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 October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pheasant Ridge Nursing And Rehabilitation during CMS and state inspections, most recent first.
The facility failed to timely notify the provider of significant changes in condition for two residents. One resident with a complex cardiac history had a pulse of 131 bpm documented, but the elevated HR was not reported or reassessed for hours before the resident was later sent to the hospital with SOB and chest pain and died there. Another resident with ESRD on dialysis and cirrhosis with ascites had a 28.6-lb weight gain, but the record did not show provider notification of the significant change.
Staff failed to prevent significant medication errors for multiple residents. A resident with moderate cognitive impairment had Eliquis discontinued but the supply was not removed from the cart, 12 tablets were unaccounted for, and the resident later had severe bleeding with critically abnormal labs before dying in the facility. Other residents experienced repeated missed or incorrect insulin administrations, and one resident with bacteremia had delayed IV penicillin doses while awaiting medication from the infusion center.
Missed Ordered Laboratory Testing: The facility failed to obtain multiple ordered labs for several residents, including PT/INR monitoring for a resident transitioning from Eliquis to Coumadin with a Lovenox bridge, urinalyses for residents with suspected UTI/CAUTI, CBC/CMP testing, anticonvulsant levels, blood cultures, and an ammonia level. One resident developed active bleeding with critically abnormal lab values and died in the facility while bleeding from multiple sites. The record also showed several ordered tests were not found or were not completed as ordered.
Failure to Protect Resident from Sexual and Physical Abuse: A resident with dementia, PTSD, and a trauma history was involved in two separate incidents with other residents. In one event, a cognitively intact resident was observed on the resident’s bed with his penis exposed while the resident was holding his penis; the resident later had no recollection of the incident. In another altercation, two residents were seen fighting in the dining room, and the resident was left with scratches, bruising, and a fracture of the right 4th metatarsal after a wheelchair-related injury.
A resident with significant cardiac history had a documented HR of 131 and low BP, but an LPN did not notify a provider or document a repeat assessment for hours. The resident later developed SOB, chest pain, and low O2 sat, was sent to the hospital, and died there the same evening. The report also found an RN competency assessment with multiple below-standard scores that lacked required reassessment and completion documentation.
Misappropriation of controlled medications occurred when staff could not account for missing oxycodone for several residents and liquid hydromorphone for another resident. One resident was severely cognitively impaired and others were cognitively intact or moderately impaired, with orders for scheduled opioid pain meds. Pharmacy records, MARs, and narcotic counts showed missing tablets, incomplete documentation, and a liquid opioid that appeared to have been replaced with water.
Multiple residents with cognitive impairment, mobility limitations, incontinence, or dependence for bathing lacked documented showers, bed baths, or personal hygiene care despite care plans calling for scheduled bathing and assistance. Records showed blank or not attempted entries, missing ADL sheets, and limited shower documentation, and one resident stated staff shortages meant showers were not always provided. Staff interviews confirmed the gaps were documentation holes and no other way was known to verify the care.
Staff failed to follow multiple provider orders for residents’ meds, monitoring, and treatments. Missed items included pulse ox checks, accuchecks, BP checks before hydralazine, a PPD, ordered meds such as buspirone, lidocaine patch, oxycodone, insulin, hydralazine, sodium chloride, and Aldactone, plus ordered weights, an abdominal binder, a urology consult, and shift pain reassessments. Documentation also showed several ordered interventions were not completed or were not recorded as required.
The facility failed to properly account for controlled substances and to ensure ordered meds were available for administration. Surveyors found mismatches between narcotic count sheets and MARs, missing documentation for Oxycodone and Suboxone, and large quantities of Oxycodone that could not be accounted for. Surveyors also found that ordered meds such as Scopolamine, Glycopyrrolate, Suvorexant, sildenafil citrate, and Phenylephrine were not available when needed, resulting in missed or held doses.
Food storage and kitchen sanitation deficiencies were observed when a Dietary Cook/Aide prepared food with hair extending beyond the hairnet, juice machine hoses had black buildup and sticky residue, and multiple refrigerated items were improperly labeled or showed spoilage. The DM stated he did not know how to clean the juice hoses, said they were cleaned weekly, and acknowledged that several items in the walk-in, including cabbage, salad mix, zucchini, watermelon, and cheese, were dirty, undated, or deteriorated.
The facility failed to keep care plans current for three residents. One resident with COPD and acute/chronic respiratory failure was admitted to hospice, but the care plan did not include end-of-life, hospice, or care coordination needs. Another resident with vascular dementia and severe cognitive impairment had an active restorative ambulation plan even though the service had been discontinued. A third resident with obstructive/reflux uropathy and severe cognitive impairment had a fosfomycin order for UTI tx/prophylaxis, but the care plan did not reflect the prophylactic antibiotic.
Medication documentation and controlled substance count discrepancies were identified for two residents. For one resident with severe cognitive impairment and chronic pain-related diagnoses, oxycodone was charted on the eMAR even though the narcotic count record did not consistently show matching removals. For another resident with chronic pain and intact cognition, the eMAR and narcotic control sheets did not match, and the facility reported missing oxycodone tablets during a controlled medication audit. Facility policy required right documentation on the MAR and signing the narcotic book for controlled substances.
A resident with CHF, COPD, malnutrition, depression/anxiety, cognitive impairment, and frequent severe pain had repeated pain complaints, but nursing documentation often lacked pain location, characteristics, and nonpharmacologic interventions, and TAR/MAR entries were inconsistent. The record also showed low BP, lethargy, poor intake, vomiting, diarrhea, and weight loss that were not consistently assessed or reported, with missing ordered lab results and no evidence of a cardiology follow-up being initiated.
Failure to Maintain Nutritional Status With Significant Weight Loss: A resident with CHF, COPD, moderate cognitive impairment, and malnutrition had poor PO intake, repeated meal documentation gaps, swallowing difficulty, and a marked weight decline from about 117 lb to 99 lb. Nursing notes described lethargy, flat affect, and poor appetite, while the provider note addressed chest pain and reflux but did not address the resident’s poor intake or weight loss; surveyors found no provider documentation addressing the nutritional decline.
A resident with CHF, COPD, lower back pain, depression, anxiety, and moderate cognitive impairment had frequent severe pain documented, including pain interfering with sleep and therapy. Staff repeatedly recorded pain scores up to 10/10 without consistently documenting pain location, characteristics, nonpharmacologic interventions, or provider notification, and ordered PRN pain medications were rarely or never administered. Chest pain and low blood pressure noted by therapy were not clearly assessed in nursing documentation, and the resident’s pain documentation was inconsistent across the MAR, TAR, and skilled notes.
A resident with dementia, gait impairment, weakness, and osteoporosis fell and complained of left hip pain. Staff ordered a hip x-ray, but it was not completed when expected, and the resident continued to have pain and difficulty moving the leg. The x-ray vendor said it was scheduled but had no time to come, and the resident was later sent to the hospital where a left hip fracture was diagnosed. The DON could not explain why the x-ray was not obtained or provide evidence of follow-up documentation.
Failure to follow hold parameters for Toprol XL: A resident with CHF, COPD, HTN, CAD, prior MI, and moderate cognitive impairment had an order for metoprolol to be held if HR was <60 or BP was <100/60. The MAR documented the medication as given even though the resident’s BP was 94/58, and the ADON agreed it was administered outside the ordered parameters.
Failure to Obtain Ordered BNP and TSH Labs: A resident with CHF, COPD, CAD, HTN, malnutrition, and moderate cognitive impairment had provider orders for a BNP to assess HF status and a TSH to monitor thyroid function while on Synthroid. When the ADON produced lab results, the BNP and TSH could not be found, and the ADON said she had even called the lab; the ordering provider later stated he did not remember the orders but suspected the BNP should have been completed if the other labs were done.
A resident's wound progress note and hospice consent were found uploaded into another resident's electronic chart during record review. The MRC said records are uploaded as soon as received when possible and that wrong records are deleted if placed in the wrong chart. The two residents had similar last names, and the facility's HIPPA Security Measures policy addressed protecting the confidentiality, integrity, and availability of resident records.
A resident with a DNR order and intact cognition experienced a sudden decline, including lethargy and labored breathing. Despite the resident's son requesting hospital transfer, staff did not initiate emergency transport or provide timely interventions, and the resident died hours later. Documentation and interviews revealed confusion among staff about the resident's care preferences, and the facility failed to follow its own policy for responding to significant changes in condition.
Facility staff did not ensure that medical provider orders entered by non-prescribing staff were signed by the prescribers, resulting in multiple unsigned orders for medications, therapies, and laboratory tests for several residents. The facility's policy requires timely provider signatures on all orders, but this was not consistently followed, as confirmed by record reviews and staff interviews.
Facility staff did not provide a resident's clinical record to an authorized representative within the required timeframe, despite documentation of a valid POA authorizing access. The request was denied due to the facility's insistence on additional proof of authority, even though the representative's rights were documented in the resident's records. The resident had expired and was previously assessed as cognitively intact.
Facility staff failed to promptly notify the provider after a resident with complex medical conditions experienced significant weight loss, with no documentation of provider notification at the time of the event. In a separate case, staff did not promptly inform a resident representative when another resident experienced a marked decline in condition, with notification occurring more than two hours after the initial symptoms were documented. Both incidents were contrary to facility policy requiring timely notification and documentation of significant changes in resident status.
A resident with intact cognition was admitted with a hospital discharge order for Prednisone on a tapering schedule for ulcerative pancolitis. Facility staff did not promptly order the medication upon admission, resulting in a missed dose on the second day. No documentation was found to explain the omission, despite facility policy requiring timely transcription and confirmation of admission medication orders.
Facility staff did not develop or implement baseline care plans within 48 hours of admission for three residents, including individuals with complex medical and mental health needs. Despite requests, the DON and leadership were unable to locate the required documentation, which is mandated by facility policy to ensure person-centered care upon admission.
Facility staff did not develop or implement a comprehensive, person-centered care plan for a resident with multiple complex medical conditions, despite assessment findings indicating needs in areas such as pain management, incontinence, pressure ulcer risk, and therapy services. The care plan on record addressed only limited issues and omitted several critical areas identified in the assessment, with staff unable to provide a complete care plan when requested.
Facility staff did not provide a resident with ordered oxygen therapy at bedtime and failed to transcribe an order for a flutter valve breathing device following hospital discharge for acute respiratory failure with hypoxia. The resident did not receive the prescribed respiratory interventions, and staff documented administration of oxygen that was not actually provided.
Facility staff failed to ensure that a prescribed Narcan nasal spray, dispensed for a specific resident, was available when it was administered to another resident without proper documentation or replacement. The nurse practitioner obtained and administered the nasal spray from the medication cart, and staff could not identify the original recipient or provide evidence that the medication was replaced or the pharmacy notified.
Staff failed to maintain complete and accurate clinical records for a resident who experienced a decline and died. Documentation was missing or incomplete regarding Narcan administration, oxygen delivery, and vital signs, with some vital signs recorded at incorrect times. Progress notes from the nurse practitioner and Medical Director were either delayed or absent, despite involvement in care decisions.
Failure to Timely Report Significant Changes in Condition
Penalty
Summary
The facility failed to notify the medical provider of a significant change in condition for two residents. For one resident, staff did not timely report a heart rate of 131 beats per minute and did not document any provider notification or further assessment for approximately seven hours. The resident had a history that included atrial fibrillation, acute diastolic congestive heart failure, takotsubo syndrome, a prosthetic heart valve, and bacteremia, and the record showed the resident had recently been hospitalized and returned to the facility before this event. For that resident, a nursing note documented tachycardia, new leg swelling, altered mental status, and later transfer to the hospital after complaints of shortness of breath and chest pain. The on-call provider note documented shortness of breath, chest pain, and low oxygen saturation, but there was no documentation that the provider had been informed earlier that day of the elevated heart rate or the resident’s cardiac history. The resident was admitted to the hospital with atrial fibrillation with rapid ventricular response and a heart rate in the 150s, and the record states the resident expired at the hospital later that evening. For the second resident, the facility did not notify the medical provider of a significant 28.6-pound weight gain over five weeks. The resident had end stage renal disease with dialysis, alcoholic cirrhosis with ascites, type 2 diabetes mellitus, portal hypertension, and congestive heart failure. The record showed an admission weight of 164.4 pounds and a later weight of 193.0 pounds, and a dietary note identified the gain as significant. The clinical record did not show documentation that the provider was notified of the weight change.
Significant medication errors involving anticoagulant, insulin, and IV antibiotic administration
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors for 6 of 51 sampled residents. The most serious event involved a resident with atrial fibrillation, COPD, respiratory failure with hypoxia, type 2 diabetes mellitus, and bladder-neck obstruction whose anticoagulant Eliquis was discontinued, but the medication supply was not removed from the active cart. Twelve Eliquis tablets were missing and unaccounted for. The resident had a BIMS score of 9, indicating moderate cognitive impairment, and later developed bleeding from the nose, mouth, urinary tract, and rectum. Lab results showed a critically low hemoglobin of 6.7, hematocrit of 20.9, and PT/INR results that could not be calculated because there was no clotting endpoint. The resident died in the facility while actively bleeding. For another resident with type 2 diabetes mellitus and diabetic polyneuropathy, staff failed to administer sliding scale Insulin Lispro on 19 separate occasions despite blood sugar readings that met the ordered parameters for administration. The resident had severe cognitive impairment with a BIMS score of 1. For a third resident with type 2 diabetes mellitus and diabetic neuropathy, staff failed to administer Insulin Glargine on two occasions. One nursing note documented that the insulin was held because the blood sugar was 150, even though the order did not include a hold parameter based on that reading. That resident had intact cognition with a BIMS score of 15. The facility also failed to begin intravenous antibiotics as ordered for a resident admitted with acute and subacute endocarditis, streptococcal arthritis, and bacteremia. The resident’s discharge summary and history and physical documented continuous penicillin G therapy that was changed to intermittent IV dosing through a PICC line, but the MAR and nursing notes showed multiple held or missed doses while the medication was awaited from the infusion center. In addition, staff failed to follow insulin parameters for one resident whose order required holding Insulin Lispro if glucose was below 175, and staff administered the medication on multiple occasions when blood sugars were below that threshold. Staff also administered Insulin aspart to another resident when blood glucose values were below the ordered hold parameter of 150.
Missed Ordered Laboratory Testing
Penalty
Summary
The facility failed to obtain multiple laboratory tests as ordered by medical providers for 8 of 51 sampled residents, including PT/INR testing, urinalyses, CBC/CMP testing, anticonvulsant drug levels, blood cultures, and an ammonia level. The report states that these missed labs involved residents with significant medical histories such as atrial fibrillation, recurrent urinary tract infections, chronic kidney disease, epilepsy, cirrhosis, and cognitive impairment. Facility policy required the facility to provide or obtain laboratory services to meet resident needs. For one resident, the deficiency involved repeated failure to obtain PT/INR testing during a transition from Eliquis to Coumadin with a Lovenox bridge. PT/INR labs were ordered every 48 hours, but several were not obtained. Later testing showed a PT greater than 90 and an INR that could not be calculated because the result was greater than linearity. The resident then developed active bleeding, including bleeding from the nose, mouth, urinary tract, and rectum. Additional labs showed critically low hemoglobin and hematocrit, and PT/INR could not be determined because there was no clot endpoint. The resident died in the facility while actively bleeding. The report also describes missed ordered labs for other residents. One resident with altered mental status and a history of recurrent UTIs had urinalysis orders that were not found in the record, while another resident with suspected CAUTI had a urinalysis with culture and sensitivity ordered but no result located. A resident on warfarin had PT/INR orders that were not obtained as scheduled, and another resident had ordered CBC and CMP testing that was not found. Additional residents had missing anticonvulsant levels, missing infection workup labs including CBC, BMP, magnesium, blood culture, and missing ammonia testing. Surveyors discussed these missing tests with facility leadership, and the record reflects that the ordered laboratory services were not completed or could not be located in the clinical record.
Failure to Protect Resident from Sexual and Physical Abuse
Penalty
Summary
The facility failed to protect a resident with Alzheimer’s disease, PTSD, generalized anxiety disorder, major depressive disorder, and moderate cognitive impairment from sexual abuse by another resident and from physical abuse during an altercation with another resident. The resident had a care plan noting a history of trauma, a potential for re-traumatization, and a history of stating she had been raped and abused, with interventions to avoid situations that reminded her of trauma. The resident also had a legal guardian in place. On one occasion, a staff member observed another resident lying on the resident’s bed with his penis exposed while the resident was sitting in her wheelchair holding his penis. The other resident had a BIMS score indicating he was cognitively intact, while the resident involved had no recollection of the incident. The medical provider later documented increased sexual behaviors in the context of impaired cognition and noted that the resident was alert but confused and had no recollection of the event. On another occasion, staff were alerted to two residents fighting in the dining room. Staff observed the resident and another resident in their wheelchairs intertwined, facing each other, with the other resident holding onto the resident’s wheelchair and not letting go. The resident was found with scratches and bruising on both arms, and later developed right foot swelling and toe discoloration. X-rays showed a closed fracture of the right fourth metatarsal neck, and the facility’s investigation linked the injury to a recent traumatic event involving a wheelchair rolling over the resident’s foot.
Failure to Recognize and Report Significant Change in Condition; Incomplete Nurse Competency Validation
Penalty
Summary
The facility failed to ensure nurses were competent to recognize and act on a significant change in condition for a resident with extensive cardiac history. The resident had diagnoses including atrial fibrillation, acute diastolic congestive heart failure, takotsubo syndrome, a prosthetic heart valve, and bacteremia. The resident’s care plan noted cognitive intactness, IV antibiotics, a diuretic, and an anticoagulant, with a goal of returning home. A nursing note documented a heart rate of 131 beats per minute and blood pressure of 98/53, but there was no documentation that a provider was notified or that the nurse further assessed the elevated heart rate. Approximately seven hours later, the next clinical entry was from an on-call provider documenting shortness of breath, chest pain, and not feeling well. The provider note included a pulse of 80 and oxygen saturation of 77, but there was no indication the nurse had informed the provider of the resident’s cardiac history, the recent hospitalization for atrial fibrillation with rapid ventricular response, or the earlier heart rate of 131. The record also did not show whether the resident remained stable during the intervening hours or whether the resident was checked during that period. The resident was later sent to the hospital and expired there the same evening. The nurse involved stated that after seeing the pulse of 131, she rechecked the resident and obtained 87, found the resident fine, and did not document the recheck. She stated that later in the evening the resident complained of shortness of breath and heart racing, at which time she assessed the resident and sent the resident out. The nurse’s file contained orientation documentation and a copy of the notification-of-changes policy, but there were no dates or signatures showing when it was reviewed and no evidence of hands-on skills validation. The report also identified that an RN’s competency assessment showed scores below expected standards in multiple skills areas, but the required reassessment and completion documentation were left blank and no further training records were found.
Misappropriation of Controlled Medications
Penalty
Summary
Facility staff failed to protect residents from misappropriation of controlled medications, including oxycodone and liquid hydromorphone, for four residents. The report states that Resident #12 had diagnoses including rheumatoid arthritis, contracture of the right shoulder, and hemiplegia/hemiparesis following cerebral infarction, and was severely cognitively impaired with a BIMS score of 3. The resident had an order for oxycodone 5 mg every 8 hours for pain, but review of narcotic control sheets and pharmacy delivery information showed multiple missing tablets that could not be accounted for, with no control sheets available for several date ranges and no destruction documentation located. Resident #44, who was cognitively intact with a BIMS score of 13 and had diagnoses including osteoarthritis of the knee and polyneuropathy, also had an order for oxycodone 5 mg twice daily for pain. The MAR showed doses documented as held, and pharmacy personnel confirmed that 60 tablets had been sent on one delivery and 30 tablets on another, leaving 30 tablets unaccounted for. The facility was unable to account for the missing oxycodone tablets. Resident #90, who had chronic pain and a BIMS score of 15, had an order for oxycodone 5 mg every 6 hours for pain/discomfort. Review of the narcotic sheets and eMAR showed doses that were not documented or accounted for, including discrepancies between the number of doses recorded on the control sheet and the number shown on the eMAR. The facility investigation identified a staff nurse as the alleged perpetrator in the missing controlled substances investigation involving Residents #90 and #91, and the nurse refused a drug screen and later terminated employment. Resident #91 had moderate cognitive impairment with a BIMS score of 7 and was ordered hydromorphone oral liquid 1 mg/mL every 4 hours for pain. The MAR showed two doses not administered before the resident’s death, and during the facility’s narcotic audit the liquid hydromorphone was found to have an abnormal color and consistency and was verified by the pharmacist to appear to have been replaced with water. The facility also reported a narcotic discrepancy during shift-change count and reviewed controlled substance records that required separate narcotic sheets and end-of-shift counts, but the medication was found altered and not properly accounted for.
Missing Bathing Documentation and Incomplete ADL Care
Penalty
Summary
The facility failed to provide evidence of showers and/or bed baths for multiple residents who had documented ADL care needs and bathing assistance requirements. Resident #8 had diagnoses including cerebral palsy, intellectual disabilities, abnormal posture, and epilepsy, and was assessed as dependent for showering/bathing self. The care plan directed showers/bathing per schedule, but the shower records for May, June, and July 2026 showed multiple blank entries and codes indicating not attempted, with no documentation of bed baths for those months. Resident #12 had diagnoses including hemiplegia and hemiparesis following cerebral infarction and a right shoulder contracture, was severely cognitively impaired, and required partial/moderate assistance with shower/bath self. The care plan directed sponge baths when a full bath or shower could not be tolerated and up to substantial assistance as needed, but no ADL shower sheets could be located and there was no documentation related to showers and/or bed baths. Resident #71 had diagnoses including cerebral palsy and hemiplegia affecting the right non-dominant side, was moderately cognitively impaired, and was coded as dependent for shower/bathe self. The resident’s care plan called for stretcher showers per schedule and PRN, yet the shower sheets showed multiple blank entries and codes indicating not applicable, with no documented evidence of bed baths. Additional residents also lacked documented bathing care. Resident #3 was assessed as requiring substantial/maximal assistance with showering/bathing self, and the 30-day look-back on the shower record showed no data found for showers or baths. Resident #10, who was cognitively intact but needed partial/moderate assistance with shower/bathing self, stated staff work short on weekends and she does not always get showers/baths; the shower record showed only two documented shower/bath entries in the look-back period. Resident #13, who had dementia and limited mobility and needed supervision or touching assistance with showering/bathing self, had only one documented shower in the look-back period and no showers/baths documented for several days after returning from an outing. Resident #89, who had severe cognitive impairment, frequent bowel and bladder incontinence, and a history of MASD to the peri-area, had multiple blanks in the CNA documentation for personal hygiene on the night shift, and staff stated the blanks meant the care was not documented and they were not aware of another way to confirm the resident received the needed care.
Failure to Follow Provider Orders for Medications, Monitoring, and Treatments
Penalty
Summary
Facility staff failed to follow multiple provider orders for monitoring, medications, and treatments for several residents. Resident #9 had an order for pulse oximetry every shift for 3 days, but the July 2026 MAR showed pulse ox monitoring was not completed on 07/22/2026 during evening and night shift and was not obtained on 07/23/2026 on any shift. Resident #42 also had an order for pulse ox every shift, and the vitals record showed oxygen saturation levels were not obtained on multiple dates and shifts. Resident #79 had provider-ordered blood pressures prior to hydralazine administration and a provider-ordered PPD, but the report states nursing staff failed to obtain the ordered blood pressures before giving hydralazine and failed to administer the PPD on 07/12/2026. Medication administration failures were identified for several residents. Resident #10 did not receive ordered buspirone, lidocaine patch, and oxycodone on 06/14/2026, and accuchecks were missed on 06/09/2026, 06/14/2026, and 06/23/2026; another oxycodone dose was missed on 07/09/2026. Resident #13 was ordered sodium chloride tablets for 14 days for hyponatremia, but the July 2026 MAR showed the medication was administered for only 13 days. Resident #43 had missed doses of insulin aspart on 06/14/2026 and hydralazine on 07/06/2026 and 07/18/2026. Resident #33 did not receive Aldactone on 07/12/2026, although the MAR note stated staff were waiting on pharmacy delivery and the facility inventory showed spironolactone tablets were available. Other ordered treatments and monitoring were also not followed. Resident #8 had an order for an abdominal binder at all times for PEG tube stability and metoprolol via G-tube with hold parameters; progress notes documented that the binder was not in place, and the MAR showed metoprolol was held with no pulse documented. Resident #48 had an order for weights related to PRN furosemide use, but no weights were recorded after 05/20/26 and none were documented in relation to the order. Resident #69 had a provider order for a urology consult, but the clinical record did not show evidence that the resident was evaluated by urology. Resident #55 had ordered pain assessments and outcome tracking each shift, but the TAR showed repeated pain scores and unchanged outcomes without documentation of pain medication administration or a progress note showing the intervention was effective or that the resident was re-evaluated.
Medication Accountability and Availability Failures
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of multiple residents by not accurately accounting for controlled substances and by not ensuring ordered medications were available for administration. Surveyors identified discrepancies between controlled substance count sheets and the actual amount of medication on hand, missing documentation for narcotic receipt and administration, and several occasions when ordered medications were not available in the facility’s medication supply or emergency supply. For one resident with epilepsy, the liquid Phenobarbital count sheet documented 233 mL on hand, but the bottle measured more than 300 mL during a controlled count with an LPN and the DON confirmed the count sheet did not match the actual quantity. For another resident with osteoarthritis and polyneuropathy, the facility could not account for 30 tablets of Oxycodone; only one nurse had signed for receipt even though facility policy required two licensed nurses, and the facility could not produce documentation accounting for the missing tablets. Additional controlled substance discrepancies were identified for other residents, including mismatches between narcotic count sheets and MARs for Suboxone and Oxycodone, and the facility was unable to account for 84 Oxycodone tablets for one resident and 60 Oxycodone tablets for another resident. Surveyors also found that several ordered medications were not available when needed. One resident with dysphagia and excessive secretions had orders for Scopolamine and Glycopyrrolate, but the record showed doses coded as held or unavailable, with progress notes stating the medications were not available and no provider order to hold was documented for at least one occurrence. Another resident with vascular dementia and insomnia missed doses of Suvorexant because it was not in the Omnicell, and a resident with end stage renal disease and pulmonary hypertension missed doses of sildenafil citrate because it was not available. A resident with COPD and chronic respiratory failure also missed multiple doses of Phenylephrine because it was not in the cart or available for administration.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards in the facility kitchen. During an initial tour of the kitchen, a Dietary Cook/Aide was observed preparing food on the tray line with visible hair uncontained and extending past the hairnet boundaries to the shoulders all the way around the head. The cook/aide stated she was hot and sweaty and that the hair must have fallen out, then left the food prep area and adjusted the hair net to place the loose hair back inside it. The juice machine hoses were observed with a moderate amount of black substances inside the tubes, sticky residue on the outside, and orange juice sitting in the middle of one tube for approximately 4 to 5 inches. The Dietary Manager stated he did not know how to clean the hoses and said the juice boxes were empty, then agreed the hoses were dirty and stated they are cleaned once a week. In the walk-in refrigerator, two pieces of watermelon were wrapped in plastic with no label or date, a box of zucchini had no receipt date and the zucchini were soft, spongy, squishy, and showed signs of decomposition and browning, a box of raw cabbage had a receipt date of 07/01/2026 and contained wilted leaves and brown spots, two bags of prepared salad mix dated 07/08/2026 had brown lettuce throughout, and a covered container of American cheese slices was labeled opened 6/16/26 and discard 7/16/26. The Dietary Manager stated he had been told cheese does not go bad and to just change the sticker, and stated he would discard the items from the refrigerator.
Care plans not revised for hospice, discontinued restorative services, and prophylactic antibiotic therapy
Penalty
Summary
The facility failed to review and revise the comprehensive person-centered care plan for 3 of 51 sampled residents. For Resident #94, the record showed admission with a history of sepsis due to Serratia, UTI, type 2 DM, and COPD, with a BIMS score of 9 indicating moderate cognitive impairment. A provider order for hospice evaluation and treatment was dated 4/20/26, and a hospice nursing admission note dated 4/21/26 documented admission with a primary diagnosis of COPD and acute and chronic respiratory failure with hypoxia. The resident’s care plan did not include a focus area for end-of-life care, hospice services, or care coordination. For Resident #2, the care plan still included restorative ambulation with a rolling walker and minimum assist up to 50 feet six days a week, even though restorative services had been discontinued about a month earlier and the clinical record did not show participation in the program. Resident #2 had vascular dementia and type 2 DM with diabetic polyneuropathy, and a significant change MDS showed a BIMS score of 1 indicating severe cognitive impairment. For Resident #12, the care plan did not reflect the use of prophylactic antibiotic therapy despite a physician order for fosfomycin 3 GM by mouth every Tuesday for UTI treatment and prophylaxis; the resident had obstructive and reflux uropathy, a history of nephrostomy tubes with recurrent dysfunction and recent removal, and severe cognitive impairment with a BIMS score of 3 out of 15.
Medication Documentation and Controlled Substance Count Discrepancies
Penalty
Summary
The facility failed to meet professional standards of practice for medication documentation for two residents by documenting oxycodone as administered when the narcotic control records did not match the eMAR entries. For one resident, who had rheumatoid arthritis, right shoulder contracture, hemiplegia and hemiparesis following cerebral infarction, and severe cognitive impairment with a BIMS score of 3, the eMAR showed oxycodone 5 mg given as ordered for pain, but the narcotic supply record documented only one tablet removed on some dates and no tablets removed on another date despite the medication being charted as administered. For the second resident, who had chronic pain, muscle weakness, chronic pulmonary edema, limitation of activities due to disability, and cellulitis of the lower right limb, the facility reported missing 60 oxycodone tablets out of 120 during an audit of controlled medications. The resident was cognitively intact with a BIMS score of 15 and was receiving scheduled pain medication. The eMAR for April and May showed oxycodone 5 mg ordered every 6 hours with Tylenol, but the narcotic control sheets did not match the documented administrations, including multiple dates where the number of doses removed did not align with what was charted as given. Surveyor review also included the facility policy requiring medications to be administered in accordance with professional standards of practice, with right documentation on the MAR and signing the narcotic book for controlled substances. An LPN stated that controlled substances must be documented according to policy with two nurses verifying counts, charting each administration, pain levels, and provider communication. The discrepancies for both residents were discussed with facility leadership, and no further information was provided before exit.
Failure to Provide Standard Pain and Condition Monitoring
Penalty
Summary
The facility failed to provide care and services that met professional standards of quality for one resident with multiple complex conditions, including acute on chronic CHF, COPD, muscle weakness, shortness of breath, moderate protein calorie malnutrition, hypertension, lower back pain, depression, and anxiety. The resident’s admission MDS showed moderate cognitive impairment, frequent pain that interfered with sleep, therapy, and daily activities, and pain as high as 9/10 over the prior five days. The resident also had poor functional status on admission, requiring substantial to maximal assistance with toileting, bathing, dressing, personal hygiene, bed mobility, and transfers, and was incontinent of bowel and bladder. The record showed repeated pain complaints and inconsistent pain assessment documentation. Skilled notes frequently documented pain levels as high as 10/10, but often did not include pain location, characteristics, or nonpharmacologic interventions. The TAR required pain assessment every shift and documentation of nonpharmacological interventions, yet the pain levels on the TAR did not consistently match the MAR or skilled notes, and some shifts had blank pain and intervention entries despite documented pain complaints. The resident also had complaints described as chest pain, stomach pain, rib pain, and back pain, but there was no corresponding nursing assessment in the record for some of those complaints. The MAR showed acetaminophen was ordered PRN but was administered only once during the stay, and nitroglycerin was ordered PRN for angina but was not administered at any point. The record also showed failure to adequately assess and respond to changes in condition, poor intake, and weight loss. Notes documented low blood pressure, lethargy, poor appetite, nausea, vomiting, diarrhea, and refusal of activity, but there was no evidence these findings were further assessed or reported to the provider in several instances. The resident lost weight during the stay, with the RD documenting a 5.2-pound loss in 9 days and poor appetite/PO intake, and the SLP documented ongoing challenges with oral intake and weight loss, including inability to effectively masticate or swallow oral trials. The provider had ordered BNP and TSH testing, but those results were not found in the record, and there was no evidence of a cardiology appointment being initiated despite a recommendation for follow-up. The resident later became unresponsive after vomiting and diarrhea and was sent emergently to the hospital, where the resident died a week later.
Failure to Maintain Nutritional Status With Significant Weight Loss
Penalty
Summary
The facility failed to maintain acceptable nutritional status for a resident admitted with acute on chronic CHF, COPD, muscle weakness, shortness of breath, moderate protein calorie malnutrition, hypertension, low back pain, depression, and anxiety. The resident’s admission weight was 115 to 117 pounds, and the admission MDS showed a BIMS score of 08, indicating moderate cognitive impairment. The record also showed a mechanical soft diet with thin liquids and a 2000 ml fluid restriction, while the resident reported poor appetite and disliked the mechanical soft texture. Documentation showed repeated low intake and missing meal documentation across multiple days, including no recorded lunch or breakfast/lunch entries on several dates, and several meals documented at 0-25% or 26-50% intake. Daily weights recorded a decline from 117.5 pounds to 112.2 pounds within days, then to 111.8 pounds and later to 99 pounds, reflecting a significant weight loss. The RD noted a 5.2-pound loss in 9 days, poor appetite, family bringing in foods, a reported usual body weight of 140 pounds before hospitalization, and a stage I pressure ulcer to the sacrum. Nursing and therapy notes documented lethargy, flat affect, poor appetite, sluggishness, and swallowing difficulty, but there was no evidence that alternatives were offered or that the medical provider was notified at those times. The provider progress note addressed chest pain, gas pain, and acid reflux worse after eating and drinking, but did not address poor intake or nutritional status. Speech therapy later documented ongoing nutritional risk, consistently low PO intake, weight loss, difficulty masticating or swallowing oral trials, and collaboration with nursing, dietician, and physician, while surveyors found no provider documentation addressing the resident’s weight loss or poor appetite.
Failure to Provide Complete Pain Assessment and Management
Penalty
Summary
The facility failed to provide pain management for a resident with multiple diagnoses including acute on chronic CHF, COPD, muscle weakness, shortness of breath, moderate protein calorie malnutrition, hypertension, lower back pain, depression, and anxiety. The resident’s MDS showed moderate cognitive impairment with a BIMS score of 08, frequent pain that interfered with sleep, therapy participation, and day-to-day activities, and pain as high as 9/10 over the prior five days. The facility policy required pain to be recognized, assessed, and managed consistent with professional standards of practice, including evaluation of pain characteristics, nonverbal indicators, and the resident’s goals and preferences. Clinical records showed repeated documentation of severe pain without a complete assessment. Daily skilled notes frequently recorded pain levels as high as 10/10, but often did not include the pain location, characteristics, or nonpharmacologic interventions offered. The MAR showed acetaminophen ordered as needed for pain, but it was administered only once during the stay, and the resident had pain levels of 7 or higher on fifteen of seventeen days. The TAR also did not consistently match the pain levels documented in the MAR or skilled notes, and one shift had blank pain documentation despite pain being recorded elsewhere. The resident also reported chest pain and other pain complaints that were not consistently assessed or communicated. A PT note documented chest wall pain, stomach, rib, and back pain along with low blood pressure, but there was no nursing note showing assessment for chest pain or low blood pressure. A provider note later described chest pain as a burning epigastric sensation relieved with Tums and included Nitrostat PRN for angina, yet the MAR showed nitroglycerin was never administered. Several later skilled notes continued to document 10/10 pain without evidence that the high pain levels were assessed or reported to the medical provider. During interviews, the ADON and DON stated the resident did not have chest pain and relied on the skilled notes and MAR for pain assessment documentation.
Failure to Obtain Ordered X-Ray After Fall
Penalty
Summary
The facility failed to provide or obtain radiology services to meet the needs of a resident who sustained a left hip fracture after a fall. The resident had diagnoses including dementia with psychotic disturbance, lack of coordination, muscle weakness, gait and mobility abnormalities, and osteoporosis, and had severe cognitive impairment with frequent pain documented on the MDS. After a witnessed fall, the resident complained of left hip pain that worsened with movement and was rated 4 out of 10, and the provider ordered a left hip x-ray and PRN medication. Clinical documentation showed ongoing pain and difficulty moving the left leg, but the x-ray was not completed when expected. A nurse note documented that staff could not find x-ray results in the system and that the mobile x-ray company said the study was ordered for that day but had no time for completion. The nurse then notified the NP, who ordered the resident sent out because of the left hip pain. The resident was admitted to the hospital and diagnosed with a left hip fracture. Interviews with staff showed no clear explanation for why the x-ray was not obtained. An LPN stated the resident had complained of pain and that the x-ray was ordered, while another LPN said the resident was not someone who complained and that the resident had 10 out of 10 pain when the aide reported it. The DON stated she would expect the x-ray to be done the same day and acknowledged she had no explanation for the failure to obtain it and could not produce evidence of follow-up documentation or a physical assessment after the fall.
Failure to Follow Hold Parameters for Toprol XL
Penalty
Summary
Facility staff failed to follow a provider order for Resident #2’s Toprol XL (metoprolol) administration. The resident was admitted on 04/17/2025 and had a medical history that included acute on chronic congestive heart failure, chronic obstructive pulmonary disease, hypertension, coronary artery disease with a history of myocardial infarction, and moderate protein-calorie malnutrition. The admission MDS dated 04/23/2025 assigned a BIMS score of 8, indicating moderate cognitive impairment. The May 2025 MAR showed an order for Toprol XL 25 mg by mouth daily for hypertension with instructions to hold the medication if heart rate was less than 60, systolic blood pressure was less than 100, or diastolic blood pressure was less than 60. On 05/03/2025, the resident’s blood pressure was documented as 94/58, yet Toprol XL was documented as given despite both blood pressure parameters being outside the hold order. During the survey, the ADON reviewed the MAR and agreed the medication had been documented as given outside parameters.
Failure to Obtain Ordered BNP and TSH Labs
Penalty
Summary
The facility failed to obtain provider-ordered laboratory tests for one resident, including a BNP and a TSH level. The resident was admitted with a medical history that included acute on chronic congestive heart failure, COPD, hypertension, coronary artery disease with a history of myocardial infarction, and moderate protein-calorie malnutrition. The admission MDS assigned a BIMS score of 8, indicating moderate cognitive impairment. A history and physical note signed by the Medical Director ordered a BNP to assess the resident’s current heart failure status, along with CBC, CMP, and magnesium levels. A provider progress note later ordered a TSH level because the resident had a history of hyperthyroidism and was receiving Synthroid 50 mg daily. When the ADON provided lab results, the BNP and TSH could not be produced, and the ADON stated, "I even called the lab." The ordering provider later stated he did not remember the orders but suspected the BNP should have been done if the other labs were completed.
Incorrect Resident Records Uploaded to Wrong Chart
Penalty
Summary
Facility staff failed to maintain medical records in accordance with accepted professional standards for 1 of 8 residents reviewed, Resident #8. During a record review for Resident #4, surveyors observed a wound progress note dated 3/17/2026 and a hospice consent dated 3/16/26 for Resident #8 uploaded into Resident #4's electronic chart. The Medical Records Coordinator stated that records are uploaded as soon as they are received when possible, that she limits who uploads records to reduce mistakes, and that if a wrong record is uploaded into the wrong chart it is deleted immediately. It was also noted that Resident #8 had a similar last name to Resident #4. The facility later provided its HIPPA Security Measures policy, which stated that it is the facility's policy to implement reasonable and appropriate measures to protect and maintain the confidentiality, integrity, and availability of residents' identifiable information and/or records in electronic format.
Failure to Provide Timely Emergency Care and Honor Resident's Preferences Following Change in Condition
Penalty
Summary
Facility staff failed to appropriately respond to a significant decline in a resident's condition, which included symptoms such as lethargy, decreased responsiveness, clammy skin, and Cheyne-Stokes respirations. The resident, who had a DNR order but no other documented care limitations, was noted to have intact cognition and diagnoses including coronary artery disease, hypertension, and paroxysmal atrial fibrillation. Despite the resident's sudden decline, there was no evidence that staff checked the resident's blood sugar or initiated timely emergency transport. Clinical documentation showed that the nurse practitioner administered Narcan despite the resident refusing opioid medications, and applied oxygen for comfort, but did not document the amount or delivery device. Communication with the resident's son revealed that he requested hospital transfer after being informed of his father's condition, but there was no evidence that staff made any effort to arrange for transport. Staff interviews and progress notes indicated confusion regarding the resident's wishes, with some staff believing the son agreed to keep the resident at the facility, while the son stated he requested hospital transfer and did not agree to keep his father at the facility. The facility's own policy required prompt notification and emergency response in the event of a significant change in condition, including calling 911 and notifying the physician and resident representative. However, documentation and interviews confirmed that no emergency transport was initiated, and the resident died approximately four hours after the initial decline was documented. There was also a lack of timely and accurate documentation by the medical director and nurse practitioner regarding the resident's care preferences and actions taken.
Failure to Obtain Provider Signatures on Medical Orders
Penalty
Summary
Facility staff failed to ensure that medical provider orders were signed by the prescribing providers when orders were entered into residents' clinical records by non-prescribing staff. Clinical record reviews revealed multiple instances where orders, including those for medications, laboratory tests, and therapies, were not signed by the medical providers who issued them. The facility's own policy requires that both admission and routine orders be reviewed, signed, and dated by the prescribing provider as soon as practicable to maintain an accurate medical record. However, several orders for different residents, including those for barrier cream, CPAP therapy, dietary modifications, medications such as oxycodone and levofloxacin, and laboratory tests, remained unsigned by the respective prescribers. Interviews with the Medical Director confirmed that they had given orders throughout the year but could not specify the last time they had signed orders entered by facility staff. The Director of Nursing was made aware of the issue but had not yet determined the full extent of unsigned provider orders at the time of the survey. The deficiency was identified through interviews, clinical record reviews, and examination of facility documentation.
Failure to Timely Provide Resident Records to Authorized Representative
Penalty
Summary
Facility staff failed to provide a copy of a resident's clinical record to the resident's representative within the required two working days after a request was made. The request was made by the resident's representative, who was documented in the clinical record as holding a Durable General Power of Attorney (POA) with explicit authorization to request, receive, and review the resident's medical and hospital records. Despite this documentation, the facility declined the request, citing a lack of supporting documentation to prove authority to access the records on the resident's behalf. The facility's documentation showed that the request was forwarded to the legal department, and a denial letter was sent to the representative, stating the request was incomplete due to missing proof of authority. An email from the Administrator reiterated the denial, specifying that proof of authority, such as a death certificate and identification, was required. The resident in question had expired while at the facility and was assessed as cognitively intact or borderline, with a BIMS score of 14 out of 15. The facility's own policy defined a personal representative as someone authorized under state or applicable law to act on behalf of the individual in making health care decisions and to exercise the individual's rights.
Failure to Promptly Notify Provider and Resident Representative of Significant Change in Condition
Penalty
Summary
Facility staff failed to promptly notify the medical provider after a resident with multiple complex medical diagnoses, including gastrointestinal disorders and diabetes, experienced a significant weight loss. The resident's weight dropped from 161.0 lbs to 139.2 lbs over a period of less than two months, which was identified as a nutritionally significant loss by the dietician. Despite this, there was no documentation that the provider was notified of the weight loss at the time it was first recorded, and the only related note was from the dietician nearly a month later. The Director of Nursing confirmed that no evidence of provider notification was found for the date of the significant weight loss. In a separate incident, staff did not promptly notify a resident representative when another resident experienced a notable decline in condition. The resident, who was assessed as cognitively intact, was documented as having increased somnolence, lethargy, clammy skin, swallowing problems, and shallow respirations over the course of several hours. Although the nurse practitioner was notified of some changes, there was no documentation that the resident representative was informed of the decline until more than two hours after the initial assessment of increased somnolence and other symptoms. Facility policy required prompt notification of the attending physician and resident representative in the event of significant changes in a resident's physical, mental, or psychosocial status, and for such notifications to be documented in the medical record. In both cases, the required notifications were either delayed or not documented, resulting in a failure to follow established procedures for changes in resident condition.
Failure to Timely Continue Hospital-Ordered Medication at Admission
Penalty
Summary
Facility staff failed to ensure that a medication ordered to be continued after hospital discharge was promptly ordered upon admission for a resident. Specifically, Prednisone, which was prescribed on a tapering schedule for ulcerative pancolitis with complications, was not ordered until the resident's second day at the facility. As a result, the resident missed a scheduled dose of Prednisone on their second day. There was no documentation provided or found to explain why this medication was not included in the admission medication orders. The resident was assessed as having intact or borderline cognition, with a BIMS score of 14 out of 15, and was able to make themselves understood and understand others. The hospital discharge summary clearly indicated the need for Prednisone to be continued, and the facility's policy required that physician orders be reviewed, verified, and transcribed to the medical record upon admission. Despite this, the order for Prednisone was not written until the second day, to be started on the third day, resulting in a missed dose.
Failure to Develop and Implement Baseline Care Plans for New Admissions
Penalty
Summary
Facility staff failed to develop and implement baseline care plans within 48 hours of admission for three residents, as required by facility policy. For one resident with multiple complex diagnoses including sepsis, diabetes, sleep apnea, anxiety, depression, dementia, and COVID-19, no baseline care plan was found in the clinical record. This resident was also noted to have severe cognitive impairment, incontinence, a colostomy, pressure ulcers, surgical wounds, and was on isolation. Despite requests, the Director of Nursing (DON) was unable to provide the baseline care plan, stating that such plans were kept on paper by unit managers but could not be located. Similarly, another resident with diagnoses including schizophrenia, depression, diabetes, COVID-19, hypertension, and colon cancer, and who was at risk for pressure ulcers and had a surgical wound, also did not have a baseline care plan in the record. This resident experienced frequent pain and was on multiple medications, including opioids, antipsychotics, antidepressants, and diuretics. A third resident, assessed as having intact or borderline cognition, also lacked a baseline care plan in their clinical record. In all cases, the DON and facility leadership confirmed that the required baseline care plans could not be found, despite the facility's policy mandating their development and implementation within 48 hours of admission.
Failure to Develop and Implement Comprehensive Care Plan
Penalty
Summary
Facility staff failed to develop and implement a comprehensive, person-centered care plan for one resident. The resident had multiple diagnoses, including a right hip fracture with surgical repair, protein calorie malnutrition, diabetes, chronic kidney disease, anemia, breast cancer, and hypertension. The Minimum Data Set (MDS) assessment indicated mild cognitive impairment, frequent incontinence, severe pain interfering with daily activities, insulin injections, risk for pressure ulcers, a surgical wound, and ongoing therapy services. The Care Area Assessment (CAA) worksheets identified the need for care plans addressing vision, communication, functional abilities, urinary incontinence, falls, pressure ulcers/injury, and pain. Upon review, the resident's care plan only included focuses for COVID-19, activities, discharge planning, nutrition, and do not resuscitate orders, with no evidence of care plans for the other identified needs. When asked, the Director of Nursing was unable to provide a comprehensive care plan and acknowledged a miscommunication regarding responsibility for care plan development. The facility's policy requires an individualized, person-centered plan of care developed by the interdisciplinary team, but this was not followed for the resident in question.
Failure to Provide Ordered Respiratory Care and Oxygen Therapy
Penalty
Summary
Facility staff failed to provide necessary respiratory care for a resident with a diagnosis of acute respiratory failure with hypoxia. The resident had a physician's order for oxygen at 2 liters via nasal cannula at bedtime for shortness of breath, as well as a hospital discharge summary indicating the need for continued use of a flutter valve breathing device after discharge. However, the order for the flutter valve was not transcribed into the resident's physician order summary, and the resident reported not having the device since leaving the hospital. Staff interviews confirmed that the resident was not using a flutter valve. Additionally, although the resident's baseline care plan and physician's order summary included an order for oxygen at bedtime, there was no oxygen concentrator observed in the resident's room, and both the resident and staff confirmed that oxygen had not been used since admission from the hospital. Despite this, the electronic treatment administration record showed that staff had been initialing oxygen as being administered per the physician's order. These findings were discussed with facility leadership, but no further information was provided prior to the survey exit.
Failure to Ensure Availability and Proper Administration of Prescribed Medication
Penalty
Summary
Facility staff failed to ensure that prescribed medications were available to meet residents' needs when a Narcan nasal spray, dispensed by the pharmacy for a specific resident, was administered to another resident without proper documentation or replacement. The nurse practitioner administered two doses of Narcan nasal spray to a resident who did not have an order for it, and the staff could not identify which resident's medication was used. The Narcan nasal spray was not part of the facility's as-needed medication stock, which only included injectable Narcan, indicating that the nasal spray had been specifically dispensed for an individual resident. Interviews with staff revealed that the nurse practitioner obtained the Narcan nasal spray directly from the medication cart, and the staff were unable to provide evidence that the pharmacy was notified or that the medication was replaced for the intended resident. The Director of Nursing confirmed the lack of documentation and inability to identify the original recipient of the Narcan nasal spray, resulting in a failure to ensure the medication's availability for the resident it was prescribed to.
Incomplete and Inaccurate Clinical Record Documentation for Resident at Time of Decline and Death
Penalty
Summary
Facility staff failed to maintain complete and accurate clinical records for one of nine sampled residents. The resident was assessed as having intact or borderline cognition and was able to communicate effectively. On the day of the resident's decline and subsequent death, documentation was incomplete and inaccurate: a nurse's note indicated administration of two doses of Narcan without specifying the route, the oxygen device, or the amount administered. Vital signs were documented at a time when they were not actually obtained, and the nurse confirmed that the recorded time was incorrect. Additionally, the clinical record lacked progress notes from the nurse practitioner or physician for the day of the resident's decline and death. Further review revealed that the nurse practitioner’s note was not provided until the afternoon of the following day and did not include times for when certain vital signs were obtained. The note also contained a respiratory rate documented after the resident's recorded time of death. The facility's policy required accurate and timely documentation of procedures and resident responses, which was not followed. The absence of a progress note from the Medical Director for the day in question was also noted, despite the Medical Director reporting involvement in care decisions and attempted communication with the resident's family.
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 9 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Roanoke
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| South Roanoke Nursing And Rehabilitation | 0.9 mi | ★★★★★ | 0 | 0 |
| Friendship Health And Rehab Center - South | 1.9 mi | ★★★★★ | 0 | 0 |
| Old Southwest Health And Rehabilitation | 2.7 mi | ★★★★★ | 0 | 0 |
| Raleigh Court Health And Rehabilitation Center | 2.9 mi | ★★★★★ | 0 | 0 |
| Brandon Oaks Nursing And Rehabilitation Center | 4 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.