Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ghent Health And Rehabilitation during CMS and state inspections, most recent first.
Unsafe and Unsanitary Resident Environment: Surveyors found multiple resident rooms and bathrooms with no hot water, toilets that would not flush, foul odors, and heating problems. Several cognitively intact residents reported these issues, and staff confirmed the conditions during interviews. Surveyors also observed roaches and mice in resident areas, and residents described ongoing pest activity in their rooms.
Failure to educate residents and staff on COVID-19 vaccination, offer the vaccine to eligible residents and staff, and maintain vaccination documentation. Surveyors found no evidence of resident COVID-19 vaccination for the year reviewed and no staff vaccination status logs. An LPN serving as the IP stated the role was new, the pharmacy initially said it did not have the vaccine, and the staff vaccination logs could not be located. The facility policy required education, offering the vaccine, and maintaining staff vaccination records, including NHSN data.
Staff failed to safeguard and return personal clothing after laundering for three residents, including individuals with stroke, diabetes, seizure disorder, hemiparesis, aphasia, atrial fibrillation, and dementia. One resident with moderately impaired cognition reported that clothing sent to the laundry had not been returned and was repeatedly observed asking staff for help retrieving it. Another cognitively intact resident stated that all of his clothing was missing after laundering, that staff brought him other residents’ clothing in his size, and that he had to accept donated items while watching others to see who might be wearing his clothes. A third cognitively intact resident reported that all his coats were missing, expressed fear of removing the coat he was wearing so it would not be lost, and continued to report missing items during interviews with the ADON.
Staff failed to consistently provide and document ADL and incontinence care for multiple dependent residents. One resident with an indwelling catheter was given a bed bath without any covering, with soap left unrinsed and the same washcloth used for both body washing and post-bowel incontinence care. A cognitively intact resident who required assistance with personal hygiene had visible chin hair despite expressing a desire for facial hair removal, which staff acknowledged should be part of routine ADL care. Another dependent resident with severe cognitive impairment and urinary incontinence received fewer showers than scheduled, and her family reported having to wash her hair at bedside due to lack of staff hair washing. Additional residents with significant ADL deficits and severe cognitive or physical impairments had multiple days and shifts with blank ADL documentation for hygiene and bowel/bladder continence, and staff interviews confirmed that care is evidenced by documentation in the electronic ADL system.
Facility staff failed to maintain an effective pest control program, as evidenced by surveyor observations of roaches on a nightstand, in a corridor, and on a toilet seat, and a mouse running across a hallway, along with pest control logs documenting ongoing mice and roach activity over many months. Multiple cognitively intact residents reported mice entering their rooms under doors or through ventilation, roaches present in rooms for an extended period, and one resident described a roach falling out of a food dome when opening a meal and a dead mouse later found in a heater motor. A moderately impaired resident reported baby mice running around his room, and another resident reported a mouse on a glue pad. Staff, including a CNA and the maintenance director, acknowledged the presence of pests and rodents and described hearing rodents in the ceiling, while the pest control contractor confirmed regular visits and use of traps, glue boards, and baiting, despite a facility policy stating it would maintain an effective pest control program to eradicate and contain pests and rodents.
Failure to monitor an ordered fluid restriction was identified for a resident with ICH, DM, and TIA. Although a physician ordered 1420 cc/day, there was no evidence on the MAR-TAR or meal slips of fluid restriction monitoring, and the resident had no knowledge of the restriction. An LPN stated fluid intake is monitored, while the DON said fluid restrictions are not tracked that way, despite the facility policy requiring the order to be verified and recorded.
Failure to monitor a resident’s dialysis access and document communication with the ESRD facility. A resident with CKD, DM, and a left arm AV fistula received HD M/W/F, but staff did not provide evidence of routine fistula checks for bleeding, bruit, or thrill, and the resident reported these checks were not done at the facility. The dialysis communication book also had multiple missing entries, while an LPN said access checks were documented on the MAR/TAR and the book was used for vital signs, weight, and other pertinent information.
Failure to Maintain Safe, Clean, and Functional Resident Environment: Surveyors found that two resident rooms lacked hot water and heat, pests were observed on all units, toilets on two units would not flush, and shower rooms on two units were not safe, sanitary, or comfortable for resident use. The Administrator stated the QAPI committee did not discuss the pest control, heat, hot water, toilet, or shower room issues and said there was no time to develop and implement data collection, monitoring, analysis, and action plans in these areas.
Governing Body failed to ensure policies were implemented to maintain a safe, clean, comfortable, and homelike environment. Surveyors found no hot water in two resident rooms on Unit 2A, no heat in two resident rooms on Unit 2A, inoperable toilets on Units 2A and 1B, unsanitary shower rooms on Units 1A and 1B, and evidence of mice and roaches on all units. The Administrator stated the QAPI committee did not discuss the pest control, heat, hot water, toilet, or shower room issues and said there was no time to develop and implement data collection, monitoring, analysis, and action plans.
QAPI committee failed to address multiple environmental deficiencies identified by surveyors, including no hot water and no heat in two resident rooms on Unit 2A, inoperable toilets on Units 2A and 1B, mice and roaches on all units, and unsanitary shower rooms on Units 1A and 1B. During interview, the Administrator stated the QAPI committee did not discuss these issues and said there was no time to develop and implement data collection, monitoring, analysis, and action plans in the identified areas.
Infection control practices were not followed in a shared shower room when a commode seat had visible brown substance on it, and staff described a process where nursing cleaned the seat before housekeeping sanitized the commode. Staff also failed to follow EBP during wound care for a resident with a right hip wound who was under hospice care and moderately impaired for daily decisions; although a room sign indicated gloves and gowns were required for wound care, an LPN and RN provided the treatment without gowns.
Unsafe and Unsanitary Shower Room Conditions: Staff failed to maintain clean, functional, and comfortable shower rooms. In one shower room, a brown substance was observed on the commode seat, and nursing staff said they would clean the toilet seat before contacting housekeeping to sanitize the commode. In another shower room, the area smelled of stale water, had shower gel and a disposable razor on the shower chair, showed worn and soiled surfaces where a resident's foot would touch, had about 21 shower chairs cluttered in the room, lacked privacy because the door was left unlocked, and had brown dirt, debris, and dingy floor stains around the toilet.
A resident with dementia, psychotic and anxiety disorders, but intact daily decision-making abilities, required extensive assistance with self-care, including bathing. During shower care, a CNA repeatedly called the resident a “witch” and then rolled the resident in front of a fan while transporting her in the corridor, causing the resident to yell from discomfort due to the cold air. Other staff later described the resident as sometimes stating she was cold and being impatient but not aggressive, and an LPN reported that staff are instructed to step away and report behaviors when they occur. Despite prior abuse education for staff, this incident showed that the resident was not protected from verbal and physical abuse.
Facility staff failed to investigate an allegation of abuse after a resident with paraplegia and depression, who was cognitively independent, was reported by another resident to have pulled a knife and made him fear for his life. Nursing staff notified the DON, contacted 911, and attempted to search the resident’s belongings, but the resident refused a full search and left the unit. Despite the Administrator’s stated procedure and facility policy requiring prompt initiation of an investigation and reporting of all abuse allegations, no incident report or investigation was completed or documented for this event.
Staff failed to implement a care-planned pain management regimen for a post-surgical resident and did not develop a care plan for a fluid restriction for another resident. One resident with a laminectomy and a surgical wound had physician orders and a care plan for Hydrocodone-Acetaminophen every 4 hours, yet multiple scheduled doses were not administered while staff documented pharmacy communication issues, despite an available in-house stock system for narcotics. Another resident with ICH, DM, and TIA, cognitively intact and requiring maximal assist for ADLs, had a physician order for a 1420 cc/day fluid restriction, but the care plan, MAR/TAR, and meal slips contained no fluid restriction monitoring, and the resident was unaware of any restriction, even though an LPN stated such an order should be on the care plan.
A resident admitted after a lumbar laminectomy arrived with a surgical dressing in place and emergency room documentation noting the recent back surgery, but the admission nursing assessment recorded no skin impairment. A later skin assessment described a lower back surgical incision with granulation tissue, scab, and moderate serous drainage, confirming the wound was present on admission. No wound treatment orders or instructions to leave the dressing intact were in place until days after admission, and the eTAR showed no wound treatments documented for that period. In interviews, nursing staff and the DON reported that their usual process is to perform a head-to-toe skin assessment on admission, identify wounds, and obtain treatment orders or orders not to remove dressings, as required by the facility’s skin assessment policy.
Staff failed to administer ordered Hydrocodone-Acetaminophen for a newly admitted resident with a post-surgical wound and documented pain. Although the ER discharge summary and physician orders specified Hydrocodone-Acetaminophen 5-325 mg every four hours, the eMAR showed multiple missed doses shortly after admission. Progress notes described repeated reports from the pharmacy that no prescription had been received and instructions from an on-call provider to hold the medication until access to e-prescribing was available. Interviews with an LPN, a unit manager, and the DON confirmed that an in-house stock of Hydrocodone-Acetaminophen and a pharmacy code system for accessing it were in place, but these resources were not used, resulting in the resident not receiving the scheduled pain medication as ordered.
Bathroom Call Bell Not Accessible From Floor: A resident with a BIMS score of 14, wheelchair use, and assistance needs for toileting had a bathroom call bell that was not reachable from the floor on one side of the toilet. Observation showed the cord hanging just below seat level on the right side, while the left side had open space with no access if the resident fell there. Staff interviews confirmed the resident could not reach the cord from that floor position, and the resident had a high fall risk with prior falls in the room.
A cognitively intact resident reported not having private access to a phone and having to ask to use the nurses station phone. Observation showed the resident using the phone outside the nurses station with staff nearby, while the phone was placed on the counter ledge above the resident’s reach. Staff confirmed residents without cell phones used the nurses station phone, sat outside the station, and were not provided a private place for calls; the DON stated there was no designated private area for resident phone use.
A resident with aphasia and moderately impaired cognition was overheard using the phone at the nurses' station to call his mother, and an LPN spoke to him during the call. The resident had previously used his own cell phone, and the LPN said a cordless phone had once been available at the nurses' station for privacy but was no longer there.
Failure to document and issue grievance resolutions for a cognitively intact resident who filed multiple grievances. The resident stated no follow-up was ever provided, and review of the grievance forms showed no documented resolutions. The SW confirmed the forms were incomplete and that the facility policy required a written decision at the conclusion of the grievance process.
Unanchored Foley Catheter Observed: A resident with a Foley catheter for urinary retention and a diagnosis of UTI was observed with the catheter unanchored during a bed bath. A CNA was unsure whether the catheter was normally secured, and an RN stated that anchoring helps prevent pulling and pressure on the bladder. The resident’s care plan included catheter care interventions, but the catheter was found unsecured during observation.
A resident with a urostomy and bladder CA had a urinary collection bag hanging from the call bell cord and touching the floor. The resident said the facility had recently changed the bags and the new clips would not attach to the bed frame, so the bag had to be hung that way. An LPN stated the bag should be below the bladder, hung on the bed rail, and kept off the floor for infection control.
A resident with muscle weakness and intact cognition was observed in bed with bilateral upper rails raised on multiple occasions. The clinical record did not show an assessment or informed consent for bed rail use, and the DON confirmed that neither was documented. Facility policy required assessment of alternatives, risks, entrapment risk, and informed consent before bed rails are used.
Menu Items Not Served as Planned: A resident with severe cognitive impairment and dependence for eating received meal trays that did not match the menu. During observed meals, the resident was served items such as mashed potatoes and whole-kernel corn instead of the ordered menu items, and she repeatedly stated she did not receive the taco toppings listed on the meal ticket and did not like the mashed potatoes.
Failure to provide snacks at resident-requested times. A dietary manager said snacks were delivered only at set times, and the available items were limited mainly to crackers, cookies, peanut butter, pudding, and juice. Three residents with nutrition-related care plans and diagnoses including DM, CVA, HIV, COPD, ICH, and TIA reported that snacks were not offered unless they asked for them, and ADL records showed hs snacks were missed on multiple shifts. One resident with intact cognition, one resident with moderate cognitive impairment, and one resident with intact cognition all had documentation showing repeated missed snack offerings.
A resident with dementia and severe cognitive impairment was admitted to hospice, but the facility did not have a hospice-coordinated plan of care in place. Staff interviews showed the hospice service details, schedule, and communication process were not available in the hospice binder until forms were later faxed to the facility, despite the resident’s hospice admission and extensive care needs.
Failure to inspect bed rails and bed frame components was identified for a resident with muscle weakness who was cognitively intact and observed multiple times in bed with bilateral upper rails raised. The clinical record lacked documentation of an assessment and consent for bed rail use, and the DON confirmed there were no bed or bed rail inspections for the resident. The Maintenance Director stated inspections had not been started, despite the facility policy assigning routine inspection responsibility for all bed frames, mattresses, and bed rails.
Two residents experienced discomfort due to non-functioning air conditioning units in their rooms, with temperatures recorded at over 83°F. One resident, with intact cognitive abilities, reported the issue, while the other, with moderate cognitive impairment, was unable to communicate effectively. The facility's maintenance staff acknowledged the problem, but repairs were delayed due to a lack of parts.
The facility's air conditioning system malfunctioned, resulting in high temperatures of 84.6°F and 85.2°F in units 1A and 1B. The Administrator confirmed the use of portable air conditioning units due to the main system's failure and was awaiting repair parts. The facility was collaborating with OSHA to address the issue.
A resident with a documented DNR order experienced a failure in the facility's communication and documentation processes, leading to CPR being performed against their wishes. The DNR document was not uploaded into the medical record, resulting in staff and EMTs being unaware of the resident's code status during an emergency. The DON acknowledged the oversight.
Unsafe and Unsanitary Resident Environment
Penalty
Summary
The facility failed to maintain a clean, safe, comfortable, and homelike environment for multiple residents across all four units. Survey observations and resident interviews identified repeated environmental problems, including bathrooms without hot water, toilets that would not flush, foul odors, and heating issues. Several residents who were cognitively intact reported these conditions directly to surveyors, and staff interviews confirmed that the problems were present when observed. For one resident with diagnoses including traumatic subdural hemorrhage, syncope, falls, and COPD, the bathroom sink had no hot water after water was left running for several minutes. The resident and the resident’s daughter both stated that hot water could not be obtained, and a CNA confirmed the water was not getting warm. Another resident with diagnoses including OSA, acute cystitis, and prostate cancer had a bathroom toilet that was half to three-fourths full of urine and would not flush, and the resident stated the heat had gone off the prior night. A third resident with diagnoses including intracranial hemorrhage, DM, and TIA had the same bathroom conditions, and later stated the heat went off again overnight and had to be reset. Staff interviews confirmed the lack of hot water and the nonfunctioning toilet. Additional observations showed a pattern of unsanitary and inoperable bathroom conditions for other residents. One resident’s commode contained dark brown, odorous liquid with feces and toilet paper, and the resident stated the toilet had not flushed for over 30 days. Another resident’s toilet was half-filled with dark brown liquid and wads of toilet paper and would not flush, while a different resident’s toilet had been removed from the floor because of a clogged pipe. Surveyors also observed a strong urine odor in a room occupied by a resident with an indwelling catheter, and staff acknowledged the odor had been present for a while. The report also documented pest activity, including a large roach observed in one resident’s room and a mouse running across a hallway into a locked room, with residents reporting mice and roaches in their rooms and pest control logs showing repeated sightings and treatments.
Failure to Maintain COVID-19 Vaccination Education, Offering, and Documentation
Penalty
Summary
The facility failed to educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member’s vaccination status. During review of Infection Prevention records on 2/10/26 and 2/11/26, surveyors found no evidence of resident COVID-19 vaccination for 2025 and no evidence that staff COVID-19 vaccination status was being maintained. In interview on 2/11/26, the Infection Preventionist stated the role was new as of June 2025 and reported that the facility’s pharmacy initially said it did not have the vaccine, and she was unsure who had contacted the pharmacy or another pharmacy to obtain it. She also stated the staff COVID-19 vaccination status logs were not available and could not be found in her file cabinets or other file cabinets. The facility’s policy stated that it would educate and offer the COVID-19 vaccine to residents and staff and maintain documentation of staff COVID-19 vaccination status, including the information required by NHSN.
Failure to Safeguard and Return Residents’ Personal Clothing After Laundering
Penalty
Summary
Facility staff failed to protect and maintain residents' personal clothing and ensure items were returned after laundering for three residents. One resident with a history of stroke, hemiparesis, and aphasia, and a BIMS score indicating moderately impaired decision-making, reported that clothing sent to the laundry over a week earlier had not been returned. He repeatedly expressed distress about having to wear the same clothing because his laundered items were missing and was observed on multiple occasions asking staff for assistance in retrieving his clothing from the laundry. During an interview in his room, he again raised the issue of his missing clothing in the presence of the ADON. Another resident with stroke, diabetes, and seizure disorder, and a BIMS score indicating intact cognition, stated that all of his clothing was missing after being sent out for cleaning and that staff continued to bring other residents' clothing in his size instead of returning his own items. He pointed out donated clothing on his bed and reported watching other residents to see who might be wearing his clothing. A third resident with stroke, atrial fibrillation, and dementia, but intact decision-making per BIMS, stated that all his coats were missing and that he was afraid to remove the coat he was wearing for fear it would be lost. He was observed wearing the same coat and later returning from a shower, and during an interview with the ADON he again reported his missing clothing. These incidents demonstrate that staff did not adequately safeguard or track these residents' personal clothing during and after laundering.
Failure to Provide and Document Adequate ADL and Incontinence Care
Penalty
Summary
Facility staff failed to provide appropriate activities of daily living (ADL) and incontinence care for multiple dependent residents, as evidenced by observations, interviews, and record reviews. One cognitively intact resident with an indwelling Foley catheter and dependence for toileting hygiene, bathing, and footwear was observed receiving a bed bath and incontinence care that did not follow basic hygiene practices. The CNA removed dirty linens without using a bed/bath blanket or towel, leaving the resident exposed throughout the bath, used only one basin of water, washed the resident’s upper body and lower extremities, and then dried the resident without rinsing off soap. The CNA then removed the resident’s brief and used the same soapy washcloth that had been used for the body bath to clean the perineal area after a bowel movement before discarding it, and later stated she had been taught to provide bed baths in this manner. Another cognitively intact resident with a need for assistance with personal care and an overactive bladder, who required setup or cleanup assistance for bathing, oral hygiene, and personal hygiene, was observed with medium-length chin hair. During interview, this resident stated she wanted both her hair and chin/facial hair trimmed. Staff interviews confirmed that removal of facial or chin hair is considered part of ADL care and should be provided during scheduled showers twice weekly, but the resident’s facial hair had not been addressed. A different dependent resident with severe cognitive impairment and urinary incontinence, who was coded as dependent for eating, oral hygiene, toileting, bathing, and personal hygiene, reported through her daughter that she wanted more showers and hair washing. The daughter produced a modified bath basin she used at bedside to wash her mother’s hair because, according to her, staff would not wash it. Review of ADL documentation showed the resident was scheduled for baths/showers twice weekly, but records for December and January reflected missed or reduced bathing, including days with no documented baths/showers and a pattern of only one shower per week over a two‑month period. Additional dependent residents with significant ADL self-care deficits had missing documentation for hygiene and incontinence care on multiple dates and shifts. One resident with CVA, diabetes, epilepsy, hemiplegia, impaired balance, and limited mobility, who was dependent for mobility, transfers, bathing, dressing, and toileting, had gaps in ADL records for hygiene and bowel/bladder continence across several days and shifts in December and January. Another resident with impaired mobility, maximal assist needs for bed mobility, transfers, and hygiene, and intact cognition had missing documentation for hygiene and bowel/bladder continence on multiple January shifts. A further resident with schizoaffective disorder, depression, severe cognitive impairment, and a need for one-person assistance with personal hygiene had extensive blanks on ADL tracking sheets for personal hygiene over numerous consecutive days in November and December, covering all shifts. CNAs and an RN stated that hygiene and incontinence care are documented in the electronic ADL system and that missing documentation means care was not done, but one CNA also stated she did not know what the blanks indicated, and no additional information was provided before survey exit to clarify or reconcile these omissions.
Failure to Maintain Effective Pest Control Program for Roaches and Mice
Penalty
Summary
Facility staff failed to maintain an effective pest control program to keep the environment free of pests and rodents, as evidenced by multiple observations of roaches and mice over an extended survey period. During observations from 2/3/26–2/6/26 and 2/9/26–2/11/26, surveyors saw a large brown roach climbing on a resident’s nightstand and a mouse running across a first-floor hallway from a biohazard room into a locked room. Additional observations on Unit 1B included a large brown roach lying on its back in the corridor and a small dark roach crawling on a toilet seat in a resident bathroom, which was witnessed by the ADON. Pest control logs and invoices showed ongoing pest activity throughout 2025 and into early 2026, with repeated entries for mice and roaches/ants across multiple months. Resident interviews further demonstrated persistent pest issues in resident rooms. One cognitively intact resident reported that a mouse “lived” in his room and entered through the ventilation system, which he had discussed with the assistant administrator. Another cognitively intact resident stated that a mouse ran from under the door and hid behind a loose baseboard. A third cognitively intact resident reported that roaches had been present in the facility for quite a while, including an incident in December when a roach fell out of a food dome when he opened his meal, and also described a mouse entering his room under the door and a dead mouse later found in his heater motor by maintenance. This same resident reported seeing a roach crawling up his wall the previous day. A moderately impaired resident stated he had seen baby mice running around his room, and another cognitively intact resident reported a mouse on a glue pad in his room during resident council. Staff and contractor interviews corroborated that pests and rodents were an ongoing problem. A night CNA acknowledged the presence of pests and rodents, stating that pest control came three times a week and that something could be heard running in the ceiling at night. The maintenance director confirmed hearing about rodents in the ceiling, placing traps there, and relying on pest control to review pest logs and treat problem areas; he also stated that residents were told not to keep food out and not to leave clothes on the floor. The pest control representative reported that the facility was on a three-times-per-week schedule, using traps, glue boards, and baiting in resident areas, and that pest sighting logs were used to identify treatment locations. Despite the facility’s written policy stating it would maintain an effective pest control program to eradicate and contain common household pests and rodents, the documented observations, resident reports, and pest control logs showed continued presence of roaches and mice in resident rooms and common areas during the survey period.
Failure to Monitor Ordered Fluid Restriction
Penalty
Summary
Failure to monitor fluid intake for Resident #137 was identified. The resident was admitted with diagnoses including ICH, DM, and TIA. The most recent MDS coded the resident as having a BIMS score of 13 out of 15, indicating the resident was not cognitively impaired, and Section GG coded the resident as requiring maximal assistance for bed mobility, transfers, and hygiene. The comprehensive care plan addressed an ADL self-care performance deficit related to impaired mobility and included an intervention to praise all efforts at self-care. A physician order dated 1/26/26 specified a fluid restriction of 1420 cc/day, but review of the January and February 2026 MAR-TAR did not evidence any fluid restriction monitoring, and the resident's meal slips also did not reveal any evidence of fluid restriction monitoring. During interview, the resident had no knowledge of fluid restrictions. An LPN described that fluid intake is monitored, but the DON later stated that fluid restrictions are not tracked that way. The facility's fluid restriction policy stated that fluid restrictions would be followed in accordance with physician orders and that the nurse would obtain and verify the order and record the amount on the medication record or other format per facility protocol.
Failure to Monitor Dialysis Access and Document Communication
Penalty
Summary
The facility failed to provide evidence of dialysis-related monitoring and communication for a resident with chronic kidney disease, diabetes mellitus, and neuromuscular dysfunction of the bladder who had a left arm AV shunt/fistula and received hemodialysis Monday, Wednesday, and Friday. The resident’s care plan directed staff to check and change the dressing daily at the access site and document as indicated, and a physician order required assessment of the left forearm fistula for bleeding and symptoms of infection every shift for dialysis. The resident stated that facility staff did not check the fistula for bleeding, bruit, or thrill, and that these checks were done at the dialysis center instead. A review of the dialysis communication book showed missing communication sheets on multiple dates between December 2025 and February 2026. The December 2025 TAR documented assessments of the left forearm fistula for bleeding and symptoms of infection every shift from 12/1/25 through 12/9/25, then the task was discontinued on 12/9/25. An LPN stated that the communication book was used to provide vital signs, weight, and other pertinent information, and that fistula checks for bruit/thrill and bleeding were documented on the MAR/TAR. The facility did not provide a dialysis care policy, and the dialysis contract stated that the nursing facility must ensure documented collaboration and communication between the nursing facility and the ESRD facility.
Failure to Maintain Safe, Clean, and Functional Resident Environment
Penalty
Summary
The facility failed to provide leadership and oversight to ensure effective systems were in place to support residents’ quality of life in the area of a safe, clean, comfortable, and homelike environment. During the recertification survey, surveyors found that two resident rooms on Unit 2A did not have hot water, two resident rooms on Unit 2A did not have heat, and current observations of mice and roaches were present on all units: 1A, 1B, 2A, and 2B. Surveyors also identified that toilets on Unit 2A and Unit 1B were not operable and could not flush, and that the shower rooms on Units 1A and 1B were not safe, functional, sanitary, or comfortable for residents to use. During an interview, the Administrator stated that the QAPI committee did not discuss the pest control issues, heat issues, hot water issues, inoperable toilets, or the unsanitary shower rooms. The Administrator also stated, "I don't have the time" regarding developing and implementing data collection systems, feedback, monitoring, analysis, and action plans in the identified areas. The Administrator further stated that the Administrator is responsible and accountable for the QAPI program. The facility policy on Administration of Facility stated that the facility will provide policies and systems to ensure it is administered in a manner focused on attaining and maintaining the highest practicable physical, mental, and psychosocial well-being of each resident, and that the governing body is responsible for establishing and implementing policies regarding management, operation, and QAPI.
Governing Body Failed to Ensure Safe, Clean, and Functional Environment
Penalty
Summary
The facility's Governing Body failed to ensure that policies were implemented for the management and operation of the facility to support an effective system for resident quality of life in the area of a safe, clean, comfortable, and homelike environment. During the recertification survey, surveyors found that two resident rooms on Unit 2A did not have hot water, two resident rooms on Unit 2A did not have heat, and toilets on Unit 2A and Unit 1B were not operable and could not flush. Surveyors also observed current evidence of mice and roaches on all units: 1A, 1B, 2A, and 2B. Surveyors further found that the shower rooms on Units 1A and 1B were not safe, functional, sanitary, or comfortable for residents to use. During an interview, the Administrator stated that the QAPI committee did not discuss the pest control, heat, hot water, inoperable toilet, or unsanitary shower room issues. The Administrator also stated, "I don't have the time" regarding developing and implementing data collection systems, feedback, monitoring, analysis, and action plans in the identified areas, and stated that the Administrator is responsible and accountable for the QAPI program. The facility's Governing Body policy stated that the governing body is legally responsible for establishing and implementing policies regarding management and operation of the facility and is responsible and accountable for the QAPI program.
QAPI Committee Failed to Address Environmental Deficiencies
Penalty
Summary
The facility failed to adequately identify, keep systems functioning properly, and implement necessary action plans through its QAPI committee to address deficiencies in the area of Safe/Clean/Comfortable/Homelike Environment. During the recertification survey completed on 2/11/26, surveyors found that two resident rooms on Unit 2A did not have hot water, two resident rooms on Unit 2A did not have heat, and toilets on Unit 2A and Unit 1B were not operable and could not flush. Surveyors also observed mice and roaches on all units, including 1A, 1B, 2A, and 2B, and found the shower rooms on Units 1A and 1B were not safe, functional, sanitary, or comfortable for residents to use. On 2/26/26, the Administrator stated during interview that the QAPI committee did not discuss the pest control issues, heat issues, hot water issues, inoperable toilets, or the unsanitary shower rooms. The Administrator also stated, "I don't have the time" regarding developing and implementing data collection systems, feedback, monitoring, analysis, and action plans in the identified areas. The facility’s QAPI policy, reviewed/revised 10/22/2025, states that the facility will maintain an effective, comprehensive, data-driven QAPI program and that documentation may include systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events.
Infection Control and EBP Failures During Shared Area Cleaning and Wound Care
Penalty
Summary
The facility failed to follow infection control practices during care and in a shared shower area. On 2/5/26 at 3:26 PM, a small to moderate amount of brown substance was observed on the commode seat in the community shower room on unit 1A. During the observation, the unit manager and LPN #6 were present, and LPN #6 stated she would make sure the area was cleaned. When asked who was responsible for cleaning the commode, LPN #6 said nursing staff should clean off the toilet seat and then contact housekeeping to have the commode sanitized. The facility also failed to follow enhanced barrier precautions during wound care for Resident #129, who had a wound to the right trochanter, was moderately impaired for daily decision-making, and was under hospice care. The physician ordered daily wound treatment to the right hip using Dakin's wound cleanser, calcium alginate, and a dry dressing. Although a sign outside the resident's room indicated that staff must wear gloves and gowns for high-contact activities including wound care, LPN #1 and RN #1 were observed providing wound care without gowns while RN #1 assisted with positioning and holding the resident. LPN #1 stated that gowns and gloves should be worn during wound care and that the gown had been overlooked.
Unsafe and Unsanitary Shower Room Conditions
Penalty
Summary
The facility staff failed to maintain a safe, functional, sanitary, and comfortable environment in the shower rooms. During an observation of the shower room on unit 1A with the unit manager/LPN, a small to moderate brown substance was seen on the commode seat. When asked who was responsible for cleaning the commode, the LPN stated that nursing staff would clean off the toilet seat and then contact housekeeping to have the commode sanitized. In a separate inspection of the Unit 1B shower room with the ADON, the room smelled of stale water and had a green bottle of shower gel and a disposable razor on the shower chair seat. Beneath the chair was a worn and soiled area where the resident's naked foot would touch. Approximately 21 shower chairs were cluttered throughout the room, and the resident had to face them while showering. The door was left unlocked because the room was frequently used by others whose in-room toilets were out of order. Around the base of the toilet there was brown dirt and debris, along with dingy floor stains. The ADON stated she was unaware of the clutter and appearance of the shower room.
Failure to Protect Resident From Verbal and Physical Abuse During Shower Care
Penalty
Summary
Facility staff failed to protect a resident’s right to be free from verbal and physical abuse when a certified nursing assistant (CNA) was verbally and physically abusive during and after a shower. The resident involved had dementia, a psychotic disorder, and an anxiety disorder, but was assessed with a BIMS score of 12/15, indicating intact cognitive abilities for daily decision making. The resident required assistance with most self-care activities, including dependence for toileting, oral hygiene, and bathing. Facility documents showed that on the date of the incident, the CNA repeatedly called the resident a “witch” and, while transporting the resident in the corridor after a shower, rolled the resident in front of a fan, causing the resident to yell due to discomfort from the cold air. Interviews conducted during the survey provided additional context. The resident later stated that no staff member had mistreated her and described herself as having a bad temper and being very vocal, which she felt irritated people. Another CNA reported that the resident typically took showers without conflict, sometimes stating she was cold during care, and described the resident as not aggressive but impatient during care. An LPN explained that when residents exhibit behaviors, CNAs are instructed to ensure safety, step away, report behaviors to the nurse, and return later. Despite these expectations and prior abuse in-services completed by the CNA involved, the documented incident of name-calling and exposure to cold air during transport constituted a failure by staff to protect the resident from verbal and physical abuse.
Failure to Investigate Allegation of Resident-to-Resident Threat with Weapon
Penalty
Summary
Facility staff failed to investigate an allegation of abuse involving one resident who had paraplegia and depression and was assessed as cognitively independent for daily decision-making. According to a nursing progress note, another resident reported that this resident had pulled a knife on him and that he feared for his life. The nurse notified the DON, who directed that the resident be placed on 1:1 supervision and remain in his room, and 911 was called. Police arrived and spoke with both residents but stated they did not have protocol to search the resident’s belongings. The nurse and a CNA attempted to search the resident’s belongings; the resident refused to allow a search of his bags but permitted a search of everything else and refused to stay in his room, leaving the unit. Despite this allegation of a resident threatening another resident with a knife and the actions taken at the time, review of facility documents showed no evidence that an incident report or facility investigation was initiated or completed. During interview, the Administrator described the facility’s process for facility-related incidents, including that allegations of abuse, neglect, or mistreatment require initiation of an investigation within two hours, notification of external agencies, and completion of findings within five days. The Administrator acknowledged that no investigation could be located for this incident and that one should have been initiated. The facility’s written policy requires all allegations of abuse, neglect, exploitation, injuries of unknown source, and misappropriation of resident property to be reported immediately to the Administrator and appropriate agencies within prescribed timeframes, but this process was not followed for this event.
Failure to Implement Pain Management Orders and Omit Fluid Restriction from Care Plan
Penalty
Summary
Facility staff failed to implement a comprehensive care plan for pain management for one resident following admission from the emergency room. The resident had a surgical wound related to a laminectomy and was assessed on the admission MDS as having a surgical wound, receiving scheduled pain medication, and experiencing occasional pain. The care plan identified actual impaired skin to the lower back related to laminectomy and pain related to the surgical wound, with an intervention to treat pain per orders prior to treatment or turning. The ER discharge summary and physician orders specified Hydrocodone-Acetaminophen 5-325 mg by mouth every 4 hours for 5 days, with the facility order entered on 3/29/2024. However, the eMAR showed that multiple scheduled doses from the evening of 3/29/2024 through the afternoon of 3/30/2024 were not administered. Progress notes documented that pharmacy reported not receiving the faxed or e-scribed prescription, and nursing staff made repeated calls to the pharmacy and on-call provider, with instructions at one point to hold the medication until the provider could send a prescription. Later documentation indicated the facility was still waiting for pharmacy delivery while the physician was aware. Despite this, the DON confirmed that the facility maintained an in-house stock of Hydrocodone-Acetaminophen 5-325 mg tablets and that all nurses had access to this stock via a code from the pharmacy, with a witness required for narcotics. Multiple nurses, including an RN, a unit manager LPN, and another LPN, stated that urgent medications could be pulled from in-house stock or obtained stat from the pharmacy, and that this in-house system had been in place for several years. The facility’s own comprehensive care plan policy required implementation of all services identified in the assessment to meet residents’ needs and professional standards of quality. Facility staff also failed to develop a comprehensive care plan addressing fluid restriction monitoring for another resident. This resident was admitted with diagnoses including intracranial hemorrhage, diabetes mellitus, and transient ischemic attack, and was cognitively intact per a BIMS score of 13. The resident required maximal assistance for bed mobility, transfers, and hygiene, and had a physician’s order for a fluid restriction of 1420 cc per day. The comprehensive care plan in place focused on ADL self-care performance deficits related to impaired mobility and included an intervention to praise all efforts at self-care, but did not address the ordered fluid restriction. Review of the MAR/TAR for January and February and the resident’s meal slips showed no evidence of fluid restriction monitoring, and the resident reported not being aware of being on a fluid restriction. An LPN stated that fluid restriction monitoring would involve watching intake and acknowledged that such a restriction should be included on the care plan.
Failure to Timely Assess and Treat Surgical Wound on Admission
Penalty
Summary
Facility staff failed to provide timely assessment and treatment of a surgical wound for one resident following admission. The resident had recently undergone a lumbar laminectomy and was admitted to the facility from the emergency room with a dressing over the laminectomy site that appeared normal and had been placed several days earlier. Emergency room discharge notes documented the recent surgery and the presence of the dressing, and the resident’s admission MDS later identified a surgical wound and surgical wound care. However, the nursing admission assessment dated 3/29/2024 documented no skin impairment, despite a subsequent skin assessment describing a surgical incision to the lower back with specific measurements, granulation tissue, scab, and moderate serous drainage, indicating the wound was present on admission. Physician orders dated 4/1/2024 directed staff to cleanse the lower back surgical wound with wound cleanser, pat dry, and apply calcium alginate and silicone foam dressing daily and as needed until healed, and the comprehensive care plan for impaired skin related to the laminectomy was also initiated on that date. There was no evidence of any wound treatment orders prior to 4/1/2024 or any order to leave the dressing intact and not remove it. Review of the eTAR for March showed no treatments completed for the surgical wound. In interviews, nursing staff and the DON stated that standard practice was to complete a full head-to-toe skin assessment on admission, identify any wounds, and obtain or confirm treatment orders from hospital discharge information or the physician, including orders to leave dressings in place if applicable. The facility’s skin assessment policy required a full body skin assessment by a licensed or registered nurse upon admission, but the resident’s surgical wound was not assessed and treated until several days after admission.
Failure to Administer Ordered Hydrocodone-Acetaminophen for Post-Surgical Pain
Penalty
Summary
Facility staff failed to implement a complete pain management program for Resident #173 by not administering Hydrocodone-Acetaminophen as ordered following admission. The resident had a recent laminectomy with a surgical wound and was assessed on the admission MDS as having a surgical wound, receiving scheduled pain medication, and experiencing occasional pain. The emergency room discharge summary and subsequent physician orders specified Hydrocodone-Acetaminophen 5-325 mg by mouth every four hours for pain for a defined period. The eMAR showed the medication was scheduled to begin on 3/29/2024 at 4:00 PM but documented multiple missed doses from the evening of 3/29/2024 through the afternoon of 3/30/2024. Progress notes indicated that on the evening of admission the pharmacy reported not receiving the faxed or e-scribed prescription, and repeated follow-up calls to the pharmacy revealed that no prescription had been received. The on-call provider reported not having access to send the prescription until the following morning and instructed staff to hold the medication until then. Despite the facility having an in-house stock of Hydrocodone-Acetaminophen 5-325 mg tablets and a system allowing nurses to obtain a code from the pharmacy to access these medications, including narcotics, the resident did not receive the ordered pain medication during this period. The resident’s care plan identified actual impaired skin related to laminectomy and pain related to a surgical wound, with an intervention to treat pain per orders prior to treatment or turning, but the ordered pain medication was not provided as scheduled.
Bathroom Call Bell Not Accessible From Floor
Penalty
Summary
The facility failed to provide a bathroom call bell that was accessible from the floor for Resident #6. The resident’s most recent MDS documented a BIMS score of 14 out of 15, indicating cognitive intactness for daily decisions, and noted no upper or lower extremity range-of-motion limitations. The assessment also documented that the resident used a wheelchair, required setup or clean-up assistance for toilet transfers and toileting hygiene, and was occasionally incontinent of urine and frequently incontinent of bowel. Observation of the shared bathroom showed the toilet on the right wall with a call bell cord hanging approximately 12 inches toward the floor just below seat level, while the left side of the toilet had about six feet of open space with no call bell access if the resident were on the floor there. The resident stated they ambulated around the room and bathroom independently and were unsure whether they could reach the bathroom call bell because they had never needed to use it. The resident had a high fall risk, with documented falls without injury in the room on 11/14/2025 and 12/6/2025. Staff interviews confirmed the bathroom call bell was intended to alert staff, but an LPN stated the resident would not be able to reach the cord if on the floor to the left of the toilet.
Lack of Private Telephone Access
Penalty
Summary
The facility failed to provide one cognitively intact resident with reasonable access to private telephone use. The resident’s most recent MDS quarterly assessment dated 1/15/2026 showed a BIMS score of 13 out of 15, indicating the resident was cognitively intact for making daily decisions. During an interview on 2/3/2026, the resident stated they did not have access to a telephone to speak to anyone privately and had to go to the nurses station and beg to use the phone. An observation on 2/5/2026 showed the resident using the telephone at the nurses station while two staff members were seated behind the station and another staff member was at the medication cart beside it. The resident was in a wheelchair outside the nurses station with the phone placed on the ledge approximately two feet above their head, and the resident was observed trying to hang up the receiver from the wheelchair and dropping it onto the nurses station because of the height. Staff interviews confirmed that residents without cell phones used the nurses station phone, sat outside the station, and were not allowed inside; staff also stated the phone could not reach far enough for privacy. The DON stated there were telephone lines throughout the building, but she did not think there was a designated spot for residents to have a private phone call, though staff could allow residents into offices to use a telephone.
Lack of Privacy During Resident Phone Call
Penalty
Summary
The facility failed to ensure a resident was allowed privacy while talking on the facility telephone located at the nurses' station. Resident #82, who was originally admitted and later readmitted after an acute care hospital stay, had diagnoses including aphasia following cerebral infarction and contracture of the muscles of the right hand. The quarterly MDS assessment coded the resident as having completed the BIMS with a score of 8 out of 15, indicating moderately impaired cognitive abilities for daily decision making. The care plan stated the resident was independent in meeting emotional, intellectual, physical, and social needs related to ambulation, with interventions to encourage ongoing family involvement and invite family to special events, activities, meals, and preferred activities. On 02/09/2026, the resident was overheard talking to his mother on the phone at the nurses' station, and an LPN was heard speaking to him during the call, asking, "You're not falling asleep, are you?" The resident shook his head and continued talking. The LPN stated the resident used to have his own cell phone but now used the phone at the nurses' station to call his mother, and said there had previously been a cordless phone at the nurses' station for privacy but did not know what happened to it.
Failure to Document and Issue Grievance Resolutions
Penalty
Summary
The facility failed to resolve grievances for Resident #125, who had filed grievances on 06/09/2025, 07/17/2025, 07/30/2025, and 07/31/2025. During an interview on 2/5/2026, the resident stated that multiple grievances had been filed and that no follow-up had been received regarding the outcomes. The most recent MDS, a significant change assessment with an ARD of 1/29/2026, showed a BIMS score of 15 out of 15, indicating the resident was cognitively intact for making daily decisions. Review of the grievance forms showed that the grievances filed by Resident #125 did not document resolutions. During an interview on 02/10/2026, the Social Worker stated that grievance forms should be completed with all portions filled out and that the resolution should be documented on the form. After reviewing the resident’s grievance forms, the Social Worker stated that no resolutions had been completed. The facility policy required the Grievance Official to oversee grievances through conclusion and issue a written decision to the resident or representative at the end of the investigation.
Unanchored Foley Catheter Observed
Penalty
Summary
Appropriate care was not provided for a resident with an indwelling Foley catheter. Resident #106 was admitted after an acute care hospital stay and later re-admitted with a current diagnosis of urinary tract infection. The resident’s care plan identified an indwelling catheter for urinary retention and included an intervention to check tubing for kinks each shift and to position the catheter bag and tubing below the level of the bladder and away from the entrance room door. The resident’s MDS indicated intact cognitive abilities, and the resident was coded as dependent for toileting hygiene and having an indwelling catheter. During a bed bath observation, the resident’s Foley catheter was observed unanchored. In a follow-up interview, the CNA stated she normally worked upstairs and was unsure whether the resident usually had something to keep the Foley catheter anchored. Later, an RN stated that anchoring a Foley catheter keeps it from pulling or causing pressure on the bladder so it does not cause injury to the bladder, and said she was going to place a Stat Lock on the resident’s leg. The concern was discussed with the DON, Administrator, and Regional Director during the end-of-day meeting, and no comments were made.
Urostomy Collection Bag Left Hanging on Call Bell Cord and Touching Floor
Penalty
Summary
Facility staff failed to provide sanitary urostomy care for Resident #125, who was admitted with diagnoses including urostomy and malignant neoplasm of the bladder. The resident’s most recent MDS showed a BIMS score of 15 out of 15, indicating cognitive intactness for daily decisions. The physician order directed staff to assess the skin around the urostomy site during care, and the care plan identified that the resident required extensive assistance with urostomy management due to generalized weakness and related conditions. During observation, the resident stated that the urostomy drained into a collection bag and pointed to the bag hanging from the call bell cord. The bag was observed touching the floor surface, and this was seen again later the same day. The resident stated the facility had recently changed the bags and the new bags did not have a clip large enough to attach to the bed frame, so the bag had to be hung on the call bell cord. An LPN stated that urinary collection bags should be positioned below the bladder, hung on the bed rail using the hooks on the bag, and should not touch the floor; she also stated the bag should not be hanging on the call bell cord. The facility policy reviewed did not include guidance for keeping the collection bag off the floor.
Failure to Obtain Assessment and Consent for Bed Rail Use
Penalty
Summary
Facility staff failed to obtain an assessment and consent for the use of bed rails for Resident #125. The resident was admitted with a diagnosis that included muscle weakness, and the most recent comprehensive MDS with an ARD of 01/29/2026 showed a BIMS score of 15 out of 15, indicating the resident was cognitively intact for making daily decisions. During observations on 02/03/2026 and 02/05/2026, the resident was found in bed with bilateral upper rails raised, and the resident stated he uses them to move in bed. Review of the clinical record did not evidence documentation of an assessment or consent for the bed rails. On 02/09/2026, the DON stated there was no consent and assessment for the resident's use of bed rails. On 02/11/2026, an LPN stated that the provider obtains consent and nursing assesses the resident to determine if bed rails are needed, and the DON stated that consent by the resident or responsible party and a bed rail assessment need to be obtained for a resident using bed rails. The facility policy also stated that the resident assessment must include evaluation of alternatives attempted prior to bed rail use, assessment of risks, assessment of entrapment risk, and informed consent.
Menu Items Not Served as Planned
Penalty
Summary
The facility failed to serve portions of food planned on the menu for 1 of 80 residents, Resident #109. Resident #109 was admitted on 05/23/25 after an acute care hospital stay and had diagnoses including need for assistance with personal care and unspecified urinary incontinence. The resident’s BIMS score was 4 out of 15, indicating severe impairment in daily decision-making, and the resident was dependent for eating, oral hygiene, toileting, showering/bathing, and personal hygiene. The care plan identified a nutritional problem related to cardiovascular disease, hypertension, hypothyroidism, advanced age, underweight BMI, and mechanically altered diet texture, with a goal for adequate nutritional status and interventions to provide and serve the ordered diet and monitor intake. During a meal observation, Resident #109 was being fed by CNA/Restorative Aide #14 when the tray did not match the meal ticket. The lunch ticket listed beef taco filling for flour tortilla, shredded lettuce topping, pinto beans, cream style corn, and ground pineapple tidbits, but the resident received those items plus mashed potatoes, whole kernel corn instead of cream corn, and no lettuce. The resident repeatedly asked where the taco sauce, tomatoes, and lettuce were and stated she did not want more mashed potatoes. In a later meal observation, CNA #9 was heard speaking with the resident, who again said she did not like the mashed potatoes. The meal ticket for that meal listed ground smothered chicken, creamed corn, sliced peaches, cornbread, and tea, but the tray contained ground-smothered chicken, mashed potatoes, whole-kernel corn, sliced peaches, and tea.
Failure to Provide Snacks at Resident-Requested Times
Penalty
Summary
Meals and snacks were not served at times in accordance with residents’ needs, preferences, and requests, and suitable alternative snacks were not provided for residents who wanted to eat outside of scheduled times. During the survey period, snacks were observed being delivered only at about 10:00 AM, 2:00 PM, and 6:00 PM, with the available items on the units limited mainly to saltine crackers, graham crackers, and on some units captain’s crackers with peanut butter. Pitchers of juice were not observed in the refrigerator on unit 2B until 2/5/26, and a cart later brought oatmeal cookies, crackers, and juice to that unit. Resident #12 had diagnoses including epilepsy, DM, and CVA, and his MDS coded him as not cognitively impaired. His care plan identified a risk for nutrition/hydration imbalance and directed staff to provide diet as ordered and per resident preference. However, the ADL record showed hs snacks were not offered on multiple dates and shifts, and during interview he stated snacks were not offered unless he asked for them and that he usually received only saltine or graham crackers. The dietary manager stated that 6:00 PM was when bedtime snacks were delivered. Resident #14 had diagnoses including polyneuropathy, HIV, and COPD, and his MDS coded him as moderately cognitively impaired. His care plan directed staff to redirect and provide more food if he was asking for food. The ADL record showed hs snacks were not offered on multiple dates and shifts, and he stated snacks were not offered unless he asked for them. Resident #137 had diagnoses including ICH, DM, and TIA, and his MDS coded him as not cognitively impaired. His care plan identified a nutritional problem related to CVA, diabetes, and anemia, but the ADL record showed hs snacks were not offered on multiple dates and shifts, and he stated snacks were not provided. The administrator and DON were made aware of the findings, and no policy was provided by the facility.
Hospice Coordination Plan Missing for Resident
Penalty
Summary
The facility failed to have a hospice-coordinated plan of care for one resident who had been admitted after an acute care hospital stay and whose diagnoses included dementia. The resident’s admission MDS coded a BIMS score of 2 out of 15, indicating severely impaired cognitive abilities for daily decision-making, and section GG showed extensive dependence for toileting, bathing, dressing, footwear, and personal hygiene, with only limited assistance needed for eating and oral care. A physician order dated 1/20/26 called for hospice evaluation and treatment, and a nurse’s note dated 1/29/26 stated the resident had been admitted to hospice with a primary diagnosis of Senile Degeneration of the brain. During observation on 2/4/26, the resident was in bed handling the tip of an indwelling catheter, and a woman was heard stating the catheter was out. Interviews with the ADON and LPN #7 showed the facility did not have information available regarding what hospice services would be provided, when they would be provided, or the communication process for notifying hospice. The RVP stated the facility uses a hospice binder for each resident receiving hospice services, but on 2/11/26 the ADON only presented a binder after hospice forms had been faxed to the facility the day before.
Failure to Inspect Bed Rails and Bed Frame Components
Penalty
Summary
The facility failed to conduct bed and bed rail safety inspections for one resident, who had diagnoses including muscle weakness and was cognitively intact on the most recent comprehensive MDS with a BIMS score of 15 out of 15. During multiple observations, the resident was found in bed with bilateral upper rails raised, and the resident stated he uses them to move in bed. Review of the clinical record did not show documentation of an assessment or consent for the use of bed rails. On interview, the DON stated there were no bed rail or bed inspections for the resident. The Maintenance Director stated that beds are inspected to ensure proper operation and to make sure mattresses fit the bed frame to prevent entrapment, and that bed rails are inspected for proper operation and to prevent entrapment; however, he also stated he had not started the bed and bed rail inspection process and that the facility had recently hired an assistant for maintenance. The facility policy stated the Maintenance Director, or designee, is responsible for adhering to a routine maintenance and inspection schedule for all bed frames, mattresses, and bed rails.
Failure to Maintain Comfortable Environment Due to Air Conditioning Issues
Penalty
Summary
The facility staff failed to maintain a clean, comfortable, and homelike environment for two residents, as observed during a survey. Resident #1, who has cerebral palsy, major depressive disorder, anxiety disorder, and schizoaffective disorder, was found in a room with a non-functioning air conditioning unit. Despite having intact cognitive abilities, as indicated by a BIMS score of 15, Resident #1 reported discomfort due to the high temperature, which was recorded at 83.8°F. The Maintenance Director acknowledged that several rooms, including Resident #1's, were experiencing air conditioning issues, but repairs were pending due to a lack of parts. Resident #2, with diagnoses including hemiplegia, hemiparesis, vascular dementia, and early-onset Alzheimer's disease, was also found in a room with a non-functioning air conditioning unit. The resident's cognitive abilities were moderately impaired, with a BIMS score of 12, and a substantial interview was not conducted. The Maintenance Assistant noted the high temperature in the room, recorded at 84.4°F, and admitted that the facility staff was unaware of the malfunction. During a final interview, the facility's administration did not provide additional information or express concerns about the findings.
Air Conditioning Malfunction Leads to Uncomfortable Environment
Penalty
Summary
The facility staff failed to maintain a comfortable environment for residents, staff, and the public due to a malfunctioning air conditioning system. On a tour of units 1A and 1B, it was observed that the air conditioning was not functioning properly, with recorded ambient temperatures of 84.6°F in unit 1A and 85.2°F in unit 1B. The Maintenance Assistant attributed the high temperatures to the outside weather. The Administrator confirmed that the facility had four portable air conditioning units in use because the main system was not working properly and was awaiting repair parts. The facility was working with the Occupational Safety and Health Administration to resolve the issue with the air conditioning system and the hot temperatures in sections of the building.
Failure to Honor Resident's DNR Wishes
Penalty
Summary
The facility's staff failed to adhere to a resident's Do Not Resuscitate (DNR) wishes, resulting in a deficiency. Resident #6, who was cognitively intact and had a documented DNR order, was admitted to the facility after a hospital stay. The resident's care plan and medical records clearly indicated a DNR status, supported by a Durable Do Not Resuscitate Order signed by both the resident and a physician. Despite this, during an incident where the resident experienced shortness of breath and subsequently became unresponsive, emergency medical personnel performed CPR, contrary to the resident's advance directives. The deficiency occurred because the DNR document was not uploaded into the medical record, leading to a misunderstanding of the resident's code status. Interviews with staff revealed that the resident had been in the facility for five months with an incorrect full code status. During the emergency, staff and emergency medical technicians were not informed of the resident's DNR status, resulting in the initiation of life-saving measures that were against the resident's documented wishes. The Director of Nursing acknowledged that the resident's DNR status should have been followed.
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Illustrative
What surveyors actually found near you
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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 Norfolk
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Signature Healthcare Of Norfolk | 1.5 mi | ★★★★★ | 0 | 0 |
| Norview Heights Rehabilitation And Nursing | 1.8 mi | ★★★★★ | 0 | 0 |
| Norfolk Health Care Center | 1.8 mi | ★★★★★ | 13 | 1 |
| Harbor's Edge | 2.2 mi | ★★★★★ | 2 | 0 |
| Portsmouth Health And Rehab | 3.4 mi | ★★★★★ | 7 | 1 |
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