis had physician orders for his dialysis treatments. Resident #65 was a male with intact cognition, end-stage renal disease, high blood pressure, and high blood sugar, and his care plan identified that he required hemodialysis three times per week. The care plan also included interventions related to dialysis access site care, monitoring for complications, and attending scheduled dialysis appointments. Record review showed the resident’s dialysis communication forms reflected treatments on Monday, Wednesday, and Friday with a 5:30 AM chair time, but the resident’s physician orders did not include an order for dialysis treatment. During interview, the resident stated he attended dialysis three times a week and had no concerns with his access site. Observation showed the access site was covered with a white bandage and had no swelling or redness. Staff interviews confirmed the missing order. An LVN stated she could not find a current physician order for dialysis and noted the order may have been deleted during a hospital stay. The ADON also stated he could not locate the order and acknowledged that missing dialysis orders placed residents at risk for missed appointments. The DON stated the admitting nurses were responsible for entering physician orders and that this chart had been missed during audit review.
Failure to Follow PPE and Hand Hygiene During High-Contact Resident Care
Penalty
Summary
The facility failed to maintain an infection control program designed to prevent the development and transmission of infection for two residents who were on Enhanced Barrier Precautions for wounds. Resident #53 had diagnoses including hypertension, Alzheimer’s disease, and respiratory failure, and had moderate cognitive impairment with partial/moderate assistance needed for toileting hygiene. Her care plan included Enhanced Barrier Precautions related to wounds, with gowns and gloves to be made available near or outside the room. During observation, CNA B entered the room without PPE, then washed hands, donned gloves, and provided incontinent care without wearing a gown. While providing care to Resident #53, CNA B removed gloves and put on clean gloves without performing hand hygiene, continued perineal care, and again changed gloves without hand hygiene before applying a clean brief. CNA B later removed gloves, gathered trash, washed hands, and exited the room. During interview, CNA B stated she knew she was supposed to wear a gown for peri care but forgot, and she forgot to perform hand hygiene during perineal care and between glove changes. She stated she had been in-serviced on infection control during orientation and acknowledged that not wearing proper PPE and not following hand hygiene could spread germs from one resident to another. Resident #22 had diagnoses including hypertension, non-Alzheimer’s dementia, cerebrovascular accident, and muscle weakness, with severe cognitive impairment. Her care plan also included Enhanced Barrier Precautions related to wounds. During wound care, LVN D prepared supplies outside the room, washed hands, put on gloves, and entered without a gown. He removed the old dressing, changed gloves without hand hygiene, cleansed the wound, changed gloves again without hand hygiene, pat dried the wound, and again changed gloves without hand hygiene before applying skin prep, calcium alginate, and a dry dressing. He then removed gloves, put on clean gloves, disinfected the table, removed gloves, washed hands, and exited. LVN D stated he was supposed to wash hands each time he changed gloves and wear a gown during wound care. The DON stated staff were expected to perform hand hygiene each time gloves were removed and before putting on clean gloves, and to wear appropriate PPE for high-contact care including incontinent care and wound care.
Call Light Not Within Reach for Two Residents
Penalty
Summary
The facility failed to ensure the call light system was within reach for two residents reviewed for accommodation of needs. One resident had diagnoses including hypertension, neurogenic bladder, non-Alzheimer’s dementia, and generalized muscle weakness, with a BIMS score of 15 indicating intact cognition. Her care plan identified impaired physical mobility related to general weakness and directed staff to ensure the call light was available. During observation, she was sitting at the foot edge of the bed asking for help to use the bathroom, but could not reach the call light because it was laying on the floor beside the bed. An LVN entered the room after the roommate’s call light was pressed, found the call light on the floor, and placed it next to the resident in bed. A second resident had non-Alzheimer’s dementia and generalized muscle weakness, with a BIMS score of 06 indicating severe cognitive impairment. Her care plan addressed impaired cognition, memory loss, and impaired decision making, and included interventions to ensure the call light was in reach. During observation, she was lying in bed awake and watching TV, and her special call light device was on the floor under the head of the bed. The roommate’s call light was activated, and the DON entered the room, found the resident’s call light on the floor, and clipped it to her linen next to her. The DON and the Administrator stated that call lights needed to always be within residents’ reach, and the facility policy stated the call light should be accessible when in bed, from the toilet, from the shower or bathing facility, and from the floor.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse of residents were reported immediately, but not later than 2 hours after the allegation was made, as required. Specifically, a resident with severe cognitive impairment and a history of reliving past trauma alleged sexual abuse to her Mental Health Habilitator (HAB). The HAB promptly informed the facility's Assistant Director of Nursing (ADON) about the allegation. Despite this, the facility did not report the allegation to law enforcement or the State Agency (SA) within the required 2-hour timeframe. The resident involved had multiple diagnoses, including Bipolar Disorder, Dementia, Down Syndrome, and severe cognitive impairment, and was dependent on staff for personal care. Her care plan noted a history of reliving trauma related to past sexual abuse and included interventions to provide consistency and avoid triggering discussions. On the day of the incident, the resident told her HAB that she had been raped, but was unable to provide specific details. The HAB, concerned due to the lack of prior similar behaviors, reported the allegation to the facility. The ADON and Administrator (ADM) interviewed the resident, who gave inconsistent responses and was unable to provide clear information about the alleged perpetrator or timeframe. The facility staff referenced the resident's care plan history and concluded the allegation was likely related to past trauma. Despite facility policy requiring immediate reporting of all abuse allegations to the Administrator, state agency, and law enforcement, the ADM and DON decided not to report the incident, believing it was a recurrence of past trauma rather than a new event. Interviews with staff confirmed that the expectation was to report all allegations, but in this case, the required notifications were not made. The facility's failure to report the allegation within the mandated timeframe constituted a deficiency in abuse reporting procedures.
Failure to Accurately Document Respiratory Treatments in MDS Assessments
Penalty
Summary
Facility staff failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the respiratory treatments being provided to several residents. Specifically, for three residents with significant cognitive impairment and complex medical conditions, the MDS did not document the respiratory treatments that were ordered and administered, such as nebulizer treatments and oxygen therapy. These omissions were identified through record reviews, observations, and interviews, which showed that the residents were receiving respiratory care that was not captured in their MDS assessments. For one resident, records indicated diagnoses of vascular dementia, acute respiratory issues with hypoxia, and atherosclerotic heart disease. The resident was dependent on staff for all activities of daily living and was receiving nebulizer treatments for wheezing, as confirmed by medication administration records and the resident's own statements. However, the MDS did not reflect these respiratory treatments. Similar findings were noted for two other residents with severe cognitive impairment and terminal illnesses, both of whom were dependent on staff and receiving respiratory treatments such as oxygen therapy and inhaled medications, but whose MDS assessments also failed to document these interventions. Interviews with facility leadership, including the DON and Administrator, confirmed that the expectation was for the MDS to accurately reflect all care and treatments provided, and that failure to do so could result in residents missing necessary care. The facility's policy on maintaining MDS assessments did not address the requirement for accuracy in documenting treatments. The MDS coordinator was not available for interview at the time the deficiency was identified.
Failure to Include Respiratory Treatments in Resident Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans that addressed all of the residents' needs, specifically omitting respiratory treatments for five residents reviewed. Despite medical diagnoses such as Alzheimer's disease, vascular dementia, metabolic encephalopathy, and acute respiratory conditions with hypoxia, the care plans for these residents did not include details about their required respiratory therapies, such as oxygen therapy, nebulizer treatments, or inhalation medications. This omission was identified through record reviews, observations, and interviews, which revealed that while physician orders for respiratory treatments existed and residents were receiving these treatments, the care plans did not reflect these interventions. For example, one resident with Alzheimer's disease and acute respiratory issues had active orders for oxygen therapy and nebulizer treatments, but her care plan only addressed her ADL self-care deficit and did not mention respiratory care. Another resident with vascular dementia and acute respiratory needs had a care plan that addressed cognitive impairment but not the use of respiratory treatments, despite having orders for oxygen and nebulizer use. Similar deficiencies were found for other residents with severe cognitive impairment and complex respiratory needs, where care plans failed to document the specific respiratory treatments being provided, even though these treatments were observed or confirmed through interviews. Interviews with staff, including the DON and ADM, confirmed that care plans are expected to reflect all medical orders and treatments, and that it is the responsibility of nursing leadership to ensure care plans are updated to match current care and treatments. The facility's own policy requires the interdisciplinary team to develop comprehensive, person-centered care plans with measurable objectives and timeframes to meet all identified needs, but this was not followed for the residents reviewed, resulting in incomplete documentation of their respiratory care.
Failure to Maintain and Document Proper Respiratory Equipment Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care to several residents who required such care, as evidenced by observations, interviews, and record reviews. Specifically, for five residents reviewed for respiratory care, deficiencies were noted including nebulizer masks not being bagged for four residents, and nasal cannula (NC) tubing not being dated for two residents. Additionally, care plans for these residents did not address their respiratory treatments, despite physician orders and ongoing needs for respiratory support. Staff interviews confirmed that the expected protocols for cleaning, bagging, and dating respiratory equipment were not consistently followed. Resident records revealed that these individuals had significant medical conditions such as Alzheimer's disease, vascular dementia, metabolic encephalopathy, and acute respiratory issues with hypoxia. Most were dependent on staff for personal care and required assistance or setup for meals. Despite these needs, care plans often omitted respiratory care interventions, and staff failed to ensure that equipment was properly maintained and stored according to professional standards and facility expectations. Observations included unbagged nebulizer masks left on nightstands and undated NC tubing in use, with some equipment showing visible debris. Interviews with nursing staff, the DON, and the administrator confirmed that the facility's protocol required respiratory equipment to be cleaned, bagged, and dated, and that failure to do so could result in infection. However, staff admitted to missing these steps during rounds, and the facility was unable to provide a respiratory care policy when requested. No interviews were conducted with weekend night shift nurses regarding respiratory equipment protocol.
Failure to Adhere to Infection Control Protocols During Resident Care
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by multiple staff not adhering to established protocols for Enhanced Barrier Precautions and hand hygiene during care of three residents. In several observed instances, certified nursing assistants (CNAs) and a licensed vocational nurse (LVN) did not perform hand hygiene before or after resident care, did not change gloves between clean and dirty tasks, and failed to don required personal protective equipment (PPE) such as gowns when providing high-contact care to residents on Enhanced Barrier Precautions. These lapses were observed during incontinence care, dressing, mechanical lift transfers, and wound care. One resident, who was severely cognitively impaired and dependent on staff for all activities of daily living, was on Enhanced Barrier Precautions due to a chronic eye infection. The assigned CNA did not perform hand hygiene before or after care, failed to wear a gown, and used the same gloves for both soiled and clean tasks, including handling the resident's clothing and wheelchair. Another resident, who was cognitively intact but required substantial assistance and had a colostomy and non-pressure wounds, also did not receive care in accordance with infection control protocols. The CNA providing care did not perform hand hygiene, did not wear a gown, and used the same gloves for incontinence care and handling personal items. Additionally, a CNA was observed leaving the resident's room and handling equipment in the hallway while still wearing PPE, only removing it outside the room. For a third resident, who was severely cognitively impaired, dependent for all care, and at risk for pressure ulcers, the LVN performing wound care did not change gloves or perform hand hygiene between cleaning multiple wounds, only doing so after all wounds were cleaned. The LVN later acknowledged not being aware of the need to change gloves and perform hand hygiene between wounds. Facility policies reviewed indicated that Enhanced Barrier Precautions and hand hygiene are required before and after resident contact, after glove removal, and when moving from soiled to clean tasks, but these protocols were not consistently followed by staff during the observed care.
Missed Physician-Ordered Wound Care for Resident with Chronic Pressure Ulcers
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, total dependence for activities of daily living, incontinence, and multiple chronic wounds did not receive physician-ordered wound care on a specified date. The resident, who had a history of Alzheimer's disease, malnutrition, abnormal posture, muscle wasting, and was at high risk for pressure ulcers, had orders for daily wound cleansing and dressing changes for multiple wounds on both feet. Documentation and direct observation confirmed that no wound care was provided on the missed date, and the dressings remained unchanged from the previous day. During an interview and observation the following day, the LVN responsible for the resident's care admitted to not performing the wound care, citing a busy shift and failing to communicate the missed treatment to the oncoming shift. The resident was found with saturated, foul-smelling dressings, particularly on the right foot, which was also edematous. The LVN acknowledged awareness of the daily wound care orders and expressed regret for not completing the treatment as required. The DON confirmed that weekend wound care was the responsibility of the assigned nurses and was unaware that the treatment had been missed until after the fact. The wound care physician stated that the wounds were chronic with a poor prognosis, but emphasized the importance of daily dressing changes to prevent odor and further deterioration. Facility policy required wound treatments to be provided as ordered and documented accordingly, which did not occur in this instance.
Failure to Follow Safe Transfer Protocols for Dependent Resident
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow the care plan and facility policy regarding safe resident transfers. The CNA provided a one-person manual lift by placing his arms under the resident's armpits to transfer her from bed to wheelchair, rather than using a mechanical lift with two staff as required. The resident involved was a female with severe cognitive impairment, dependent on staff for all activities of daily living except eating, and required two-person assistance with transfers due to impaired balance and diagnoses including dementia and multiple sclerosis. The care plan specifically indicated the use of a mechanical lift with two staff for all transfers. During the incident, the CNA did not use a gait belt and was unfamiliar with the resident's care needs, admitting he should have checked the care plan or asked for guidance. Interviews with facility staff, including the physical therapy assistant and the director of nursing, confirmed that the proper procedure for this resident was a mechanical lift with two staff, and that lifting under the arms is prohibited due to risk of injury. Facility policy also mandates the use of appropriate lifting devices and techniques, and manual lifting is to be eliminated when feasible. The failure to follow these protocols resulted in a deficiency related to accident hazards and inadequate supervision.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This omission was observed during the review of resident records, where it was noted that the care plan did not comprehensively cover the resident's needs as required.
Antipsychotic Medication Prescribed Without Appropriate Diagnosis
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications. Specifically, a resident with Alzheimer's disease and no documented psychosis was prescribed and administered Seroquel, an antipsychotic medication, without an appropriate diagnosis to justify its use. The medication order listed 'agitation' as the indication, but did not include a corresponding diagnosis, and the resident's records did not reflect behaviors such as physical or verbal aggression that would typically warrant antipsychotic therapy. The resident was observed to be calm and unable to answer questions, and her medical history included memory problems and inability to make daily decisions, but not psychosis. Interviews with facility staff revealed that the Assistant Director of Nursing (ADON) entered the Seroquel order without ensuring a proper diagnosis was included, despite being trained to do so. The Psychiatric Nurse Practitioner (NP) stated he diagnosed the resident with unspecified psychosis after several meetings, but acknowledged the order should have specified the diagnosis. The Director of Nursing (DON) confirmed that orders are checked for accuracy and that the diagnosis should have been included. The facility's policy on psychotropic medication use did not address the requirement for a diagnosis to accompany medication orders. Manufacturer information for Seroquel highlighted increased mortality risks for elderly patients with dementia-related psychosis, and the drug is not approved for such use.
Failure to Develop and Implement Comprehensive Care Plans for Hospice and Enteral Feeding
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, as identified through observation, interview, and record review. One resident, a female with moderate cognitive impairment, traumatic brain injury, anxiety disorder, and depression, was receiving hospice services. Despite documentation of her hospice admission and ongoing care, her care plan did not address her hospice services. Interviews with nursing staff and the MDS Coordinator confirmed that the omission was not identified or corrected, and responsibility for updating the care plan was unclear among staff. Another resident, a female with severe cognitive impairment and total dependence for eating, was receiving enteral nutrition via a feeding tube. Her physician orders specified continuous tube feeding and water flushes, but her care plan did not reflect her need for tube feeding. Nursing staff were aware of her feeding regimen through shift reports and direct care experience, but had not reviewed or updated the care plan to include this critical information. The MDS Coordinator and other staff acknowledged that the care plan should have included tube feeding and that its absence could lead to miscommunication about her care needs. Facility policy required that comprehensive, person-centered care plans describe all services to be provided and assign responsibility for each element of care. However, the care plans for both residents lacked essential information about their hospice and enteral feeding needs, as confirmed by staff interviews and record reviews. This failure to update and implement care plans as required placed the residents at risk of not receiving appropriate care.
Failure to Follow Physician Orders for Enteral Nutrition
Penalty
Summary
The facility failed to ensure that residents receiving enteral nutrition via feeding tubes were provided care in accordance with physician orders, resulting in deficiencies for two residents. For one resident with severe cognitive impairment and a diagnosis of malnutrition and Alzheimer's disease, the prescribed enteral formula (Isosource 1.5) was not available, and staff substituted it with a different formula (Jevity 1.5) without obtaining or documenting a physician order for the change. Observations confirmed that the substituted formula was administered over multiple days, and interviews with nursing staff and the DON revealed that although the nurse practitioner verbally approved the substitution, the required documentation and order entry were not completed. There was also no monitoring tool in place to ensure the correct formula was administered. For another resident with severe cognitive impairment and total dependence for eating, the facility failed to follow physician orders regarding the timing of enteral feedings. The resident's order specified that the feeding pump should be turned off at 8:00 AM and restarted at 12:00 PM to allow for a four-hour break. However, observations showed that the feeding continued past the prescribed stop time and was restarted before the full break was completed, resulting in less than the ordered downtime. The nurse responsible for the resident's care acknowledged not adhering to the order and had not contacted the physician or documented the deviation. Record reviews of the facility's policies confirmed that staff were required to administer enteral nutrition consistent with practitioner orders, including formula type, rate, and timing. Both the DON and ADON confirmed that it was the responsibility of nursing staff to follow these orders and document any changes or deviations, which did not occur in these cases.
Failure to Ensure Safe and Documented Dialysis Care
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for two residents requiring such services, as evidenced by incomplete documentation and lack of physician orders. For one resident with end-stage renal disease, there was no nursing documentation of post-dialysis vital signs monitoring, and dialysis communication forms for multiple dates were either incomplete or missing. Interviews with nursing staff confirmed that while vital signs were reportedly checked, there was no record of this in the resident's file or on the required forms. The resident's care plan and physician orders specified the need for monitoring and documentation, but these were not followed. For the second resident, also with end-stage renal disease, although communication forms regarding pre- and post-dialysis vital signs were present, there were no physician orders in place for the dialysis treatments or for obtaining and documenting vital signs before and after dialysis. Nursing staff interviews revealed that the admitting nurse, ADON, and DON were responsible for ensuring such orders were entered, but this was not done. The absence of orders was acknowledged by staff, who noted that this could lead to miscommunication and potential missed treatments. The facility's hemodialysis policy required nurses to monitor and document the status of the resident's access site after dialysis and to specify treatment orders, including frequency and duration. Despite this policy, the required documentation and orders were not consistently completed or maintained for the residents reviewed, resulting in a failure to meet professional standards of practice and the residents' care plans.
Failure to Accurately Document and Account for Narcotic Administration
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for three residents across three medication carts. Specifically, the narcotic counts on the medication carts for these residents did not match the actual number of pills in the blister packs. For example, the narcotic administration records for hydrocodone-acetaminophen and lorazepam for one resident, oxycodone for another, and hydrocodone-acetaminophen for a third resident all reflected one more pill than was present in the blister packs. The discrepancies were identified during observation and record review, which revealed that the nurse responsible for administering the medications had not signed off on the Narcotic Administration Record log after giving the medications. The nurse admitted to administering the medications but forgetting to document the administration on the required logs. She acknowledged that she was aware of the requirement to sign both the narcotic count sheet and the Medication Administration Record after administration but failed to do so. Interviews with the Director of Nursing confirmed that staff are expected to document narcotic administration on both the MAR and the narcotic log, and that failure to do so could result in missing pills or overdoses. Additionally, when training records on narcotic administration were requested, none were provided. The facility's own policy required all controlled substances to be recorded on the designated usage form with clear and legible documentation, which was not followed in these instances.
Failure to Follow G-Tube Medication Administration Protocols
Penalty
Summary
A deficiency was identified when a licensed vocational nurse (LVN) failed to follow physician orders for administering medications via gastrostomy tube to a resident. The LVN did not flush the gastrostomy tube with the prescribed 5-10 mL of water between each medication, as required by the resident's orders and facility policy. Instead, the LVN flushed the tube only before and after administering all medications, omitting the necessary flushes between each medication. Additionally, the LVN left residual medication in five cups, indicating that the full doses were not administered to the resident. The resident involved was an elderly female with diagnoses including hypertension and anemia, and was receiving nutrition and medications through a feeding tube. The LVN was aware of the correct procedure but stated she forgot to flush between medications and realized there was residual medication left after administration. Record review showed the LVN had not attended the most recent g-tube medication administration training. Facility policy and physician orders both required individual administration of medications with appropriate flushing between each dose, which was not followed in this instance.
Failure to Serve Correct Portion Sizes for Pureed Diets
Penalty
Summary
The facility failed to ensure that menus were followed and correct portion sizes were served for pureed foods during a lunch meal. Observations in the kitchen revealed that staff used incorrect scoop sizes for pureed broccoli and cauliflower, pureed pizza pasta bake, and pureed garlic bread. The Dietary Manager (DM) and a staff member reviewed the recipes and selected scoop sizes, but both became confused about the correct portions, particularly for the pureed garlic bread. As a result, the portions served were significantly smaller than required by the menu and recipe card. A sample tray reviewed by surveyors and the DM confirmed that the portions were not accurate. Interviews with the DM indicated that both she and the staff member did not realize the wrong scoop sizes were used during meal service. The DM acknowledged responsibility for ensuring correct portion sizes and stated that staff had been trained to review recipes and use the correct scoops, but nervousness led to the mistake. Record reviews showed that eight residents were on a pureed diet, and the facility's policy required specific portion sizes to be served using standard utensils. The deficiency was identified based on direct observation, interviews, and review of facility policies and menus.
Failure to Provide Properly Pureed Food for Residents on Modified Diets
Penalty
Summary
During the lunch meal service, the facility failed to provide pureed food with a smooth, pudding-like texture as required for residents on a pureed diet. Observation in the kitchen revealed that the Dietary Manager (DM) prepared a pizza pasta bake by pureeing it, but the resulting product still contained bits of pasta and was not smooth. A sample tray tasted by surveyors and the DM confirmed that the pureed pizza pasta bake was chunky and did not meet the required consistency. The DM acknowledged that the food was not properly pureed and stated that she should have mixed it more to achieve the correct texture. The DM indicated that both she and the cook are responsible for ensuring pureed foods meet the required consistency. Record review showed that eight residents were ordered a pureed diet, and the facility's policy assigns responsibility for preparing and serving the correct diet and fluid consistency to the food service department. The deficiency was identified through observation, interview, and record review, specifically during the lunch meal service.
Incomplete Documentation of Wound Care for Hospice Resident
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident with a stage 4 pressure ulcer who was on hospice care and had severe cognitive impairment. Specifically, the wound care documentation for this resident was incomplete for several dates in April and May, as wound care was not recorded as completed on multiple occasions. The resident's care plan required adherence to facility protocols for wound prevention and treatment, and physician orders specified daily wound care procedures. However, the wound care report lacked entries for several days, and staff interviews confirmed that documentation was either omitted or not possible to complete due to limitations in the electronic health record system. The Wound Care Nurse acknowledged that the absence of documentation would indicate that wound care was not performed, and another nurse stated that blank entries likely meant the Weekend Supervisor performed the care but failed to document it. Attempts to contact the Weekend Supervisor were unsuccessful. The DON confirmed that the expectation was for charge nurses to provide and document wound care on weekends, and that blank wound care reports could indicate care was not given. Facility policy required all treatments to be documented in the treatment administration record or electronic health record, which was not consistently done in this case.
Failure to Maintain Infection Control During Wound and Incontinence Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple staff not adhering to proper hand hygiene and glove-changing protocols during resident care. Specifically, a Wound Care Nurse did not change gloves or perform hand hygiene after removing old dressings and before proceeding with wound cleansing and dressing changes for two residents with pressure ulcers and open wounds. The nurse continued to handle wounds and apply treatments without the required hand hygiene steps, despite having received training on infection control and wound care procedures. Additionally, two CNAs providing incontinence care to a resident did not consistently perform hand hygiene when changing gloves during the care process. One CNA changed soiled gloves without washing hands before donning new gloves, and both CNAs failed to ensure proper hand hygiene at critical points during and after care. The same CNA also handled supplies and equipment outside the resident's room without first washing hands, potentially contributing to cross contamination. The trash can used during care was not lined with a plastic bag, further increasing the risk of infection spread. Interviews with the involved staff and the Director of Nursing confirmed that the expected protocol was to perform hand hygiene and change gloves at specific points during wound care and incontinence care. Training records indicated that the staff had previously received instruction on infection control and hand hygiene, yet the observed practices did not align with facility policy or standard infection control procedures. The deficiencies were observed in residents with significant cognitive impairment and complex medical needs, including pressure ulcers and neurological conditions.
Failure to Provide Ordered Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary pressure ulcer care and prevent new ulcers from developing for three residents with existing wounds. For one resident with a history of neurological conditions, malnutrition, and Alzheimer's disease, the facility did not provide PRN wound care to a right buttocks wound as ordered. Observations revealed the resident was without a dressing on the wound, and interviews with staff indicated a lack of communication and awareness regarding the missing dressing. The wound care nurse and CNA both expected the other to notify or address the missing dressing, and the nurse on duty was unaware of the wound, resulting in the dressing not being replaced as required. Another resident with diabetes and renal insufficiency did not receive daily wound care to a left foot ulcer on two consecutive days. The wound care administration record had blank entries for those days, and the resident reported that her dressings had not been changed as scheduled. The wound care nurse confirmed that the dressing was not changed over the weekend and stated that the charge nurse was responsible for wound care during that time. The DON confirmed that staff were trained to check orders and provide care when the wound care nurse was absent, but the care was not provided as ordered. A third resident with a non-traumatic brain injury and muscle weakness did not receive wound care to a sacrum wound on a scheduled day. The wound care administration record was blank for that day, and the charge nurse responsible was not aware that the wound care nurse was absent. The DON stated that charge nurses were notified in the morning meeting about the wound care nurse's absence, but the wound care was not completed. In all three cases, the facility failed to follow physician orders and professional standards of practice for wound care, as confirmed by record reviews, staff interviews, and direct observations.
Resident Relocated Without Personal Belongings or Entertainment
Penalty
Summary
A deficiency occurred when a resident was temporarily relocated to another room without any of her personal belongings or sources of entertainment. The resident, who had a history of depression, moderate cognitive impairment, limited mobility, and was dependent on staff for activities of daily living, was moved due to her roommate's declining condition and increased family presence. Upon relocation, the resident was left in a bare room with no television, non-functioning clock, and no reading materials or activities, despite her care plan indicating a need for activity engagement and her use of antidepressant medication. Observations and interviews revealed that the resident expressed sadness and discomfort about the move, stating she had nothing to do and was left with only blank walls to look at. Staff interviews confirmed that none of her personal items were moved with her, and there was no immediate effort to provide alternative entertainment or activities. Nursing staff acknowledged awareness of the resident's boredom and the lack of a television, but did not consider or provide other forms of engagement. The Activity Director was noted to leave activities for residents, but it was the responsibility of nursing staff to ensure the resident was not left bored or sad. Facility policy required that residents be oriented to transfers and reassured that all personal effects would be brought to the new room. However, this was not followed, as staff did not move the resident's belongings or provide adequate support to maintain a home-like and comfortable environment. Multiple staff members, including the ADON and DON, recognized after the fact that the resident should have had some of her personal items and entertainment to prevent feelings of sadness or depression during the temporary relocation.
Failure to Provide Required Dementia Training for Nurse Aides
Penalty
Summary
The facility failed to ensure that nurse aides received the required training in dementia management, as evidenced by the lack of documented annual dementia training for one certified nurse aide (CNA) reviewed. Personnel records showed that the CNA, hired in April 2023, did not have any evidence of annual dementia training, which was expected for her role. Interviews with the Human Resource Specialist revealed that new hires did not receive dementia training during orientation, and job description responsibilities were not reviewed with newly hired staff. The Human Resource Specialist indicated that the Director of Nursing (DON) was responsible for all training, but could not provide documentation of dementia training for staff. Further interviews with the Assistant Director of Nursing (ADON) and the DON confirmed that while group in-services were conducted monthly, there was no documentation that dementia training had been provided. The DON stated she was responsible for annual trainings but acknowledged that not all required topics were covered. The Administrator, who had recently joined the facility, was unable to provide evidence of annual trainings and expected employee files to be up to date. The facility's policy on training was requested but not provided before the survey exit.
Inadequate PPE for Droplet Precautions
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by the lack of appropriate Personal Protective Equipment (PPE) for staff entering rooms on droplet precautions. Observations revealed that rooms on Halls 600, 700, and 800, which were designated for droplet precautions, did not have face shields or goggles available in the PPE bins outside the rooms. This deficiency was noted in rooms #605, #607, #608, #703, #704, #801, and #805, all of which were on droplet precautions due to the presence of residents with COVID-19. Interviews with staff, including an LVN and the Director of Nursing (DON), confirmed the absence of necessary PPE, specifically face shields, which are required for droplet precautions. The LVN admitted to wearing only gloves and a mask, relying on her eyeglasses instead of a face shield, due to the unavailability of the latter. The DON acknowledged the protocol for droplet precautions, which includes wearing an N95 mask, face shield, gloves, and a gown if providing direct care, and stated that the responsibility for ensuring PPE availability lay with her and the Assistant Director of Nursing (ADON). Despite the facility's policy and CDC guidelines requiring full PPE, the lack of face shields in the PPE bins placed residents, staff, and visitors at risk of communicable diseases.
Inaccurate Medication Documentation on MDS Assessments
Penalty
Summary
The facility failed to ensure that the assessment accurately reflected the resident's status for one of the five residents reviewed for accuracy of assessments. Specifically, the facility did not correctly document the medications of a resident on their quarterly and annual Minimum Data Set (MDS) assessments. This discrepancy was identified during a review of the resident's face sheet and medication orders, which showed that the resident had been prescribed and administered several medications, including antipsychotics, antianxiety, and anticonvulsants, that were not accurately recorded in the MDS assessments. The resident in question was a male with multiple complex medical conditions, including metabolic encephalopathy, end-stage renal disease, quadriplegia, and schizophrenia, among others. The resident's annual MDS assessment indicated that he had not taken any high-risk drug classes in the seven days prior to the assessment, while the quarterly MDS assessment noted the use of antipsychotic, antianxiety, and anticonvulsant medications. However, a review of the resident's medication administration records (MARs) confirmed that these medications were indeed administered according to physician orders during the relevant periods. Interviews with the MDS Coordinator and the Director of Nursing (DON) revealed that the inaccuracies were not initially known to the staff responsible for completing the MDS assessments. The MDS Coordinator acknowledged the oversight and explained the process used to complete the assessments, which involved reviewing medical documentation and physician orders. The DON and the Administrator were informed of the inaccuracies and recognized the importance of accurate assessments to ensure appropriate care planning and service delivery for residents. Despite the acknowledgment of the issue, the report does not detail any corrective actions taken to address the deficiency at the time of the survey.
Resident Abuse Due to Improper Transfer by CNA
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving a Certified Nursing Assistant (CNA) who transferred the resident roughly and slapped her hand. The resident, who had a history of dementia and required substantial assistance for transfers, was handled inappropriately by CNA B during a transfer from her bed to a geri-chair. The CNA did not use a gait belt and attempted to lift the resident manually, resulting in a rough transfer where the resident's head and legs were placed on the armrests of the chair. This incident was captured on video by the resident's Power of Attorney (POA). The resident's medical history included non-Alzheimer's dementia, seizure disorder, and senile degeneration of the brain, which affected her cognitive abilities and required her to be dependent on staff for transfers. During the incident, the resident attempted to hold onto the bed, and CNA B forcefully removed her hand and slapped it. The facility's Director of Nursing (DON) and Administrator were notified of the incident by the resident's POA, who provided video evidence of the abuse. The facility's investigation confirmed the abuse, and the CNA was terminated. The facility's failure to ensure the resident's right to be free from abuse placed her at risk of physical and psychosocial harm. The incident was identified as past noncompliance, with immediate jeopardy beginning on the date of the incident and ending a few days later. The facility's policies on abuse and neglect were not followed, as the CNA's actions were considered willful infliction of injury, resulting in mental anguish for the resident.
Inadequate Supervision and Rough Transfer of Resident
Penalty
Summary
The facility failed to ensure adequate supervision and use of assistance devices to prevent accidents for a resident, leading to rough care during a transfer. The incident involved a CNA who did not use a gait belt while transferring a resident from a bed to a geri-chair. The resident, who had significant cognitive impairments and required substantial assistance for transfers, was handled roughly during the process. The CNA attempted to transfer the resident by lifting her without the proper equipment, resulting in a rough and unsafe transfer. The resident involved was a female with a history of non-Alzheimer's dementia, seizure disorder, and senile degeneration of the brain, which affected her cognitive abilities and required her to be dependent on staff for transfers. During the incident, the CNA struggled to transfer the resident safely, as the geri-chair moved backward, and the resident was placed in the chair improperly. The CNA's actions were captured on video, which showed the resident being handled roughly and without the use of a gait belt, as required by the facility's policy. The incident was reported by the resident's POA, who provided a video of the transfer to the facility's administrator. The video showed the CNA attempting to transfer the resident without the necessary assistance or equipment, leading to rough handling. The facility's policy required the use of a gait belt for transfers, and the CNA's failure to comply with this policy resulted in the deficiency. The resident did not sustain any visible injuries from the incident, but the handling was deemed inappropriate and abusive.
Deficiency in Timely Incontinence Care for Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for two residents, leading to deficiencies in timely incontinence care. Resident #1, a female with cognitive impairments due to non-Alzheimer's dementia and other neurological conditions, was observed in a geri-chair with a soaked brief. The Certified Nursing Assistant (CNA) responsible for her care admitted that the resident had not been changed since before 10:00 AM, despite the resident's high fluid intake. This delay in care was observed during a surveyor's visit, highlighting a lapse in the facility's adherence to its care plan for the resident, which aimed to prevent skin breakdown due to incontinence. Resident #2, who had no cognitive impairment but required moderate assistance for toileting due to physical limitations from a stroke, also experienced a delay in receiving incontinence care. The resident expressed frustration at having to wait since breakfast to be changed, resulting in a soaked brief and towel. The CNA assigned to Resident #2 confirmed that the resident had been changed earlier in the morning but was not informed of the need for additional care during breakfast service. This oversight resulted in the resident remaining in a wet state for an extended period, contrary to the facility's policy of providing care every two hours. Interviews with the Assistant Director of Nursing (ADON) and the facility Administrator revealed that the facility's policy required CNAs to provide timely incontinence care to prevent skin breakdowns and infections. However, the ADON was unaware of the delays in care, and the Administrator emphasized the importance of regular checks and rounds to ensure residents' needs are met. The facility's failure to adhere to its ADLs policy and care plans for these residents resulted in deficiencies that were observed and documented by surveyors.
Failure to Notify Physician of Medication Refusal
Penalty
Summary
The facility failed to immediately notify a resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status. Specifically, the facility did not consult with the physician when a resident refused to take her Lactulose medication on three occasions over two days. The medication was crucial for managing the resident's hyperammonemia, a condition characterized by elevated ammonia levels due to her cirrhosis of the liver and hepatic encephalopathy. The resident's refusal was not communicated to the physician or documented by the staff, which was against the facility's policy. The resident, who had a history of cirrhosis of the liver, hepatic encephalopathy, and diabetes, was receiving hospice care. Her medical records indicated that she had mild cognitive impairment and was on a regimen of Lactulose to manage her ammonia levels. Despite the importance of the medication, the resident missed three doses, and the facility staff failed to notify the physician or the family about these refusals. This lack of communication and documentation was a significant oversight, as the resident's condition could have been adversely affected by the missed doses. Interviews with facility staff revealed a breakdown in communication and adherence to policy. The medication aide did not inform the licensed vocational nurse (LVN) about the resident's refusal of Lactulose, and the LVN did not document the refusals or notify the physician. The facility's policy required that any medication refusal, especially those critical to the resident's health, be reported to the physician and documented. The failure to follow these procedures resulted in a delay in addressing the resident's altered mental status, which was eventually noticed by the family, leading to the resident being sent to the hospital for evaluation.
Resident Left Unattended in Shower Chair Resulting in Injury
Penalty
Summary
The facility failed to ensure adequate supervision for a resident, leading to an accident. The incident involved a male resident who had a history of stroke and hemiplegia, making him dependent on staff for transfers. On the day of the incident, the resident was left unattended in a shower chair by CNA B, who left the room to find a Hoyer sling. During this time, the resident fell from the shower chair and sustained a right shoulder fracture. The resident's care plan indicated a high risk for falls, and staff were instructed to use a shower bed for showering. However, on the day of the incident, the resident was placed in a shower chair, and the necessary supervision was not provided. CNA B, who was responsible for monitoring the resident, left the room, resulting in the resident's fall and subsequent injury. Interviews with staff revealed that CNA B was not supposed to leave the resident unattended. The facility's policy on resident showers did not address the need for supervision while a resident is seated in a shower chair. This lack of supervision and failure to follow the care plan directly contributed to the resident's fall and injury.
Improper Food Storage and Labeling in Freezer
Penalty
Summary
The facility failed to ensure that food items stored in the freezer were properly labeled with the contents and dates after being removed from their original packages. Observations revealed multiple clear plastic bags containing frozen chicken parts, breaded patties, pork chops, tater tots, an unknown frozen meat, and meatballs that were undated and unlabeled. Additionally, a grey tub at the bottom of the freezer contained bags of chicken breast for easy access. A dark substance, identified as spilled tea, was observed frozen at the bottom of the freezer, indicating a lack of immediate cleaning. Interviews with Cook Q and the Dietary Manager confirmed that the labeling and dating process was not followed, and the spillage was not cleaned promptly as required by the facility's policy. The Dietary Manager stated that it was the responsibility of the cooks to label and date leftover food items and to conduct daily walk-throughs to remove any items stored for more than two weeks. The Dietary Manager also confirmed that any spillage in the freezer or refrigerator should be cleaned immediately. The facility's Food Storage policy, dated 2023, mandates that all foods should be covered, labeled, and dated, and that freezer units should be kept clean and in good working condition at all times. The failure to adhere to these policies could lead to serving residents food that is not appropriate for cooking or serving, potentially causing foodborne illness.
Failure to Follow Physician Orders and Obtain Necessary Orders for Resident Care
Penalty
Summary
The facility failed to follow physician orders for weekly weights for a resident, resulting in a significant weight fluctuation. The resident, an elderly female with severe cognitive impairment and multiple diagnoses including dementia, depression, heart disease, and diabetes, had an active order for weekly weights. However, the resident was weighed weekly only until early August, sporadically in September, and then monthly thereafter. This inconsistency led to a 30-pound weight loss followed by a 30-pound weight gain over several months. The Director of Nursing (DON) acknowledged the failure and the potential risks associated with not adhering to the physician's orders. In another instance, the facility failed to obtain physician orders for the use of a hinged knee brace for a male resident with a history of falls, end-stage renal disease, and a recent leg fracture. The resident was provided with a knee brace after a fall but did not have corresponding physician orders in his electronic health record (EHR). Interviews with the resident, nursing staff, and the Therapy Director revealed that the brace was always worn and monitored for skin issues, but no formal orders were documented. The Assistant Director of Nursing (ADON) admitted to not noticing the missing orders and acknowledged the oversight. The facility's policy requires written and/or verbal orders for residents' immediate care needs to ensure essential care is provided. The DON emphasized the importance of following physician orders and monitoring for skin breakdowns. Despite the orthopedic order for the knee brace being available on paper, it was not updated in the resident's chart, highlighting a lapse in the facility's process for managing physician orders and ensuring proper documentation and care.
Failure to Report Positive Urine Culture Results
Penalty
Summary
The facility failed to ensure the system for identifying and reporting infections and communicable diseases was followed for a resident. Specifically, the staff did not notify the physician of a resident's positive urine culture for an infectious agent, resulting in a delay in starting antibiotics and implementing contact isolation. The resident, a [AGE] year-old female with diagnoses including difficulty swallowing, dementia, muscle weakness, and diabetes, had a urine sample collected on 03/04/24, which tested positive for klebsiella oxytoca on 03/08/24. However, the physician was not notified until 03/20/24, leading to a delay in treatment and isolation measures. Interviews with staff revealed that the delay was due to a lack of follow-through in reporting the lab results. The Nurse Practitioner discovered the positive results while reviewing lab reports on 03/20/24, and the Director of Nursing confirmed that the results should have been reported immediately upon receipt. The delay in reporting and subsequent delay in treatment and isolation could have prolonged the resident's infection and increased the risk of spreading the infection to other residents.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program to ensure the facility was free of pests, specifically gnats, in three of six halls and one conference room. Observations over a three-day period revealed the presence of gnats in the conference room and multiple resident rooms in the 100 Hall. Residents reported seeing gnats in their rooms, and some mentioned that staff had sprayed chemicals to address the issue, but the gnats persisted. Interviews with residents confirmed that while their rooms were cleaned daily, the gnat problem remained unresolved, with some residents noting that the issue had been ongoing for an unspecified period. Staff interviews indicated that the presence of gnats had been observed by various personnel, including CNAs, LVNs, and housekeeping staff. The Maintenance Supervisor acknowledged the issue, attributing it to recent rain and standing water outside the facility. He mentioned that pest control services had been increased in frequency, and he had been spraying bug spray weekly. Despite these efforts, the gnats continued to be a problem, particularly in the 100 Hall and areas near the kitchen. The facility's pest control records from January to March 2024 showed multiple visits from pest control services for various pests, including gnats. The facility's Pest Control Program policy, dated April 2023, stated that the facility aimed to maintain an effective pest control program to eradicate and contain common household pests and rodents. However, the continued presence of gnats indicated that the program was not effectively implemented, leading to potential risks for residents' quality of life and infection control.
Failure to Implement Policies and Report Incident
Penalty
Summary
The facility failed to implement written policies and procedures that prohibit and prevent neglect, as evidenced by an incident involving Resident #302. The resident, a [AGE] year-old female with diagnoses including hypertension, diabetes, arthritis, and a left artificial shoulder joint, was being transported in a facility van when her wheelchair tilted, causing her to fall and sustain a bruise and abrasion to the right side of her face. Despite the incident, the facility did not report it to the State Survey Agency as required by their policy, which mandates reporting within specified timeframes depending on the severity of the incident. Interviews with the resident, the van driver, RN E, and the Administrator revealed that the resident's wheelchair tilted while the van was turning, and the resident was reaching for her purse. The van driver stopped and adjusted the wheelchair, and the resident was assessed upon return to the facility. The Administrator did not believe the incident warranted reporting because there was no severe injury, despite the facility's policy requiring such incidents to be reported. This failure to report could place residents at risk of lacking timely reporting of incidents.
Failure to Report Incident Involving Resident in Wheelchair
Penalty
Summary
The facility failed to report an incident involving a resident who tilted in her wheelchair while being transported in the facility van. The resident, a [AGE] year-old female with diagnoses including hypertension, diabetes, arthritis, and a left artificial shoulder joint, was being transported back to the facility from an orthopedic appointment. During the transport, the resident reached for her purse on the floor, causing her wheelchair to tilt. The van driver stopped and adjusted the wheelchair, and upon return to the facility, the resident was assessed by a nurse who noted a bruise and abrasion on her face and mild pain in her right rib area. X-rays were ordered, and the resident was medicated for pain. The incident was documented, but the facility did not report it to the State Survey Agency within the required 24-hour timeframe as it did not involve abuse or result in serious bodily injury. Interviews with the resident, van driver, RN, and Administrator revealed that the incident was not considered severe enough to report. The Administrator provided additional training to the van driver to ensure proper securing of residents in the van. The facility's policy on abuse, neglect, and exploitation requires reporting all alleged violations to the appropriate authorities within specified timeframes, but this incident was not reported as required. The failure to report could result in a delay in identifying abuse or neglect and a lack of timely follow-up on recommended interventions to prevent harm or impairment.
Failure to Complete PASARR Screening Accurately
Penalty
Summary
The facility admitted a resident with a mental disorder before the State mental health authority had determined she was appropriately placed. The MDS Coordinator failed to complete the PASARR screening process accurately for the resident, who had diagnoses including severe unspecified dementia with psychotic disturbance, cognitive communication deficit, and schizophrenia. The resident's PASARR I screening completed by the transferring facility indicated evidence of a mental illness, but the facility's screening incorrectly indicated no evidence of mental illness due to an unchecked box. This error prevented the PASARR Level II evaluation from being triggered, which is necessary for determining the appropriate setting and specialized services for the resident. The resident's quarterly MDS assessment revealed significant cognitive and functional impairments, including a BIMS score of 00, indicating the score was not able to be completed. The resident required various levels of assistance with daily activities and had active diagnoses including schizophrenia. The care plan included interventions for impaired thought processes, communication problems, and the use of antipsychotic medication. Despite these documented needs, the resident was not receiving PASARR services due to the screening error. Interviews with facility staff, including the ADON and MDS Coordinator, confirmed the resident's diagnosis of schizophrenia and the error in the PASARR screening process. The ADON acknowledged that the resident was not receiving PASARR services, which could place her at risk of not meeting care plan goals and having a lower quality of life. The MDS Coordinator admitted responsibility for the error and recognized that it placed the resident at risk of not receiving necessary specialized services.
Failure to Update Care Plan for Resident's Knee Brace
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who had a hinged knee brace following a fall that resulted in a fracture. The resident, a male with a history of hyperkalemia, end-stage renal disease, type 2 diabetes, and a fracture of the left tibia, was observed to always wear the knee brace. Despite this, the care plan did not address the use of the knee brace, which was confirmed by interviews with the resident, an LVN, the ADON, and the DON. The resident's care plan included interventions for falls but did not include specific instructions for the knee brace, which was necessary for the resident's fracture care and recovery. The deficiency was identified through observations, interviews, and record reviews. The resident had a BIMS score indicating intact cognition and had experienced a fall after returning from dialysis, leading to a fracture. The LVN and ADON acknowledged the omission in the care plan, and the DON confirmed that the care plan should have included the knee brace to ensure proper care and monitoring. The facility's policy required comprehensive care plans to meet residents' medical, nursing, and psychosocial needs, but this was not followed in this case, placing the resident at risk of not receiving appropriate care for his fracture.
Failure to Provide Necessary Grooming and Personal Hygiene Services
Penalty
Summary
The facility failed to provide necessary grooming and personal hygiene services to two residents who were unable to perform these activities themselves. Resident #35, who had severe cognitive impairment and required maximal assistance with activities of daily living (ADLs), was observed with facial hair that had not been removed. Despite the resident expressing a desire to have the facial hair shaved, staff had not addressed this need. Similarly, Resident #83, who had moderate cognitive impairment and also required maximal assistance with ADLs, was observed with facial hair and expressed dissatisfaction with it. The resident stated that she had asked staff to remove the facial hair, but it had not been done. Interviews with staff revealed a lack of clarity and responsibility regarding the removal of residents' facial hair. The assigned Certified Nursing Assistants (CNAs) and Licensed Vocational Nurses (LVNs) indicated that they believed it was either the beautician's responsibility or were unsure if they were allowed to remove facial hair. The Director of Nursing (DON) stated that it was the responsibility of the CNAs, nurses, Assistant Director of Nursing (ADON), and herself to ensure ADLs were completed, including the removal of facial hair if the resident desired. The facility's policy on Activities of Daily Living (ADLs) indicated that care and services should be provided for grooming and personal hygiene. However, the failure to remove facial hair for Residents #35 and #83, despite their expressed wishes, demonstrated a lapse in adhering to this policy. This deficiency could affect the residents' dignity and personal hygiene, as noted by the DON.
Inadequate Supervision and Assistance Devices
Penalty
Summary
The facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for two residents. The first incident involved a van driver who did not properly restrain a resident's wheelchair in the facility transportation van, resulting in the wheelchair tipping over on its side. The resident, who had multiple medical conditions including hypertension, diabetes, and arthritis, sustained a bruise and abrasion to the right side of her face and mild pain in the right rib area. The van driver claimed to have secured the wheelchair properly, but the incident occurred when the resident reached for her purse on the floor during transport. The second incident involved a resident who was stuck outside in the courtyard and unable to call the facility because the phone lines were down. The resident, who had coronary artery disease, hypertension, end-stage renal disease, and diabetes, was found by her family member after being outside for an hour and twenty minutes. The resident's wheelchair had gotten stuck in the landscape area around a water fountain. Despite being independent in her wheelchair and cognitively intact, the resident was unable to free herself and had to rely on her family member for assistance. Both incidents highlight the facility's failure to provide adequate supervision and ensure the safety of its residents. The first incident resulted from improper securing of a wheelchair during transport, while the second incident was due to a lack of supervision and communication issues caused by downed phone lines. These deficiencies could place residents at risk for serious injury or harm, decline in health, and decreased quality of life.
Failure to Follow Physician Orders for Enteral Feeding
Penalty
Summary
The facility failed to ensure a resident who was fed by enteral means received appropriate treatment and services to prevent complications. Specifically, the nursing staff did not follow the physician's orders for water flushes on the feeding pump for a resident with severe cognitive impairment and multiple medical conditions, including hypertension, stroke, and hemiplegia. The resident's care plan required adherence to specific water flush orders, but observations revealed discrepancies in the settings, which were not corrected over multiple days. Interviews with the nursing staff and administration confirmed that the water flush settings were not verified against the physician's orders, leading to incorrect administration. The Licensed Vocational Nurse (LVN) admitted to not checking the settings thoroughly, and the Assistant Director of Nursing (ADON) and Director of Nursing (DON) acknowledged the importance of following orders to ensure proper nourishment and hydration. The facility's policy on the care and treatment of feeding tubes emphasized the need to follow physician orders, which was not adhered to in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Arlington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Pavilion At Creekwood | 3.8 mi | ★★★★★ | 14 | 0 |
| Arbrook Plaza | 3.8 mi | ★★★★★ | 12 | 0 |
| Town Hall Estates - Arlington, Inc. | 4.3 mi | ★★★★★ | 2 | 1 |
| Avir At Mansfield | 4.4 mi | ★★★★★ | 0 | 0 |
| Mansfield Medical Lodge | 5.8 mi | ★★★★★ | 10 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.