Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Parham Health Care & Rehab Center during CMS and state inspections, most recent first.
Facility staff allowed unsafe smoking practices by permitting a resident, assessed as an independent smoker with no cognitive impairment, to smoke in a non-designated courtyard lacking ashtrays, fire-safe disposal containers, a fire extinguisher, or a fire blanket, and to extinguish and discard a cigarette into a trash can containing combustible materials during high winds. Staff acknowledged that residents sometimes smoked in this non-designated area and were only redirected when noticed, while the designated smoking courtyard, though equipped with a fireproof disposal can and smoking blanket, contained a fire extinguisher with no inspection tag or documented inspection. These actions and inactions conflicted with the facility’s smoking policy requiring designated outdoor areas and noncombustible ashtrays, leading surveyors to identify immediate jeopardy and substandard quality of care related to accident hazards and smoking safety.
Staff failed to follow a physician’s order requiring blood pressure checks before administering Nifedipine ER to a resident with hypertension and multiple comorbidities. Over a two-week period, there were 15 administrations of the medication without any documented pre-dose BP readings in the MAR or EHR. An LPN reported that BPs are only taken when specifically ordered and acknowledged that nurses are expected to read orders prior to giving medications. The DON later stated that blood pressure had been checked and the medication was eventually discontinued.
A resident with dysphagia, severe cognitive impairment, and an order for a pureed/mechanically altered diet was repeatedly served food and beverages that did not match the prescribed texture, including improperly textured chicken and a cookies-and-cream milkshake. The resident’s care plan and MDS documented the need for a pureed diet, yet observations and interviews showed multiple instances of incorrect meal trays and non-pureed items being provided and consumed. A provider later documented radiographic evidence of recurrent aspiration pneumonia and noted a report that the resident had recently received a milkshake containing candy pieces, which was identified as likely contributing to the aspiration episode.
Staff on two nursing units failed to protect the confidentiality of clinical records by using personal laptop computers to access resident information. Multiple nurses reported they brought their own computers because there were not enough facility devices, some unit computers lacked chargers, and uncharged equipment delayed medication passes. Leadership confirmed that staff were not authorized to use personal computers, that the EHR was only accessible on the facility network, and that there was no system to prevent staff from saving residents’ personal or medical information on personal devices, despite a policy stating employees should use company computers primarily for company business.
An LPN with long artificial nails repeatedly failed to follow hand hygiene and infection control practices during a med pass involving multiple residents. The LPN handled oral meds directly in the bare hand, including scooping pills from multi‑dose bottles with a fingernail and transferring pills from blister packs into the palm before placing them in cups, and picked up a pill from the top of the med cart with a bare hand. After performing a fingerstick blood glucose check with a glucometer and administering meds, the LPN removed gloves, placed the glucometer on and then into the med cart without disinfecting it, and documented on the computer without performing hand hygiene. The LPN continued to administer meds, prepare MiraLAX, access the treatment cart, and handle wound care supplies while moving between resident rooms, the med cart, and the nurses’ station, all without hand hygiene, contrary to facility policies on handwashing, ABHR use, and fingernail standards.
Facility staff failed to maintain adequate linen supplies and a sanitary, comfortable environment across all units. An oriented resident reported waiting hours for incontinence care due to insufficient linens, and observations showed linen carts on all units with only minimal towels, wash cloths, sheets, and blankets, forcing CNAs to search other units for supplies. Hallways and common areas on one wing had dirty floors, debris in corners, and soiled or empty hand sanitizer dispensers, while a water fountain near a nurses’ station had a brown stain around the drain and gnats emerging when water was run, which a unit manager said resembled a nutritional supplement used during med pass. One cognitively impaired resident with multiple neurologic diagnoses had a room with clothes piled on the floor, debris, dirty dishes, and a brown substance on the floor and in the bathroom, and two residents sharing another room reported infrequent cleaning as their room remained in disarray with trash and soiled floors. Throughout the survey, cobwebs and a spider web remained in a window near the therapy gym, and housekeeping and regional housekeeping leadership acknowledged reduced housekeeping staffing and described daily cleaning expectations that were not met in the observed areas.
Failure to check BP before giving an antihypertensive medication. A resident with HTN, MS, quadriplegia, aphasia, and total ADL dependence had an order for nifedipine ER to be held if systolic BP was below 120, but the MAR showed no BP documented before administration on 15 occasions. An LPN stated BP is not automatically taken with BP meds and could not find any recorded BP prior to nifedipine administration.
Facility staff failed to notify a resident’s responsible party after the resident, who had severe cognitive impairment and multiple neurologic and respiratory diagnoses, was found on the floor with a bruised orbital area and later sent to the ER. The resident’s face sheet listed a family member as the responsible party and primary emergency contact, and facility policy required responsible party notification for significant changes of condition. Review of clinical records and interviews with leadership, including the DON, showed no documentation or evidence that the responsible party was informed of either the fall or the hospital transfer.
A resident’s right to voice grievances was not honored when the facility failed to fully resolve a complaint about missing clothing sent by the resident’s family. The grievance documented that clothing delivered to the front desk was never received by the resident, and the facility’s investigation noted the items could not be located and that the resident’s sister would be reimbursed for the loss. Despite documentation of the planned reimbursement and supporting receipts, the family later reported they had not received any payment, and the administrator confirmed the reimbursement was still pending, indicating the grievance remained unresolved.
Facility staff failed to protect a resident’s right to be free from misappropriation of property when clothing delivered by the resident’s family was left at the front desk, never reached the resident, and could not be located. The resident’s record contained no documentation of a request for clothing or receipt of the items. A grievance from the family stated the clothes were missing, and the facility’s investigation noted the items could not be found and that reimbursement would be provided. However, the family later reported they had not received reimbursement, and the administrator confirmed that payment had not been sent despite documentation indicating otherwise.
Facility staff failed to consistently implement a comprehensive care plan for a resident with dysphagia and severe cognitive impairment, including not obtaining weekly weights as care-planned and not reliably providing the ordered puree diet. Record review showed only two documented weights over about a month despite a weekly weight intervention. Observation of a lunch meal revealed chicken that was a mixture of mechanically altered and pureed textures, which the SLP deemed unsafe for this resident. A family member reported the resident had been given an inappropriate milkshake with solid mix-ins and had received incorrect meal trays on multiple occasions, demonstrating inconsistent adherence to the resident’s diet and nutritional care plan.
Multiple residents were physically assaulted by peers, including being punched and sustaining injuries that required medical attention, due to staff failing to provide required supervision and timely intervention. Some residents with known behavioral risks were not adequately monitored, and staff did not consistently follow care plans or document incidents, resulting in harm and immediate jeopardy.
Multiple residents with cognitive impairment and behavioral issues physically assaulted others due to inadequate supervision, despite some having orders for 1:1 monitoring. In several cases, residents were left unsupervised in high-risk areas, such as the smoking courtyard, leading to injuries that required medical attention. Staff failed to update care plans or consistently document incidents, and residents assessed as needing supervised smoking were allowed to possess smoking materials independently, violating safety protocols.
A resident with dysphagia, dementia, and a history of aspiration was not consistently served the ordered pureed diet. Surveyors observed a lunch tray with chicken that the dietician and SLP said was not fully pureed, and family reported the resident had also been given a milkshake with candy pieces and other wrong meal trays. The provider documented recurrent aspiration pneumonia and linked the candy-containing milkshake to the aspiration episode, with antibiotic treatment started for pneumonia.
Facility staff did not provide a full-time, qualified social services director, as the current director worked remotely and part-time after accepting another full-time job. The social services assistant lacked the necessary qualifications, resulting in the facility not meeting residents' social service needs as required.
Facility staff failed to maintain an effective QA program, resulting in multiple residents being abused by staff and other residents. There were repeated failures to report, investigate, and prevent abuse, as well as inadequate supervision and lack of adherence to abuse policies. Despite previous corrective actions, additional residents were harmed, and immediate jeopardy was identified due to ongoing non-compliance.
Facility staff did not conduct complete investigations into multiple allegations of abuse and misappropriation involving several residents. In one case, a resident with a TBI physically assaulted another resident, but the investigation lacked staff witness statements and failed to identify all individuals present. In another incident, a resident was assaulted in the hallway, yet there was no evidence that residents or staff were interviewed or that all witnesses were identified. Additionally, when a resident reported missing money after a room change, the investigation was limited to a brief summary and did not include staff interviews or efforts to locate the missing funds.
Facility staff failed to follow professional standards by not documenting or transcribing a physician's order for Benadryl after a resident's allergic reaction, administering medications outside the scheduled window for another resident, and not documenting resident-to-resident altercations in the clinical records for three residents. Nursing and administrative staff confirmed these actions did not meet basic nursing practice requirements.
Dietary staff failed to follow sanitary practices during meal preparation and service, including not wearing beard guards, not taking holding temperatures before serving, using the same gloves to handle multiple items and surfaces, directly handling food without utensils, and serving food on wet plates. These actions did not comply with facility policies for food safety and staff hygiene.
Facility staff did not ensure a clean environment in four resident rooms, as evidenced by trash and dirty floors, strong urine odors, and stained or discolored tiles. A resident reported unaddressed housekeeping requests, and the environmental services manager confirmed that daily cleaning was insufficient for the level of soiling observed. Some rooms required deep cleaning or tile replacement, but these actions had not been completed.
A resident with MS and muscle weakness reported missing showers and preferred showers and a shave, but staff documentation showed repeated bed baths, refusals, and inconsistent shower records. Several residents also had room clocks that were missing or displayed incorrect times, and one resident repeatedly asked staff what time it was and whether it was time to eat because the clock was wrong. Staff and leadership acknowledged that accurate clocks were important for resident orientation and daily routines.
Resident clinical records were not kept private and confidential on two nursing units when multiple nurses used personal laptops to access resident records and documents. Staff said there were not enough facility computers, one unit computer was available, and missing chargers or uncharged computers delayed med passes, so they brought their own computers. The RDCS stated staff were not to use personal computers and that there was no system to ensure resident medical or identifying information was not saved on those devices.
The facility failed to maintain a safe, clean, comfortable, and homelike environment. Surveyors observed stained and bulging ceiling tiles, broken blinds and furniture, soiled items in resident areas, and a water fountain near the nurses station with a brown stain and gnats coming from the drain. In one resident room, a strong urine odor was traced to soiled personal clothing stored in a closet, and on the Central unit several ceiling tiles had dark brown ringed stains.
An LPN failed to follow infection control practices during med pass on the west wing, repeatedly handling meds with bare hands, using a fingernail to scoop pills from a bottle, and not performing hand hygiene after resident contact or between residents. The LPN also used a glucometer for blood sugar checks and then placed it on the med cart or in a drawer without disinfecting it, while administering meds to multiple residents and touching resident surfaces during care.
Failure to Obtain BP Before Antihypertensive Administration: A resident with HTN and significant functional dependence received Nifedipine ER on 15 occasions without a documented BP check beforehand, despite an order to hold the medication if systolic BP was below 120. MAR review showed no BP recordings before administration, and an LPN stated BP is not automatically taken with BP meds and could not find any prior BP documentation.
A resident was found with an over-the-counter medication at the bedside and reported self-administering it daily without a documented assessment or physician order. Despite facility policy requiring an interdisciplinary team assessment for self-administration, staff confirmed that no such assessment or order was in place for any residents on the unit.
Facility staff did not follow required procedures for timely reporting and thorough investigation of multiple abuse, neglect, and theft allegations. In several cases, incidents were not reported within the mandated timeframe, and investigations lacked interviews with all involved parties and witnesses, resulting in incomplete documentation and failure to meet policy standards.
Facility staff did not report allegations of misappropriation and physical abuse involving three residents to the required agencies within the mandated timeframes. In one case, a resident's missing money was not reported for several days, and in another, two residents involved in an altercation were not reported within the two-hour window required for abuse allegations. Staff interviews and documentation confirmed that reporting procedures were not followed as outlined in facility policy.
Facility staff did not create a comprehensive care plan for a resident with multiple food and drug allergies, resulting in an allergic reaction after being served fish. Although allergies were noted in various records, there was no care plan addressing them, and no documentation of physician orders, medication administration, or nursing assessment following the incident.
Staff did not review or update care plans for two residents after each was involved in a physical altercation with another resident. Both residents had documented histories of behavioral issues, including aggression, but following the incidents, there was no evidence that their care plans were evaluated for effectiveness or revised. Interviews with LPNs and a unit manager confirmed that care plans should be updated after such events, but this was not done in these cases.
Staff failed to provide timely incontinence care and repositioning for a dependent resident with multiple medical conditions, resulting in the resident remaining in bed for over five hours without necessary ADL assistance. Upon eventual care, the resident was found with a wet brief, a small bowel movement, and a new pink area on the sacrum. Facility leadership confirmed this lapse exceeded expected care intervals.
A resident who sustained a hematoma to the forehead after an unwitnessed fall was not properly monitored for latent injuries, as required neurological checks were incomplete or missing. Despite staff knowledge of the protocol and facility policy mandating neuro checks at specific intervals, documentation showed that these assessments were not performed as required after the incident.
Facility staff did not complete annual performance evaluations for two certified nursing assistants, as confirmed by the DON during interviews and document review. The facility was also unable to provide a policy on staff training and performance evaluations when requested.
The facility failed to maintain complete and accurate medical records for two residents: one with multiple allergies who experienced an undocumented allergic reaction and did not have a physician's order for Benadryl transcribed or assessment documented, and another involved in a physical assault incident where details were missing from the clinical record and the aggressor was misidentified in facility documentation.
The QAPI committee did not consistently include the Infection Preventionist as required, and documentation for one quarterly meeting was missing. The DON confirmed that the Infection Preventionist was not always present at meetings, and facility policy mandates their attendance.
Staff failed to maintain a working call bell system, leaving multiple residents without a reliable way to call for help from their rooms or bathrooms during repeated outages. Interviews and documentation revealed that staff were unaware of the location of hand bells, there was no clear policy for alternative assistance, and residents experienced prolonged periods without functioning call bells, leading to fear and frustration.
A dietary aide was found to have not received the required Resident's Rights training, as confirmed by a review of employee records and interviews with the DON and Regional Director of Clinical Services. Documentation provided was either dated prior to the aide's hire or did not show evidence of the necessary training, and no facility policy or additional proof was presented.
A dietary aide was found to have no credible evidence of completing required abuse and neglect training, as revealed during a review of employee records and interviews with the DON and RDCS. Documentation provided was either dated prior to the aide's hire or did not show completion of the necessary training, and no facility policy on staff training was produced when requested.
Facility staff did not provide required Quality Assurance and Performance Improvement (QAPI) training for a dietary aide, as shown by a lack of credible documentation in the employee's record. The DON confirmed that all staff, including dietary, should receive QAPI and related training, but could not provide evidence that this occurred. No staff training policy was presented when requested.
A dietary aide was found to have no credible evidence of completing mandatory infection control training, as required by facility policy. The DON and Regional Director of Clinical Services confirmed that all employees should have this training, but documentation was lacking and no policy was provided when requested.
A dietary aide was found to have no credible evidence of having completed required compliance and ethics training after being hired. Documentation provided was either dated before employment or did not include the necessary training, and facility leadership could not produce a staff training policy or additional proof of compliance.
A resident with vascular dementia, stridor, cerebral infarction, and dysphagia fell in his room, sustained a small bruise to the orbital area, and was later sent to the ER. The resident had severe cognitive impairment, and surveyors found no documentation that the RP was notified of the fall or transfer, despite facility policy stating the RP will be notified of a change in condition.
A resident’s family filed a grievance that clothing delivered to the facility was never received by the resident. The facility documented that the items could not be located and that reimbursement would be issued, but the family later reported they had not received it, and the administrator confirmed the payment was still pending approval with the business office.
A resident's family sent clothing to the facility, but the items were left at the front desk and the resident never received them. The chart had no documentation of a request for clothing or receipt of the items, and the resident could only recall getting some new clothes months earlier but could not identify what was received or who gave them to him. A grievance later documented that the facility could not locate the clothing.
Failure to complete ordered pressure ulcer treatment occurred for a resident with MS and quadriplegia who had a stage 3 sacral pressure ulcer and a stage 4 pressure ulcer. The care plan included treatments per TAR, and a provider order directed wound care twice daily and PRN. An LPN documented that wound care was unable to be completed and used a TAR code indicating other/see progress note, but there was no documentation showing the ordered treatment was completed.
Menu items were not consistently provided on a resident’s meal trays. The resident had dysphagia, vascular dementia, severe cognitive impairment, and was on a mechanically altered/puree diet. Observations showed missing milk, coffee, condiments, and pureed cornbread, and one beverage was frozen, even though the tray tickets listed those items. The facility menu showed cornbread should have been served, but the meal trays did not match the listed items.
Loose Corridor Handrail: A handrail in an East Wing corridor was observed to be wobbly and could be lifted completely from its wall attachment. Residents were seen walking in the hallway and touching the handrail, and an LPN stated handrails should not be loose. The RD of Clinical Services later observed the same loose handrail and lifted the unattached end.
A resident with nicotine dependence and intact cognition was observed smoking, but the record did not contain the required signed Patient Smoking Acknowledgement form. The care plan allowed independent smoking, and the smoking safety screen noted the resident may smoke independently and to educate on the facility smoking policy. The facility policy required residents who wish to smoke to agree to the policy and sign the acknowledgment form, and the DON confirmed the form was missing.
Surveyors observed persistent urine odors, flies, missing or loose hand sanitizer units, damaged breakfast trays, missing tiles, stained mattresses, and unresolved maintenance issues such as a leaking sink and a detached footboard. Residents with complex medical histories were directly affected, and staff interviews confirmed awareness of some issues but lack of resolution or reporting to management.
A resident with a history of stroke, left-sided weakness, and chronic heart disease was injured when a poorly maintained closet door, lacking proper screws and showing signs of water damage, fell onto her while she was seated in her wheelchair. The closet was also infested with cockroaches, and the facility had not implemented an effective pest control or timely maintenance program, despite being aware of ongoing issues with closet safety and building climate control.
Unsafe Smoking Practices and Inadequate Fire Safety Controls
Penalty
Summary
Facility staff failed to ensure the environment remained free of accident hazards and did not provide adequate supervision and safety measures related to resident smoking. Staff permitted residents to smoke in a non-designated courtyard that lacked required fire safety controls, including ashtrays or fire-safe disposal containers, a fire extinguisher, or a fire blanket. The trash receptacle in this area contained combustible materials such as paper, cardboard, and plastic liners, and there were high winds at the time of observation, all of which were documented as increasing the fire ignition risk. On one observed occasion, a resident admitted for post-surgical rehabilitation, with an MDS BIMS score of 15 indicating no cognitive impairment and assessed as an independent smoker, was seen smoking in the non-designated courtyard. The resident extinguished a cigarette on the ground and discarded it into the trash receptacle containing combustible waste. No appropriate smoking safety equipment or supervision was present in that courtyard at the time. Staff interviews confirmed that the courtyard where the resident was observed smoking was not a designated smoking area, although residents sometimes smoked there and staff only attempted to redirect them when noticed. The designated smoking courtyard, located in a different area, was reported to have a fireproof metal can for cigarette disposal, a fire extinguisher, and a smoking blanket; however, the fire extinguisher in that designated area had no inspection tag or date and appeared to be a store-bought unit with no evidence of inspection. The facility’s smoking policy required the Administrator to designate outdoor smoking areas and mandated access to noncombustible ashtrays in those areas, but these requirements were not consistently implemented or enforced, contributing to the identified deficiency and immediate jeopardy related to accident hazards and smoking safety.
Removal Plan
- Resident #10 was placed on 1:1 observation for safety reasons due to smoking in an unauthorized area.
- Resident #10 was re-educated on the smoking policy and procedure, including smoking location and cigarette disposal.
- Locks were ordered to be installed on the courtyard doors to prevent unauthorized smoking.
- Lock installation on the non-designated courtyard began.
- The Facility Administrator will conduct a town hall meeting with residents that smoke to review the facility smoking policy (locations, cigarette disposal, and consequences for non-compliance up to suspension of smoking privileges or potential discharge).
- All residents that smoke will have a new smoking policy acknowledgement obtained.
- The Interdisciplinary Team will be educated by the President of Operations on the smoking policy and designated smoking areas.
- Facility staff will be educated by the Director of Nursing or designee on the smoking policy and designated smoking areas; no employee will be allowed to work until educated.
- The Administrator or designee will conduct weekly environmental safety rounds three times a week for 4 weeks, then monthly audits for 2 months to ensure no resident is smoking in a non-designated smoking area.
- The Administrator made the Medical Director aware of the Immediate Jeopardy via telephone.
Failure to Obtain Ordered Blood Pressure Readings Before Antihypertensive Administration
Penalty
Summary
Facility staff failed to ensure a resident was free from significant medication errors by not following a physician’s order requiring blood pressure assessment prior to administering an antihypertensive medication. The resident had diagnoses including quadriplegia, primary progressive multiple sclerosis, aphasia, anemia, cognitive communication deficit, and essential primary hypertension, and was assessed as cognitively intact with a BIMS score of 15 but dependent on staff for all ADLs, requiring a mechanical lift for transfers and an electric wheelchair for ambulation. The physician’s order for Nifedipine ER 30 mg once daily for hypertension, dated 6/2/25, directed staff to hold the medication if the systolic blood pressure was less than 120. Review of the MAR from 3/31/26 through 4/14/26 showed no recorded blood pressures prior to administration of Nifedipine on 15 occasions. During interview, an LPN stated that blood pressures are not automatically taken when administering blood pressure medications and that if there is an order to obtain blood pressure prior to administration, it would be recorded on the MAR, and blood pressures are documented in the EHR. The LPN was unable to locate any blood pressure readings prior to Nifedipine administration in the EHR and acknowledged that nurses should read orders before giving medications and that not checking blood pressure before administration could result in the resident’s blood pressure “bottoming out.” The DON later stated that blood pressure had been checked and the medication was discontinued because the resident no longer needed it.
Failure to Provide Ordered Pureed Diet Resulting in Aspiration Pneumonia
Penalty
Summary
Facility staff failed to provide a provider-ordered pureed/mechanically altered diet to a resident with dysphagia and severe cognitive impairment, resulting in pneumonia requiring antibiotic treatment. The resident’s diagnoses included dysphagia, vascular dementia, stridor, and cerebral infarction, and the hospital discharge summary specified a pureed diet. The admission MDS documented severe cognitive impairment (BIMS score 2/15) and a mechanically altered diet, and the comprehensive care plan identified dysphagia requiring a puree diet. Although an initial order on 12/19/25 was for a regular diet with dysphagia advanced texture and thin liquids, this was changed on 12/22/25 to a pureed diet per hospital recommendations. Despite these orders, the resident was observed on 02/11/26 with a lunch tray containing chicken that the dietician and SLP determined was a mixture of mechanically altered and pureed textures; the SLP stated it would not be safe for this resident to consume. The tray ticket listed the entrée as puree crispy chicken thigh, indicating a discrepancy between the ordered/printed diet and the actual food consistency served. In addition, the resident’s family reported multiple occasions when the resident did not receive the correct diet, including being provided a milkshake containing Oreo cookies and Reese’s Pieces on Super Bowl Sunday and receiving wrong meal trays on three occasions. Facility emails related to this incident showed a CNA first acknowledging giving an Oreo milkshake to a resident on a puree diet, then later stating the milkshake given was safe and that the Oreo milkshake was not provided. Another resident reported ordering a cookies and cream milkshake for the resident via a delivery service and instructing that the pieces be ground up because the resident was on a puree diet, and confirmed the resident consumed it. The provider documented that a chest radiograph on 02/11/26 showed infiltrate consistent with recurrent aspiration pneumonia and noted it was reported the resident recently received a milkshake containing candy pieces, which likely contributed to this aspiration episode. Documentation from the DON also indicated the resident had previously been served the wrong diet over the weekend of 12/20/25–12/21/25, which the resident ate, followed by chest X-ray findings of bilateral perihilar atelectasis/infiltrate and initiation of antibiotic therapy for pneumonia on 12/24/15.
Failure to Protect Confidentiality of Clinical Records Due to Staff Use of Personal Computers
Penalty
Summary
Facility staff failed to maintain resident clinical records in a manner that ensured privacy and confidentiality on two of three nursing units (Central and West/[NAME] wings). During observations on the units, six nurses were seen using their own personal laptop computers to access resident clinical records and documents. Staff interviews revealed that they resorted to using personal computers because there were not enough facility computers available, only one computer per unit, and some facility computers were missing chargers or were not charged, which staff stated caused delays in passing medications. Staff also reported that they could not access resident clinical records when offsite using their personal computers. In a meeting with the administrator, DON, and regional director of clinical services (RDCS), it was confirmed that staff were not supposed to use personal computers and that access to the electronic health record was limited to the facility’s network. During this discussion, it was acknowledged that there was no system in place to ensure that staff did not save residents’ personal medical or identifying information on their personal computers for later use. Facility documentation titled “Technology & Information Systems Acknowledgement,” updated 09/2023, stated that employees should use company computers and information systems primarily for company business only, but no additional information was provided to address the observed practice of using personal devices for resident record access.
Failure to Follow Hand Hygiene and Glucometer Disinfection Practices During Med Pass
Penalty
Summary
The deficiency involves failure to follow infection prevention and control standards during medication administration on the west wing, involving four residents over a 42‑minute observation period. An LPN with long artificial nails was observed repeatedly handling oral medications with bare hands, including inserting a finger into multi‑dose bottles and using a fingernail to scoop pills out, then placing the pills into a medication cup. On multiple occasions, pills were removed from pharmacy blister cards into the palm of the LPN’s bare hand before being transferred to a medication cup, and a pill that fell onto the top of the medication cart was picked up with a bare hand and placed into the cup. These practices occurred despite facility policies requiring good hand hygiene prior to handling medications and maintaining fingernails short, neat, and trimmed. During blood glucose monitoring and medication administration for one resident, the LPN donned gloves to perform a fingerstick and used a glucometer, but after completing the procedure, disposed of the lancet, medication cup, and gloves, placed the glucometer on top of the medication cart, and began documenting on the computer without performing any hand hygiene. The glucometer was later placed into the medication cart drawer without any cleaning or disinfection. The LPN then proceeded to administer medications to additional residents, again handling medications in the bare hand and entering and exiting resident rooms without performing hand hygiene between residents or before returning to the medication cart and computer. Throughout the observation period, the LPN moved between multiple residents, the medication cart, the nurses’ station, and the treatment cart without performing hand hygiene, despite direct contact with resident environments and equipment. After administering medications and preparing a dose of MiraLAX for another resident, the LPN again failed to perform hand hygiene before accessing the treatment cart drawers and manipulating wound care supplies, which were then taken into a resident’s room. When questioned, the LPN acknowledged the importance of hand hygiene to prevent spreading germs between residents and stated that sanitizer was normally kept in a pocket but was in a bag at that time. Facility policies reviewed by surveyors specified that staff must perform hand hygiene before beginning a medication pass, prior to handling any medication, after direct resident contact, and before and after invasive procedures such as fingerstick blood sampling, as well as maintain appropriate fingernail hygiene.
Widespread Environmental and Linen Deficiencies Affecting Resident Care and Cleanliness
Penalty
Summary
The facility failed to provide a functional, sanitary, and comfortable environment on all three units, beginning with inadequate linen supplies necessary for resident care. An alert and oriented resident with a BIMS score of 15/15 reported having to wait long periods, sometimes hours, for incontinence care because staff did not have enough linen. Observations on multiple days showed linen carts on all units with only a scarce amount of linen, including limited blankets, gowns, wash cloths, towels, fitted sheets, incontinence pads, and pillowcases. CNAs reported they frequently did not have enough linen and often had to go to other units to find supplies, with one CNA stating the facility did not have adequate linens to meet resident care needs. The facility also failed to maintain clean and sanitary common areas and resident rooms. On the East Wing, hallway floors were dirty with debris and dirt buildup in the corners, and several hand sanitizer dispensers outside resident rooms were dirty with white debris caked on the bottom dish, with some dispensers empty and their casings dirty. In one resident’s room, wet towels with dark orangish-brown stains were observed under bins by the window and remained in place with the stains appearing larger over two days. A water fountain near the East Wing nurses’ station had a brownish stain around the drain, and when the button was pressed, gnats emerged from the drain while gnats were also flying over the fountain and landing on the walls. The Unit Manager stated the stain looked like a nutritional supplement used during medication pass and acknowledged that nurses were expected to ensure residents consumed medications and supplements. Individual resident rooms were observed to be unclean and cluttered. One resident with diagnoses including metabolic encephalopathy, aphasia, hemiplegia, and hemiparesis, and a BIMS score of 6 indicating severely impaired cognitive skills, had a room with clothes piled on the floor, debris scattered on the floor, dirty dishes on the overbed table, and a brown substance on the floor at the doorway and in the bathroom. This resident required assistance with ADLs and had behaviors with an intervention of 1:1 until seen by a provider, and did not have a roommate at the time. Another shared room on the west wing occupied by two residents was in disarray with refuse throughout the floor, a pile of paper trash in front of bedside tables, soiled floors, and debris in the bathroom; one resident reported it had been four days since someone cleaned, and the other stated cleaning did not occur every day and depended on who was working. Additional environmental concerns included cobwebs and a spider web in a window across from the therapy gym that remained present throughout the survey. Housekeeping staff reported that the number of housekeepers had been reduced from 5–6 per day to about 3–4 per day, and one housekeeper stated she sometimes worked until late in the evening to get to every room and that after weekends the facility looked very unkempt. The regional housekeeping director stated there were only three housekeepers per day recently, described that each room was supposed to be cleaned daily according to a defined task list, and acknowledged that the observed conditions were not sanitary or comfortable. Facility policy for daily resident room cleaning outlined tasks such as straightening rooms, dusting, cleaning vents and surfaces, sweeping and mopping floors, emptying and cleaning trashcans, and wet mopping with disinfectant, which contrasted with the observed state of multiple areas and rooms.
Failure to Check BP Before Administering Antihypertensive Medication
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when blood pressure was not obtained before administering nifedipine ER as ordered. The resident was admitted with diagnoses including quadriplegia, primary progressive multiple sclerosis, aphasia, anemia, cognitive communication deficit, and essential primary hypertension. The most recent MDS coded the resident as cognitively intact with a BIMS score of 15, and as dependent on staff for all ADLs, including transfers with a mechanical lift and use of an electric wheelchair. The clinical record showed an order for nifedipine ER 30 mg daily for hypertension with instructions to hold if systolic BP was less than 120. Review of the MAR showed that from 3/31/26 through 4/14/26 there were no recorded blood pressures prior to administration of nifedipine on 15 occasions. During interview, an LPN stated that blood pressures are not automatically taken when administering blood pressure medications and that if an order exists it would be recorded on the MAR; however, she could not find any recorded blood pressures prior to nifedipine administration. The LPN stated nurses should read medication orders before administration and acknowledged that failing to check BP could result in giving the medication when it should be held.
Failure to Notify Responsible Party of Resident Fall and ER Transfer
Penalty
Summary
Facility staff failed to notify the responsible party of a resident’s change in condition following a fall and subsequent transfer to the emergency room. The resident had diagnoses including vascular dementia, stridor, cerebral infarction, and dysphagia, and an admission MDS with a BIMS score of 2/15, indicating severely impaired cognitive skills for daily decision making. The resident’s face sheet identified a family member as the responsible party and primary emergency contact. Nursing documentation showed that in the early morning hours the resident was found on the floor in his room with a small bruise to the orbital area, and later that same day the resident was sent to the ER. During clinical record review, the surveyor was unable to locate any documentation that the responsible party had been notified of either the fall or the ER transfer. When requested during an end-of-day meeting, facility leadership could not provide evidence of such notification, despite a facility policy titled “Significant Change of Condition” stating that the responsible party will be notified of a change of condition. The DON later confirmed they were unable to find any notification to the responsible party regarding the fall and acknowledged that the responsible party should have been notified when the resident fell and was stabilized.
Failure to Resolve Grievance Regarding Missing Personal Clothing
Penalty
Summary
Facility staff failed to honor a resident’s right to voice grievances without discrimination or reprisal by not appropriately responding to and resolving a grievance related to missing clothing. A resident’s clinical record, including progress notes and care plan, contained no documentation of a request for the resident’s family to provide clothing. The resident reported receiving some new clothes a few months prior but could not recall details and stated his memory was not perfect. Attempts to reach the resident’s family, who was the designated representative, were initially unsuccessful. Subsequently, the facility produced a grievance filed by the resident’s family member, dated 9/26/25, stating that clothes sent to the facility and left at the front desk were never received by the resident. The grievance investigation summary documented that the facility searched but was unable to locate the clothing and that the resident’s sister would be reimbursed $119.34 for the missing items. Attached documentation included a delivery receipt to the facility and a purchase receipt for the clothes. However, during a later phone call, the family member reported never receiving the reimbursement, and the administrator confirmed that the reimbursement was still pending approval with the business office, demonstrating that the grievance had not been fully resolved.
Failure to Protect Resident From Misappropriation of Personal Property
Penalty
Summary
Facility staff failed to protect a resident’s right to be free from misappropriation of property when clothing items delivered for the resident were not provided to him and were subsequently unable to be located. A review of the resident’s clinical record, including progress notes and care plan, showed no documentation that the family had been asked to provide clothing or that any clothing had been received. During an interview, the resident recalled receiving some new clothes a few months prior but could not remember what items were received, who provided them, and stated that his memory was not perfect. A grievance filed by the resident’s family member documented that clothing had been sent to the facility, left at the front desk, and never received by the resident. The grievance form indicated that the facility searched but was unable to locate the clothing and that the resident’s sister would be reimbursed for the missing items, with attached receipts for both delivery and purchase. In a subsequent phone call, the family member reported that reimbursement had never been received despite multiple conversations with facility leadership. The administrator later confirmed that the reimbursement had not been sent, contrary to what was documented on the grievance form, and stated it was still pending approval with the business office.
Failure to Implement Care-Planned Puree Diet and Weekly Weights
Penalty
Summary
Facility staff failed to consistently implement a person-centered comprehensive care plan for one resident with dysphagia, vascular dementia, stridor, and cerebral infarction. The resident’s admission MDS showed a BIMS score of 2/15, indicating severely impaired cognitive skills for daily decision making, and Section K documented a mechanically altered diet. The resident’s care plan identified risk for weight loss or malnutrition related to chronic disease, cognitive impairment, need for assistance with eating, and dysphagia requiring a puree diet, with an intervention for weekly weights initiated on 12/22/25. However, clinical record review revealed only two documented weights over approximately a one-month period, despite the weekly weight intervention, with weights recorded on 12/31/25 and 01/30/26. The facility also failed to consistently provide the correct diet texture as ordered and care planned. A provider order dated 12/19/25 specified a regular diet with dysphagia advanced texture and thin liquids, which was changed on 12/22/25 to a puree diet per hospital recommendations. On observation during a lunch meal, a CNA questioned the consistency of the resident’s chicken; the dietician stated the chicken needed more liquid, and the SLP determined the chicken was a mixture of mechanically altered and pureed and stated it would not be safe for this resident to eat. In a family interview, a family member reported concerns that the resident had not been receiving the correct diet, including being given a milkshake containing Oreo cookies and Reese’s Pieces on Super Bowl Sunday and receiving the wrong meal trays on three occasions. Facility administrative staff later terminated a CNA for providing the wrong texture milkshake. These findings demonstrated that the resident’s care-planned puree diet and weekly weights were not consistently implemented.
Failure to Protect Residents from Physical Abuse by Peers
Penalty
Summary
Facility staff failed to protect multiple residents from physical abuse by other residents, resulting in several incidents of harm and injury. In several documented cases, residents were physically assaulted by peers, including being punched in the face, head, or chest, and in some cases, these assaults resulted in hospital transfers, visible injuries such as bruising, lacerations, abrasions, and the need for medical treatment. The incidents involved residents with known behavioral issues or histories of aggression, some of whom had orders for 1:1 supervision or required supervision during specific activities such as smoking. Despite these known risks, staff did not consistently provide the required supervision or intervene in time to prevent altercations. Specific events included one resident being repeatedly assaulted by a roommate, another being attacked in a smoking area where supervision was required but not provided, and others being struck in common areas or hallways. In several cases, staff documentation was incomplete or failed to describe the altercations, and there were lapses in following care plans or behavioral interventions. Witness statements and staff interviews confirmed that staff were not always present or able to intervene promptly, and that some residents were fearful of aggressive peers due to repeated incidents. The facility's own policies defined physical abuse as intentional harm by another person, and staff interviews confirmed their understanding of the responsibility to protect residents from abuse by anyone, including other residents. However, the documented events show that staff did not consistently implement or maintain necessary supervision, failed to reassess and update care plans in response to behavioral changes, and did not always document or communicate incidents effectively. These failures resulted in immediate jeopardy to resident safety and placed all residents at risk of abuse.
Removal Plan
- Resident #32, #7, #26 are under 1:1 supervision with staff in close proximity to deescalate or intervene with any possible altercations.
- Resident #40 and #26 will not be allowed to smoke unsupervised.
- A dedicated staff member has been assigned to monitor residents #40 and #26 during smoking breaks.
- A dedicated staff member has been established in the designated smoking area within a secure part of the facility grounds.
- Resident #37, #41, and #39 will have trauma screens performed on all residents that were abused by other residents.
- Resident #12 and #43 no longer reside in the facility.
- All staff will be educated on the abuse policy.
- The DON or designee will educate on abuse and 1:1, ensuring staff doing 1:1 are in close proximity to intervene and provide privacy during bodily functions.
- The DON or designee will conduct an audit of residents currently on 1:1 to ensure the person assigned is monitoring the patient.
- Nursing staff on all shifts will document any unusual, increased, or change in behaviors in the medical records.
- Clinical review will determine residents at risk for aggressive behaviors and appropriate interventions will be put in place.
- All residents that require supervised smoking will be evaluated using the Smoking Safety Screen Assessment upon admission and as needed.
- Current residents that smoke will be reassessed using the Smoking Safety Screen Assessment to determine if supervision is required.
- The facility will schedule a staff member to be in the courtyard while smoking occurs.
- The Interdisciplinary Team (IDT) will be educated by the Regional Director of Clinical Services on the policy and procedures to identify abuse.
- IDT will be educated on what a 1:1 entails, including maintaining arm's length inside and outside of the room.
- Anyone providing 1:1 care will be scheduled by staffing with their relief person for break noted on the schedule.
- Resident on 1:1 will be documented on daily by assigned staff, collected by charge nurse.
- Staff will be educated that they may not leave the resident until they have a relief person and must remain in close proximity to intervene.
- The Regional Director of Clinical Services will educate the IDT team on the need for supervision for residents identified as requiring supervision while smoking.
- The DON or designee will create a schedule for supervision of residents that smoke and ensure they are in the smoking courtyard while residents requiring supervision are present.
- This education will be provided to all staff, and no employee will be allowed to work until they are educated, including agency staff.
- A review of resident #32, #7, #26 care plan will be conducted to assess the effectiveness of the interventions and make adjustments.
- The DON or designee will audit residents with 1:1 supervision to ensure staff is remaining in close proximity to intervene.
- Facility will monitor all residents who have been identified as supervised smokers.
- All supervised smokers will smoke in the designated smoking area within a secure part of the facility grounds.
- If supervision is deemed necessary, the resident will be supervised by a designated staff.
- The DON or designee will audit residents who are supervised smokers to ensure they are supervised while smoking.
Failure to Prevent Resident-to-Resident Altercations and Inadequate Supervision
Penalty
Summary
Facility staff failed to provide adequate supervision and care to prevent resident-to-resident altercations and ensure a safe environment for multiple residents. Several residents with known histories of aggressive behaviors, cognitive impairment, traumatic brain injury, or dementia physically assaulted other residents on multiple occasions. In several cases, residents had active provider orders for 1:1 supervision, yet were still able to engage in physical altercations resulting in injuries to others. Documentation revealed that after each incident, care plans and interventions were not reviewed or revised to address the ongoing risks, and there was a lack of consistent documentation regarding the incidents and supervision provided. In one instance, a resident with a traumatic brain injury and intellectual disability, who had a history of aggression and was under orders for 1:1 supervision, physically assaulted other residents on three separate occasions, causing injuries that required hospital evaluation and treatment. Another resident with severe cognitive impairment and behavioral issues also physically assaulted other residents multiple times, with no evidence of care plan updates or intervention changes following these events. Additionally, two residents in a designated smoking area, both assessed as requiring supervision while smoking, were left unsupervised, resulting in one resident being pulled from his wheelchair and assaulted, sustaining injuries that required medical treatment. Staff and resident interviews confirmed that supervision was not present at the time of the incident, and documentation errors further complicated the facility's response. Other deficiencies included a resident on 1:1 supervision who was able to strike another resident, and a resident assessed as needing supervised smoking who was observed carrying smoking materials independently through the facility, contrary to safety protocols. Multiple staff interviews confirmed that residents requiring supervision were not being adequately monitored, and that facility policies did not clearly address the requirements for 1:1 supervision or the handling of smoking materials for residents assessed as needing supervision. These failures resulted in harm to residents and placed all residents at risk of abuse and unsafe conditions.
Removal Plan
- Resident #32, #7, #26 is now under 1:1 supervision being in close proximity to ensure staff can deescalate or intervene with any possible altercations.
- Resident #40 will not be allowed to smoke unsupervised.
- Resident #26 will not be allowed to smoke unsupervised.
- A dedicated staff member has been assigned to always monitor residents #40 and #26 during smoking breaks.
- The dedicated staff member has been established to the designated smoking area within a secure part of the facility grounds.
- The facility will educate all staff on the abuse policy.
- The DON or designee will educate on abuse and 1:1, ensuring that staff doing 1:1 are in close proximity to the resident to de-escalate or intervene with any possible altercations and will provide privacy while performing bodily functions outside of the door.
- The DON or designee will conduct an audit of those residents currently on 1:1 to ensure the person assigned is monitoring the patient.
- Nursing staff on all shifts will document any unusual, increased, or change in behaviors, which will be reported and documented in the medical records.
- During clinical review, residents at risk for aggressive behaviors will be determined and appropriate interventions will be put in place.
- Patients who wish to smoke will be evaluated using the Smoking Safety Screen Assessment upon admission and as needed to determine a need for supervision.
- Current residents that smoke will be reassessed using the Smoking Safety Screen Assessment to determine if supervision is required.
- The facility will schedule a staff member to be in the courtyard while smoking occurs.
- The Interdisciplinary Team (IDT) will be educated by the Regional Director of Clinical Services on the policy and procedures to identify abuse.
- IDT will be educated on what a 1:1 entails, which includes maintaining arm's length while inside and outside of the room.
- Anyone providing 1:1 care will be scheduled by staffing, with their relief person for break noted on the schedule.
- Resident on 1:1 will be documented on daily by assigned staff, and this will be collected by the charge nurse.
- Staff will be educated that you may not leave the resident until you have a relief person; you have to remain in close proximity to the resident to ensure staff can deescalate or intervene with any possible altercations while on one-to-one inside and outside of room.
- The Regional Director of Clinical Services will educate the IDT team on the need for supervision for residents identified as requiring supervision while smoking, ensuring all residents requiring supervision are supervised while smoking.
- The DON or designee will create a schedule for supervision of residents that smoke and ensure they are in the smoking courtyard while residents requiring supervision are present.
- This education will be provided to all staff, and no employee will be allowed to work until they are educated, including agency staff.
- A review of resident #32, #7, #26 care plan will be conducted to assess the effectiveness of the interventions and make adjustments.
- The DON or designee will audit residents with 1:1 supervision to ensure staff is remaining in close proximity to the resident to ensure staff can deescalate or intervene with any possible altercations.
- Facility will monitor all residents who have been identified as supervised smokers.
- All supervised smokers will smoke in the designated smoking area that has been established within a secure part of the facility grounds.
- If supervision is deemed necessary, the resident will be supervised by a designated staff.
- The DON or designee will audit residents who are supervised smokers to ensure they are supervised while smoking.
Failure to Provide Ordered Pureed Diet
Penalty
Summary
The facility failed to provide a provider-ordered mechanically altered diet for a resident with dysphagia, vascular dementia, stridor, and cerebral infarction. The resident’s hospital discharge summary ordered a pureed diet, and the care plan identified the resident as needing puree consistency due to dysphagia and cognitive impairment. However, the clinical record also showed a provider order for a regular diet with dysphagia advanced texture and thin liquids, later changed to puree based on hospital recommendations. During observation, the resident was served lunch with chicken that the dietician and SLP described as not fully pureed; the SLP stated that, knowing the resident, it would not be safe for the resident to eat the chicken. The tray ticket listed puree crispy chicken thigh as the entree. The resident also received other incorrect food items, including a milkshake with Oreo cookies and Reese’s Pieces and wrong meal trays on multiple occasions, according to family interview and facility documentation. The provider documented recurrent aspiration pneumonia and noted that the recent milkshake containing candy pieces likely contributed to the aspiration episode, with antibiotic treatment started for pneumonia. The DON also provided documentation showing the resident had received the wrong diet during the weekend of 12/20/25-12/21/25, and an ad hoc QAPI plan stated the resident ate the wrong diet served over the weekend. A chest x-ray after that event showed bilateral perihilar atelectasis/infiltrate, and the provider ordered Avelox for pneumonia.
Failure to Employ Full-Time Qualified Social Services Director
Penalty
Summary
Facility staff failed to employ a full-time, qualified social services worker to meet residents' individual needs. Interviews and document reviews revealed that the facility did not have a full-time social services director on-site. The social services assistant confirmed she did not have the qualifications to serve as the director, and the current social services director was reported to be working remotely, primarily during evenings and weekends, rather than being present in the facility. Further interviews established that the social services director had accepted full-time employment elsewhere and was only working part-time at the facility as needed, focusing on audits and compliance checks rather than providing direct, full-time services. Prior to this change, the director was responsible for trauma screenings, psychosocial assessments, MDS reviews, and direct support to residents and families. The absence of a full-time, qualified social services director resulted in the facility not meeting the requirement to provide adequate social services staffing for its residents.
Systemic Failure to Prevent and Address Resident Abuse Due to Ineffective QA Program
Penalty
Summary
Facility staff failed to maintain an effective quality assurance program focused on outcomes of care and quality of life, resulting in multiple residents across all units being victims of abuse. Survey findings revealed that seven residents were abused by staff and/or other residents, with failures in reporting allegations, investigating incidents, and preventing further abuse. The facility's quality assurance program was involved in developing a plan of correction and ongoing monitoring, but these actions did not sustain compliance. During a subsequent survey, nine residents were identified as victims of abuse, with continued failures in reporting, investigation, and supervision, leading to deficiencies in abuse prevention and quality of care. Further review showed that the facility was previously cited for failing to protect residents from abuse, failing to report and investigate abuse, and not correcting repeated willful abuse. Despite audits and staff education on abuse policies, additional residents were found to have been abused, and immediate jeopardy was identified due to the facility's failure to protect residents' rights. The facility did not implement interventions such as 1:1 supervision, psychiatric services, timely reporting, thorough investigations, and staff education as outlined in their plan of correction. The DON acknowledged the lack of evidence for an effective QA program, and the administrator was not available for interview.
Failure to Conduct Thorough Investigations into Abuse and Misappropriation Allegations
Penalty
Summary
Facility staff failed to conduct thorough investigations into multiple allegations of abuse and misappropriation involving four residents. In one incident, a resident with a traumatic brain injury physically assaulted another resident in the smoking area, resulting in injury. Documentation of the incident was incomplete, lacking details such as staff witness statements and identification of all individuals present. Interviews revealed that no staff were present during the incident, and the assigned staff member for supervision was not interviewed as part of the investigation. The investigation file contained only a single resident witness statement and did not include comprehensive evidence collection or interviews with all potential witnesses. In another case, the same resident assaulted a different resident in the hallway, and there was a lack of evidence that a thorough investigation was conducted. The investigation file did not indicate that either resident or any staff were interviewed, nor were attempts made to identify additional witnesses. Documentation showed that the resident was on one-to-one supervision at the time, but there was no evidence that the assigned staff member was interviewed. The clinical records and incident summaries provided were insufficient to demonstrate a complete investigation into the events. Additionally, a resident reported missing money after being moved to a different room, but the facility failed to provide credible evidence of an investigation. The investigation file contained only an incident summary, a facility synopsis, and a handwritten, undated, and unsigned statement. There was no indication that staff interviews were conducted or that efforts were made to determine if anyone had seen the money prior to the report. The facility's own policies require immediate and thorough internal investigations, including evidence collection and interviews, but these procedures were not followed in the cases reviewed.
Failure to Meet Professional Standards in Medication Administration and Documentation
Penalty
Summary
Facility staff failed to provide care and services in accordance with professional standards for five residents. For one resident with multiple food and drug allergies, staff did not transcribe a physician's order for Benadryl, failed to document an assessment of an allergic reaction after the resident was served fish, and did not update the care plan to address allergies. Interviews and record reviews confirmed that the allergic reaction was not properly documented, and there was no evidence of the medication being administered or the event being recorded in the clinical record. Another resident received medications outside of the scheduled administration window on multiple occasions, as shown by medication administration records. The medications involved included midodrine, sennosides-docusate sodium, carbamazepine, and pregabalin. Nursing staff confirmed that medications should be administered within a two-hour window for resident safety, but records showed doses given significantly outside this timeframe. Additionally, for three separate residents involved in resident-to-resident altercations, staff failed to document the incidents in the clinical records as required by professional nursing standards. Facility synopses described the altercations and subsequent assessments, but there were no corresponding progress notes in the residents' clinical records. Interviews with nursing staff and administration confirmed that documentation of such events is a basic nursing practice and should include a description of the incident, steps taken to ensure safety, and assessment results.
Failure to Maintain Sanitary Food Preparation and Serving Practices
Penalty
Summary
Facility dietary staff failed to maintain sanitary food preparation and serving practices in the kitchen. During dinner preparation, multiple staff members with facial hair did not wear beard guards, despite being aware of the requirement. Staff also failed to take holding temperatures of food items prior to serving them from the steam table. Throughout the meal service, staff wore the same gloves while serving multiple plates, touched the steam table surface with gloved hands, and then used those same gloves to handle serving utensils and directly pick up baked fish and rolls without using utensils. This resulted in the contamination of serving utensils and glove surfaces. Additionally, one staff member used gloved hands to shape rice after touching the steam table and serving utensils, and food was served on plates that had visible water droplets. Interviews with staff confirmed awareness of the need for beard guards and the risks associated with improper glove use, cross-contamination, and serving food on wet plates. Facility policies reviewed indicated requirements for proper staff attire, hand washing, glove use, temperature monitoring, and appropriate use of serving utensils to prevent cross-contamination. These policies were not followed during the observed meal service.
Failure to Maintain Clean and Sanitary Resident Rooms
Penalty
Summary
Facility staff failed to maintain a clean environment in four of 88 resident rooms, as evidenced by direct observations and resident and staff interviews. One resident reported requesting housekeeping services multiple times in a single day without response, and surveyors observed trash and unclean floors in the resident's room on consecutive days. Additional observations in several rooms revealed dark stains along the walls and floors, strong urine odors in bathrooms, and significant discoloration of bathroom tiles. The environmental services manager confirmed that daily cleaning was supposed to occur, including mopping floors and cleaning all horizontal surfaces, but acknowledged that the current cleaning methods were insufficient to address the level of staining and odor present in the rooms. The environmental services manager further explained that some rooms required more intensive cleaning, such as stripping and waxing of floors, or even tile replacement, to achieve an acceptable level of cleanliness. However, the rooms identified as deficient had not been included in the recent schedule for stripping and waxing, and some tiles were described as beyond repair. Facility records confirmed that the affected rooms had not received the necessary deep cleaning. The director of nursing and regional director of clinical services were informed of these findings, but no additional information was provided prior to the survey exit.
Failure to Honor Resident Preferences and Maintain Accurate Room Clocks
Penalty
Summary
The facility failed to accommodate resident preferences and needs related to bathing and room environment for multiple residents. One resident with multiple sclerosis and muscle weakness, who was cognitively intact and dependent on staff for personal hygiene, stated he had not had a shower in 2 weeks and said he was missing his showers. He reported that staff charted whatever they wanted. He was observed with crumbs on his shirt, dry flaky skin on his forehead, and facial hair, and he stated he preferred showers and a shave. The record showed shower days were Wednesday, Saturday, and as needed, but the documentation included showers, refusals, not applicable entries, no entries, and repeated bed baths over the same period. The DON stated the facility did not have a shower team. The facility also failed to ensure several residents had clocks in their rooms that were working and displayed the correct time. One resident stated there was no clock in the room and that he had been asking for one for a while. In other rooms on the East Wing, clocks were observed displaying incorrect times, including times that were several hours off from the actual time. Residents in those rooms were observed during survey rounds, and one resident stated he did not know what time it was and said the clock was wrong. Staff members were observed in the rooms providing care, administering medications, and delivering trays and water, but no one addressed the inaccurate clocks during those observations. A resident in another room asked the surveyor what time it was and whether the clock was right, and also asked if it was time to eat. The clock in that room was observed to read 1:15 while the actual time was 3:45 p.m. The next day, the same resident again asked if it was time to eat and stated, "That clock ain't right," while the clock still read 1:15. The unit manager was notified both times and confirmed that a different clock had been fixed instead. The DON and other facility leaders stated the clocks should have been accurate because they were important for resident orientation and for knowing the time for meals, medications, activities, and care preferences.
Resident Records Accessed on Personal Laptops
Penalty
Summary
Resident clinical records were not maintained in a manner that ensured privacy and confidentiality on two of three nursing units, Central and the [NAME] wings. During observation on 2/12/26 at 9:30 AM, six nurses on the central and west wings were seen using their personal laptop computers to access resident clinical records and documents. Staff interviews at that time confirmed that they were using their own computers because there were not enough facility computers available, only one computer was on the unit, and there was no charger for it. Staff also reported that missing chargers and uncharged facility computers caused delays in medication passes, leading them to bring their own computers to complete daily tasks and access records. During a later meeting on 2/12/26 with the administrator, DON, and RDCS, the concern was discussed that staff were not to use personal computers. The RDCS stated that staff could not access the EHR when offsite using personal computers and that there was no system to ensure resident medical or identifying information was not saved on personal computers for later use. The administrator stated that nine computers had recently been sent back and nine more had been ordered, but she did not know when replacements would arrive. A facility document titled Technology & Information Systems Acknowledgement, updated 09/2023, stated that employees should use company computers and information systems primarily for company business only.
Unsafe and Unclean Resident Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment on the East Wing and Central unit. During surveyor rounds, multiple environmental concerns were observed, including stained and bulging ceiling tiles in several resident rooms, broken blinds, broken nightstand drawers with clothes hanging out, a heating-unit filter lying on the floor, soiled towels under bins, and a brownish stain with gnats in the water fountain near the nurses station. The water fountain was observed to have a soiled drain area, and when the button was pressed, gnats came out of the drain while water flowed from the spigot. In the East Wing quad room where four residents lived, a pungent urine odor was repeatedly noted in the hallway and room during multiple rounds. Staff checked each resident for incontinence and found none wet at the time, but the odor remained. The odor was later traced to Bed B's closet, where soiled personal clothes were found stored. The Housekeeping Director stated there were staffing issues in laundry and that laundry staff would focus on laundering personal belongings as well as linens. On the Central unit, ceiling tiles in rooms 42, 51, 55, and 57 were observed to have dark brown ringed stains. These conditions were reviewed with facility leadership, including the Administrator, DON, and Regional Director of Clinical Services, who were informed of the observations during the survey. No additional information was provided before exit conference.
Failure to Perform Hand Hygiene and Disinfect Equipment During Medication Pass
Penalty
Summary
The facility failed to follow infection control standards during medication administration on the west wing when an LPN did not perform hand hygiene and did not disinfect a glucometer during a 42-minute observation period involving four residents. The LPN was observed with long artificial nails and, while preparing medications, used her fingernail to scoop pills from an OTC bottle, removed medications from pharmacy-prepackaged cards into her bare hand, and picked up a pill from the top of the medication cart with her bare hand before placing it into a medication cup. For Resident #132, the LPN checked the resident’s blood sugar with a glucometer while wearing gloves, administered medications, then returned to the medication cart, disposed of the lancet, medication cup, and gloves, and placed the glucometer on top of the cart without performing hand hygiene. For Resident #133, the LPN again removed medications into her bare hand, placed the glucometer into a medication cart drawer without disinfecting it, entered the resident’s room to administer medications, and returned to the cart without hand hygiene. During a narcotic count with the surveyor, no concerns were noted, but the LPN still had not performed hand hygiene. The same pattern continued with Resident #134 and the resident’s roommate, Resident #106. The LPN repeatedly placed medications into the palm of her hand before putting them into a medication cup, entered resident rooms to administer medications, touched the footboard of a bed while speaking with a resident, and returned to the medication cart and nursing station without hand hygiene. Later, while retrieving wound supplies from the treatment cart and taking them to Resident #134’s room, the LPN continued working without hand hygiene and stated that she normally kept sanitizer in her pocket but it was in her bag and that she was going to wash her hands then. The facility’s handwashing and medication administration policies required hand hygiene before and after invasive procedures, before handling medications, after direct contact with residents, and at regular intervals during medication passes.
Failure to Obtain Blood Pressure Before Administering Antihypertensive Medication
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when blood pressure was not obtained before administering Nifedipine ER 30 mg on 15 occasions. The physician order for the medication, dated 6/2/25, directed staff to give one tablet by mouth daily for hypertension and to hold the dose if systolic blood pressure was less than 120. Review of the MAR showed no recorded blood pressures prior to administration from 3/31/26 through 4/14/26. The resident had diagnoses including quadriplegia, primary progressive multiple sclerosis, aphasia, anemia, cognitive communication deficit, and essential primary hypertension. The most recent MDS coded the resident as cognitively intact with a BIMS score of 15 out of 15 and dependent on staff for all ADLs, including feeding, bathing, dressing, grooming, and toileting. During interview, an LPN stated blood pressures are not automatically taken when administering blood pressure medications and that if an order exists to obtain blood pressure before administration, it would be recorded on the MAR; she could not find any recorded blood pressures prior to Nifedipine administration.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
Facility staff failed to ensure that a resident was properly assessed for self-administration of medication, as required by facility policy. During the survey, an over-the-counter bottle of Thera-Flu Max was observed at the bedside of a resident who reported self-administering the medication daily for congestion. The resident had a history of cerebral infarct, hemiplegia, cognitive communication deficit, and asthma, but demonstrated no cognitive impairment with a BIMS score of 15 out of 15 and required assistance with activities of daily living. Upon review, there was no documented assessment or physician order authorizing self-administration of the medication or allowing the medication to be kept at the bedside. Staff interviews confirmed that no residents on the unit had completed assessments or orders for self-administration of medications. Facility policy requires an interdisciplinary team determination for clinical appropriateness and safety before permitting self-administration, which was not completed in this case.
Failure to Timely Report and Thoroughly Investigate Abuse, Neglect, and Theft Allegations
Penalty
Summary
Facility staff failed to implement their abuse policy for reporting and conducting thorough investigations in multiple incidents involving five residents. In two cases, staff did not report incidents of abuse within the required two-hour timeframe. Specifically, after a physical altercation between two residents, the incident was not reported to the state survey agency, adult protective services, or the ombudsman until several hours after the event, exceeding the facility's policy and regulatory requirements for timely reporting. The DON confirmed that the facility's process was to report within 24 hours, which contradicted the policy's two-hour requirement for abuse or bodily injury cases. Additionally, the facility did not conduct comprehensive investigations into allegations of abuse and misappropriation of property. In one instance, a resident was assaulted by another resident in the smoking area, but the investigation file lacked statements from staff or all potential witnesses, and only included a single resident's account. Another incident involved a resident being struck in the face by a peer, but the investigation did not include interviews with the victim, the alleged perpetrator, or the staff assigned to supervise. In the case of a resident reporting missing money, the investigation was limited to a brief summary and did not include interviews with staff or attempts to identify witnesses, despite the resident's claim of seeing a staff member near his belongings. The facility's documentation and interviews revealed that required investigative steps, such as collecting evidence and interviewing all involved parties, were not consistently followed. The investigation files provided to surveyors were incomplete, often missing critical witness statements and lacking evidence of a thorough review as outlined in the facility's own policies. These deficiencies were confirmed through interviews with the DON and review of facility records, which showed a pattern of incomplete and delayed responses to allegations of abuse, neglect, and theft.
Failure to Timely Report Allegations of Abuse and Misappropriation
Penalty
Summary
Facility staff failed to report allegations of misappropriation and abuse to the required agencies within the mandated timeframes for three residents. In one case, a resident reported missing money from his bedside drawer after being moved to a different room. The incident was documented in the clinical record, and an internal investigation was initiated, but the allegation was not reported to the state survey agency, adult protective services, or the ombudsman until four days after the initial report, exceeding the required reporting period. In another instance, two residents were involved in an altercation resulting in physical abuse. The clinical record indicated that one resident, who had a diagnosis of traumatic brain injury, hit another resident and exhibited threatening behavior toward staff. Emergency services were called, and the resident was sent to the hospital for evaluation. Despite the seriousness of the incident, the facility did not report the event to the appropriate agencies until more than eight hours after it occurred, which was outside the two-hour reporting requirement for abuse allegations. Interviews with facility staff, including the DON, confirmed that the facility's process for reporting such incidents did not align with the policy requirements, which mandate immediate reporting—no later than two hours for abuse or bodily injury and no later than 24 hours for other incidents. Facility policies reviewed by surveyors clearly outlined these requirements, but the staff failed to adhere to them in the cases identified.
Failure to Develop Comprehensive Care Plan for Resident Allergies
Penalty
Summary
Facility staff failed to develop a comprehensive, person-centered care plan to address a resident's multiple food and drug allergies. The resident, who was cognitively intact and independent in activities of daily living, reported having numerous allergies, including to fish and seafood. Despite this, he experienced an allergic reaction after being served fish in the dining room. Although the kitchen staff removed the fish from his plate upon his reminder, they did not provide a clean plate, and he subsequently had a reaction requiring emergency intervention with an EpiPen and Benadryl. Interviews with staff revealed that while allergies were documented on meal tickets, the MAR, and in CNA tasks, there was no care plan in place specifically addressing the resident's allergies. The Unit Manager and MDS nurse both confirmed that allergies were not included in the care plan, and the Director of Nursing stated that the facility did not care plan for allergies. Review of the resident's clinical record showed no evidence of a care plan for allergies, no physician orders, and no documentation of the administration of Benadryl or EpiPen, nor any nursing assessment or follow-up after the allergic reaction. Facility policy required a comprehensive care plan to be completed and updated as changes occurred, with input from relevant staff and the resident. However, in this case, the care plan did not address the resident's significant allergy history, and there was a lack of documentation and follow-up regarding the allergic event. The deficiency was identified through interviews, record review, and facility documentation, confirming the absence of a comprehensive care plan for the resident's allergies.
Failure to Review and Revise Care Plans After Resident Altercations
Penalty
Summary
Facility staff failed to review and/or revise care plans for two residents following resident-to-resident altercations. In the first instance, a resident with a history of traumatic brain injury, cognitive impairment, restlessness, agitation, mood disorder, and physical aggression was involved in an altercation where he punched another resident in the face. The incident resulted in the aggressor being placed on 1:1 supervision and the victim sustaining abrasions and undergoing neurochecks. Despite these events, there was no evidence that the care plan interventions for the aggressor were reviewed for effectiveness or revised after the incident. In the second case, another resident with dementia and a history of hoarding and physical aggression struck a peer in the chest as the peer attempted to pass by in a common area. Staff immediately separated the residents and placed the aggressor on 1:1 supervision. However, the care plan for this resident, which already noted aggressive behaviors, was not reviewed or updated following the altercation. Interviews with LPNs and a unit manager confirmed that care plans are intended to guide staff in meeting residents' needs and should be reviewed and updated after incidents such as physical altercations. Facility policy also requires care plans to be updated as changes occur and reviewed quarterly. Despite these requirements, there was no documentation of care plan review or revision for either resident following their respective incidents.
Failure to Provide Timely ADL Assistance and Incontinence Care
Penalty
Summary
Facility staff failed to provide necessary activities of daily living (ADL) assistance, specifically incontinence care and repositioning, to a resident who was completely dependent on staff for these needs. The resident, who had significant medical conditions including intracerebral hemorrhage, hemiplegia, aphasia, chronic respiratory failure, and was always incontinent, was observed in bed for at least five continuous hours without staff checking for incontinence or repositioning. During this period, only brief interactions occurred for medication administration and tube feeding, with no ADL care provided. When staff eventually entered the room to provide care, the resident was found with a wet brief containing a small bowel movement and a newly observed pink area on the sacral region, which had not been present two days prior. Interviews with staff and the DON confirmed that the facility's expectation was to check dependent residents for incontinence and repositioning at least every two to four hours, and the observed lapse exceeded this standard. The documentation reviewed did not specify required frequency for incontinence care, and no additional information was provided by facility leadership regarding the incident.
Failure to Complete Neurological Assessments After Resident Fall with Head Injury
Penalty
Summary
Facility staff failed to appropriately assess and monitor a resident following a fall with injury. After an unwitnessed fall, the resident was found alert and responsive with a hematoma on her forehead. Initial interventions included checking the resident, helping her onto a chair, applying ice, and notifying the on-call physician and family. Although the facility's policy and staff interviews confirmed that neurological checks (neuro checks) should be performed at specific intervals following a fall with a head injury, the clinical record review revealed that the neurological assessment for this resident was grossly incomplete. Vital signs and other required neuro check components were either missing or dated incorrectly, indicating that the assessments were not performed as required. Staff interviews confirmed knowledge of the protocol for neuro checks after a fall with possible head injury, including the frequency and components of the assessment. The facility's policy also outlined the need for thorough and timely neurological assessments to detect early signs of brain injury. Despite this, documentation showed that the required neuro checks were not completed, and the resident was not adequately monitored for latent injuries following the fall.
Failure to Complete Annual Performance Evaluations for C.N.A.s
Penalty
Summary
Facility staff failed to complete annual performance evaluations for two out of five reviewed certified nursing assistants (C.N.A.s). Specifically, there was no evidence of annual performance reviews for C.N.A.s hired on 7/22/1986 and 11/29/2022. During staff interviews, the Director of Nursing acknowledged responsibility for ensuring annual evaluations and confirmed that evaluations for these two C.N.A.s had not been completed, although evaluations for the other three reviewed C.N.A.s were provided. Additionally, when requested, the facility was unable to present a policy on staff training and performance evaluations. No further information or documentation was provided by facility leadership regarding this concern.
Failure to Maintain Complete and Accurate Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for two residents. For one resident with multiple food and drug allergies, staff did not transcribe a physician's order for Benadryl, nor did they document the assessment or follow-up after the resident experienced an allergic reaction to fish served at lunch. The resident reported symptoms such as swelling and redness of the lips and a funny feeling in the mouth after being served fish, despite having informed staff of his allergy. Interviews with staff and review of the clinical record revealed that no documentation existed for the physician's order, administration of Benadryl, or nursing assessment related to the event. Additionally, there was no care plan addressing the resident's multiple allergies. Another resident's clinical record was incomplete regarding an incident where the resident physically assaulted another resident. Progress notes indicated the resident was placed on 1:1 supervision for physical assault, but there were no details documented about the incident itself. Facility incident summaries and witness statements described the resident punching another resident in the face in the smoking area, resulting in an abrasion to the victim's head. However, the clinical record lacked documentation of the incident's specifics, and there was confusion in the facility's incident summary regarding the identity of the aggressor. Interviews with staff and residents confirmed the occurrence of the assault and the lack of staff presence in the smoking area at the time. The facility's director of nursing acknowledged the documentation errors and the absence of detailed records regarding the incident. The facility's own policy requires thorough documentation of adverse events, including objective findings, measures taken, and patient interpretation, but these standards were not met in either case.
QAPI Committee Lacked Required Members and Documentation
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Performance Improvement Committee (QAPI) was composed of the minimum required members for three out of five meetings during the year. Specifically, review of the QAPI meeting attendance/sign-in sheets for the dates provided showed that the Infection Preventionist did not attend the meetings on three occasions. Additionally, there was no sign-in sheet available for one of the required quarterly meetings, indicating a lack of documentation for that meeting. During interviews, the Director of Nursing confirmed the typical attendees of the QAPI meetings and acknowledged that the Infection Preventionist was not always present, sometimes due to other duties. The facility's own policy requires the Infection Preventionist, along with other specified staff, to be part of the QAPI committee. No further information or documentation was provided by facility staff to address the absence of the Infection Preventionist or the missing meeting documentation.
Failure to Maintain Operational Call Bell System and Provide Alternative Means for Resident Assistance
Penalty
Summary
Facility staff failed to maintain an operational call bell system in resident rooms, bathrooms, and bathing areas, resulting in multiple instances where residents had no reliable means to call for assistance. During the survey, it was observed that at least one resident did not have a functioning call bell and no alternative method to summon help. Staff interviews revealed a lack of knowledge regarding the location and distribution of hand bells, with only five hand bells initially found for the entire facility, which houses up to 180 residents. Additional hand bells were later located in a locked maintenance room, but staff were unaware of their availability or how to access them during emergencies. There was no established policy or procedure for staff to follow when the call bell system was inoperable, and staff did not know how to mitigate the risk to residents during outages. Resident interviews confirmed repeated and prolonged outages of the call bell system, with some residents reporting that their call bells were nonfunctional for several days at a time. Residents described situations where they were unable to call for help from their beds or bathrooms, and in some cases, hand bells provided as alternatives could not be heard outside the room. Residents expressed feelings of fear and frustration during these outages, particularly those with limited mobility. Documentation review, including resident council minutes and maintenance logs, showed ongoing and unresolved issues with the call bell system, including entire wings being affected and repeated system failures requiring maintenance intervention. The facility's own policy required monthly inspection and testing of all call systems, including in bathrooms and shower rooms, and documentation of any malfunctions and repairs. Despite this, the facility was aware of ongoing problems with the call bell system but did not provide staff with procedures to ensure residents had a means to call for help during outages. Staff interviews and documentation confirmed that there was no contingency plan in place, and residents were left without reliable access to assistance during repeated system failures.
Failure to Provide Required Resident's Rights Training for Dietary Staff
Penalty
Summary
Facility staff failed to provide required Resident's Rights training for one dietary aide, as identified during a review of six employee records. The dietary aide in question was hired on 8/26/25, but no credible evidence was found in the employee records to confirm completion of Resident's Rights training. The Director of Nursing (DON) stated that training on resident rights, abuse, and similar topics was expected for all staff, including dietary staff, prior to beginning their duties. However, the only documentation provided was a Skills Competency Validation Record dated before the employee's hire date, and a transcript from the employee's phone app that did not show completion of Resident's Rights training. During interviews, the DON and Regional Director of Clinical Services confirmed that all employees were expected to complete Resident's Rights training, but were unable to provide a facility policy on staff training or any additional documentation to support that the dietary aide had received the required training. No further information was provided by facility staff when given the opportunity to do so.
Failure to Provide Required Abuse and Neglect Training for Dietary Staff
Penalty
Summary
Facility staff failed to provide required abuse and neglect training for one dietary aide, as identified during a review of six employee records. The dietary aide in question was hired on 8/26/25, but there was no credible evidence in the employee records to show that this individual had completed the mandated abuse and neglect training. The Director of Nursing (DON) confirmed that all staff, including dietary staff, were expected to receive training on abuse, neglect, infection control, kitchen safety, quality assurance, compliance, ethics, and resident rights prior to beginning their duties. However, documentation provided by the DON and Regional Director of Clinical Services (RDCS) included a Skills Competency Validation Record dated before the employee's hire date and a transcript from a phone app that did not show completion of abuse and neglect training. During interviews, the DON stated that training on resident rights and abuse was part of the basics covered during orientation, and affirmed that all staff should receive this training. Despite this, no policy on staff training was provided when requested, and no additional information or documentation was submitted by facility leadership to demonstrate that the required training had been completed for the dietary aide. The RDCS confirmed the expectation that all employees complete abuse and neglect training, but the facility was unable to produce evidence that this requirement was met for the identified staff member.
Failure to Provide Required QAPI Training for Dietary Staff
Penalty
Summary
Facility staff failed to provide required Quality Assurance and Performance Improvement (QAPI) training for one dietary aide, as identified during a review of six employee records. The dietary aide in question was hired on 8/26/25, but there was no credible evidence in the employee's record to show completion of the mandatory QAPI training. The Director of Nursing (DON) acknowledged that her focus was primarily on clinical staff training and that new employees received basic orientation, but could not confirm that QAPI training was included for dietary staff. When asked, the DON agreed that dietary staff should receive training on infection control, abuse, kitchen safety, quality assurance, compliance and ethics, and resident rights before starting their duties. Further review of documentation provided by the DON and Regional Director of Clinical Services revealed a Skills Competency Validation Record for the dietary aide, but it was dated prior to the employee's hire date and was not considered credible evidence of QAPI training. The dietary aide's own training transcript also did not show completion of QAPI training. Additionally, the facility was unable to provide a policy on staff training when requested. No further information or documentation was provided by facility leadership to address the concern.
Failure to Provide Required Infection Control Training for Dietary Staff
Penalty
Summary
Facility staff failed to provide required infection control training for a dietary aide, as evidenced by a review of six employee records during an extended survey. The dietary aide in question was hired on 8/26/25, but there was no credible evidence that this employee had completed the mandatory infection control training. The Director of Nursing (DON) acknowledged that her focus was primarily on clinical staff training and could not provide documentation that the dietary aide had received infection control training. A document presented as evidence of training was dated prior to the employee's hire date and was therefore not considered credible. Further review of the dietary aide's training transcript did not reveal any infection control training since employment at the facility. The Regional Director of Clinical Services confirmed that all employees were expected to complete infection control training. Additionally, when asked, the DON was unable to provide a copy of the facility's policy on staff training. No further information or documentation was provided by facility leadership to address the concern regarding the lack of infection control training for the dietary aide.
Failure to Provide Compliance and Ethics Training for Dietary Staff
Penalty
Summary
Facility staff failed to provide the required compliance and ethics training for one dietary aide, as identified during a review of six employee records. The dietary aide in question was hired on 8/26/25, but there was no credible evidence that this individual had completed the necessary compliance and ethics training. The only documentation produced was a Skills Competency Validation Record dated prior to the employee's hire date, and a transcript from the employee's phone app showed no record of the required training since employment. The Regional Director of Clinical Services confirmed that all employees were expected to complete compliance and ethics training. During interviews, the DON stated that her focus was primarily on clinical staff training and that all new employees should receive training on resident rights, abuse, and other basics during orientation. When specifically asked about dietary staff, the DON agreed that they should receive training on infection control, abuse, kitchen safety, quality assurance, compliance, ethics, and resident rights before starting their duties. However, no staff training policy was provided upon request, and no additional information was presented by facility leadership to demonstrate compliance with training requirements.
Failure to Notify Responsible Party of Resident Fall and ER Transfer
Penalty
Summary
The facility staff failed to notify the resident’s responsible party of a change in condition after the resident fell and was later sent to the emergency room. The resident had diagnoses including vascular dementia, stridor, cerebral infarction, and dysphagia. The admission MDS assessment showed a BIMS score of 2 out of 15, indicating severe impairment in cognitive skills for daily decision making. The resident’s face sheet identified a family member as the responsible party and emergency contact #1. The clinical record included a nursing progress note documenting that the resident was found on the floor in his room with a small bruise to the orbital area, and later documentation showed the resident was sent to the ER. During record review, surveyors could not locate documentation that the responsible party had been notified of either the fall or the transfer to the ER. The facility provided a policy stating that the responsible party will be notified of a change in condition, and the DON stated that the responsible party should have been notified when the resident fell and was stabilized, but no evidence of notification was found.
Failure to Resolve Resident Grievance
Penalty
Summary
The facility failed to respond to a grievance filed on behalf of one resident, R121, regarding clothing sent to the facility that the resident never received. A clinical record review found no documentation in the progress notes or care plan about the request for the resident’s family to provide clothing. During an interview, R121 stated he remembered receiving some new clothes a few months earlier but could not recall what he received and said his memory was not perfect. The grievance submitted by the resident’s family member stated that clothes were left at the front desk and the resident never received them. The grievance investigation summary documented that the facility searched but could not locate the items and that the resident’s sister would be reimbursed $119.34. However, the family later reported they had never received the reimbursement, and the administrator confirmed it was still pending approval with the business office at the time of the surveyor’s follow-up.
Misappropriation of Resident Clothing
Penalty
Summary
The facility failed to protect one resident from the wrongful use of the resident's belongings when clothing sent by the resident's family was left at the front desk and the resident never received the items. A review of the resident's clinical record and care plan found no documentation that the family had been asked to provide clothing or that clothing had been received by the facility. During interview, the resident stated he recalled getting some new clothes a few months earlier but could not recall what he received or who gave them to him, and he said his memory was not perfect. A grievance filed by the resident's family member stated that clothes were sent to the facility, left at the front desk, and never received by the resident. The facility's investigation summary stated the facility searched but was unable to locate the clothing, and the grievance documentation indicated the resident's sister would be reimbursed for the missing items.
Failure to Complete Ordered Pressure Ulcer Treatment
Penalty
Summary
Failure to provide ordered pressure ulcer treatment occurred for one resident with multiple sclerosis and quadriplegia. The resident’s quarterly MDS assessment indicated the resident was cognitively intact, was at risk for pressure ulcers, and had one stage 3 and one stage 4 pressure ulcer. The care plan addressed the stage 3 sacral pressure ulcer and included treatments per the TAR. A provider order dated 01/15/26 directed treatment to the sacral pressure ulcer twice daily and PRN. On 01/29/26, the day shift LPN documented a code of 9 for the treatment on the TAR, which per the preprinted code meant other/see progress note. The clinical record also showed the LPN documented, “Unable to complete wound care, oncoming nurse aware.” There was no documentation corresponding to the PRN order on the TAR to show the treatment had been completed. When interviewed on 02/12/26, the LPN stated they honestly could not say why the wound care had not been completed. The issue was reviewed with the Administrator, DON, and Regional Nurses on 02/13/26, and no further information was provided to the survey team before exit.
Menu Items Missing From Resident Meal Trays
Penalty
Summary
The facility staff failed to consistently follow menus for resident meals for one of forty-three sampled residents, R119. R119 had diagnoses including dysphagia, vascular dementia, stridor, and cerebral infarction. The admission MDS dated 12/26/25 showed a BIMS score of 2 out of 15, indicating severe impairment in cognitive skills for daily decision making, and the swallowing/nutritional status section indicated the resident was on a mechanically altered diet. The comprehensive care plan identified risk for weight loss or malnutrition related to chronic disease, cognitive impairment, needing assistance to eat, and dysphagia requiring a puree diet. During observation of lunch on 02/10/26, R119 did not have condiments, milk, or pureed cornbread on the meal tray, even though both items were listed on the tray ticket; the dietary manager confirmed the items were not on the tray. During breakfast on 02/11/26, R119 did not have milk or coffee, and the orange juice was frozen, while milk, hot coffee, or tea were listed on the tray ticket. During lunch later that day, R119 again did not have milk on the tray, although whole milk 8 ounces was listed on the tray ticket. A review of the facility menu showed cornbread should have been served on Tuesday 02/10/26, and the menu did not list beverages provided by the facility.
Loose Corridor Handrail
Penalty
Summary
Firmly secured handrails were not maintained in the corridor on the East Wing between rooms [ROOM NUMBERS]. During the initial tour on 2/10/2026, the handrail was observed to be wobbly between room [ROOM NUMBER] and room [ROOM NUMBER]. On 2/11/2026, closer examination showed the handrail could be lifted completely from the wall attachment at the end closest to room [ROOM NUMBER]. Residents were observed walking in the hallway, and some were seen touching the handrail. An LPN stated that handrails should not be loose. Later, the Regional Director of Clinical Services toured the East Wing with the surveyor, observed the loose handrail in the corridor between rooms [ROOM NUMBERS], and lifted the unattached end, stating it needed to be repaired.
Missing Smoking Acknowledgement Form
Penalty
Summary
The facility failed to implement its smoking policy for one resident who had nicotine dependence and was cognitively intact with a BIMS score of 15. The resident’s care plan identified that the resident preferred to smoke and included interventions allowing independent smoking and smoking assessment as needed. The resident’s clinical record contained a smoking safety screen dated 02/02/26 indicating the resident may smoke independently and to educate on the facility smoking policy, but the record did not include a signed Patient Smoking Acknowledgement form. Surveyors observed the resident smoking, and the facility’s policy stated that patients who wish to smoke must be evaluated, agree to the policy, and sign the Patient Smoking Acknowledgement Form to be maintained in the medical record. The DON confirmed the signed acknowledgment was not present.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
Facility staff failed to ensure a safe, clean, comfortable, and homelike environment for all residents, as evidenced by multiple observations and interviews. Surveyors noted a strong urine odor in the hallway past the lobby on two separate occasions, and flies were observed throughout the facility, including resident rooms and hallways over several days. Breakfast trays were served with plastic utensils due to staff callouts, and a damaged breakfast tray with sharp corners was delivered to a resident before being removed. Wall-mounted hand sanitizer units were found to be missing or loose, and there were missing tiles in hallways and resident rooms, as well as a baseboard pulled away from the wall with a blackish gray residue. Mattresses in one room were heavily stained and had a crackled appearance. A resident with multiple chronic conditions, including hypertension, heart failure, and chronic kidney disease, was observed eating breakfast after his tray with sharp corners was removed due to safety concerns. Staff interviews confirmed that damaged trays should be reported and replaced, but the Dietary Manager was not aware of any damaged trays prior to the surveyor's inquiry. Another resident, also with significant medical history, experienced a persistent leaking sink in her room, with a bath basin repeatedly observed full of water under the sink over several days. The resident reported that the issue had not been resolved despite staff emptying the basin. Additionally, a footboard was observed leaning against the wall in a resident room, with the corresponding bed missing its footboard. The resident, who has moderate cognitive impairment and multiple diagnoses, stated the footboard belonged to his roommate, but could not recall how long it had been there. These findings were reviewed with facility leadership during the survey, and no further information was provided at that time.
Unsafe Closet and Pest Infestation Result in Resident Injury
Penalty
Summary
Facility staff failed to provide safe and secure clothing and storage closets in a resident's room, resulting in a closet door falling onto a resident who was seated in her wheelchair. The door, which was not properly fastened with the required screws, struck the resident on the right side of her face, causing three abrasions. The closet structure was found to be deteriorating, with separated, chipped, and peeling particle board, and water damage was observed on the ceiling above the closet. The air conditioning and heating system in the building was known to be inoperable, contributing to condensation and further damage to the closet structure. The facility was aware of the need for closet repairs and replacements in other rooms, but did not act quickly enough to prevent the incident. Additionally, the closet in the resident's room was infested with cockroaches, which were observed darting into the closet and cracks in the wall during inspection. The closet's poor condition, including sawdust-like disintegration and water damage, created an environment conducive to pest infestation. The resident involved had a history of stroke with left side weakness, hypertension, chronic heart disease, and was unable to stand alone. At the time of the incident, the resident was cognitively intact, as indicated by a recent assessment. The facility failed to implement an effective pest prevention and control program, as well as timely maintenance to ensure resident safety.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 154 citations issued within 25 miles in the last 12 months — including the 8 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Richmond
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lakeside Health & Rehabilitation | 1.9 mi | ★★★★★ | 0 | 0 |
| Elizabeth Adam Crump Health And Rehab | 2.9 mi | ★★★★★ | 8 | 0 |
| Westport Rehabilitation And Nursing Center | 3.3 mi | ★★★★★ | 16 | 0 |
| Westminster-canterbury Of Richmond | 3.4 mi | ★★★★★ | 0 | 0 |
| Glenburnie Rehab & Nursing Center | 3.6 mi | ★★★★★ | 14 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.