Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Thalia Gardens Rehabilitation And Nursing during CMS and state inspections, most recent first.
Surveyors found that the facility did not ensure monthly drug regimen reviews by a licensed pharmacist were documented or acted upon for multiple residents with complex medical and psychiatric conditions. Records for several residents showed no monthly pharmacy reviews for extended periods and no documentation of staff responses to pharmacist-identified irregularities, even when PRN psychotropic and opioid medications were frequently administered. The DON reported that she did not know the location of the monthly reviews, that the facility could not provide them, and that no process or system was in place to respond to pharmacist-identified irregularities, including those requiring urgent action.
The governing body failed to ensure an effective QAPI program and overall management systems, resulting in multiple unresolved deficiencies in environmental services, sanitation, infection control, and medication storage and administration that affected all residents’ quality of life. Resident Council minutes and grievance logs documented ongoing complaints about inadequate linens and delayed laundering of personal clothing, while surveyors observed large amounts of unfolded clean laundry and other unsatisfactory conditions in the laundry area. Significant turnover in key leadership roles, including a new DON, Social Services Director, HR Director, and Maintenance Director, coincided with persistent maintenance and pest control issues. The facility also failed to notify the State agency when a fire watch was initiated after fire panel trouble alarms, and surveyors found the facility lacked an effective staff training program on required topics such as QAPI, effective communication, and behavioral health.
The facility failed to maintain an effective QAPI program for most of the review period, with no documentation of QAPI meetings, no Performance Improvement Plan, and no active Performance Improvement Projects despite multiple identified system issues. Resident Council minutes and grievance logs showed that administration was aware of ongoing concerns from residents and families that persisted without resolution. The Assistant Administrator reported no available QAPI documentation from prior leadership and confirmed that expected monthly QA and quarterly QAPI meetings were not occurring as required. Surveyors also found the facility lacked an effective staff training program, including required training on QAPI, effective communication, and behavioral health, contributing to substandard quality of care findings and an extended survey.
The facility lacked a functioning QAPI program and active performance improvement projects for most of the four reviewed quarters, affecting all residents. Surveyors conducting an extended survey for substandard quality of care found no documentation of QAPI activities from the prior administrator and no current performance improvement projects. An assistant administrator reported having no QAPI information before early 2026 and stated that, although the facility was expected to hold monthly Quality Assurance and quarterly QAPI meetings, three of four quarters reviewed contained no QAPI information. Facility leadership, including the administrator, assistant administrator, regional nurse consultant, and DON, were informed of these findings during survey debriefings.
Facility staff did not maintain required documentation of staff COVID-19 vaccination education, offers, or vaccination status. When surveyors requested Infection Control information for staff, the IP reported she had not been directed to track staff COVID-19 vaccination status and had no records showing that staff were educated on COVID-19 vaccine benefits and risks, offered the vaccine, or given information on how to obtain it. In a subsequent interview, facility leadership, including the Administrator and DON, did not provide any additional information regarding staff COVID-19 vaccination data.
The facility failed to maintain an effective QAPI training program for all staff, as evidenced by missing QAPI content in orientation materials, use of an outdated annual education calendar without QAPI, and lack of documented QAPI education for sampled RNs, an LPN, and CNAs. The staff development coordinator reported she did not provide QAPI training and believed it was handled by HR, while the HR director confirmed QAPI was not included in new-hire orientation. Limited computer-based QAPI training records showed only some employees from various disciplines had completed QAPI modules, with no clear evidence that all staff were trained or that training was updated after new QAPI goals were set.
Surveyors found that the facility failed to maintain an effective training program that included required behavioral health education for all staff. When training records for several RNs, an LPN, and CNAs were reviewed, there was no documentation of behavioral health training, and interviewed staff could not recall receiving such training, only noting that some education occurred in person or on the computer. The Staff Development Coordinator acknowledged having no evidence that employees had received behavioral health care training, and facility leadership was informed that required behavioral health training was not documented or effectively implemented.
Staff failed to maintain a safe, clean, and homelike environment across all units, with multiple residents reporting large flying roaches in rooms and common areas, difficulty sleeping due to pests, and unclean shower rooms. Surveyors observed live and dead roaches in bathrooms, a wasp nest at a resident window with a gap into the room, leaking toilets with pans catching water, stained and bulging ceiling tiles over beds, damaged doors and thresholds, and filthy floors with food debris and encrusted brown substances in several rooms. On one unit, many semi-private rooms were very small, with one bed abutted against the wall, limiting access for care and cleaning and reducing privacy for residents and visitors; staff and visitors confirmed these concerns. Hallways were cluttered with equipment, furniture, and supplies, and an emergency bathroom pull cord used by an independently ambulating resident did not activate the nurse call system. Shower rooms and the laundry area were cluttered and soiled, with used dressings, soiled items, and large amounts of unfolded and soiled laundry present, and the kitchen had missing floor tiles at the entrance, creating a trip hazard.
Staff failed to ensure that large wall clocks in the rooms of four cognitively impaired residents were functioning and displayed the correct time. Over several days, surveyors repeatedly observed clocks stuck at the same time or showing inconsistent, incorrect times while residents were in their rooms, either in bed or in wheelchairs. Staff entered these rooms multiple times to deliver care, pick up meal trays, and provide ice and water but did not address or report the non-functioning clocks. Some residents verbally indicated that the clocks were wrong or that they did not know the time when looking at the clocks. The unit manager and DON later acknowledged that accurate clocks are important for resident orientation and that staff should have noticed the problem.
Facility staff did not ensure that residents knew they could review the survey results binder or where it was located. In a resident group meeting with the council president and several residents, all attendees reported they were unaware of their ability to access the survey book and could not identify its location, with one suggesting it might be behind the nurse’s station. The Activities Director stated that residents were educated at each resident council meeting about the binder’s location and that this was documented in council minutes, but no approach was described for updating residents going forward. When these findings were presented to the Interim Administrator, DON, ADON, and a corporate nurse consultant, they offered no comments or concerns.
The facility failed to ensure that a resident with dementia and limited English proficiency, and her family, were invited to and able to participate in person-centered care plan meetings, despite a care plan that emphasized communication needs and family involvement. Medical record review confirmed that care plan meetings occurred but did not document resident or family attendance, while the resident’s daughter reported never being invited. In a separate case, the facility did not update another resident’s care plan after her clinical status changed: although an indwelling Foley catheter order had been discontinued months earlier and staff reported the resident was now incontinent without a catheter, the care plan continued to list an active catheter problem with related interventions, and also continued hospice-related goals and interventions after hospice services had been certified as ending because the resident was no longer terminal.
Facility staff did not consistently post required daily nurse staffing information in a prominent, accessible location for residents, staff, and visitors. Over several days of surveyor observation, no nurse staffing postings were seen on the units or at the receptionist’s desk, and multiple alert residents and a regular visitor reported not knowing where to find this information. The Administrator was unsure of the posting location, and the Assistant Administrator directed surveyors to a Human Resources hall bulletin board displaying only an “as worked” schedule for a single shift, while the usual frame at the receptionist’s desk was empty and being replaced. The staffing coordinator reported she typically posted staffing daily and kept prior postings, but available records covered only part of the preceding months and showed numerous missing dates and incomplete entries, including absent census data and blank RN slots, contrary to facility policy requiring daily shift-specific posting of nursing personnel providing direct care.
Surveyors found that staff failed to discard expired Humulin R insulin on two of three medication carts. During separate medication cart audits on two units, an LPN on each unit identified a bottle of Humulin R insulin that had been open longer than the 28-day discard period and acknowledged that the insulin was no longer good and should have been discarded. A subsequent interview with facility leadership did not provide additional information regarding these expired insulin vials.
Surveyors found that the facility failed to conduct and document required QAPI activities, with no QAPI records for most of the review period and no active Performance Improvement Projects. The Assistant Administrator reported that current leadership could not locate prior QAPI documentation and that expected monthly QA and quarterly QAPI meetings were not evidenced. Review of maintenance, pest control, Resident Council, and grievance records showed that administration was aware of ongoing resident and family concerns that persisted without resolution. The survey also identified an ineffective staff training program on QAPI, communication, and behavioral health, and there was no documentation that the governing body was informed of or acting on the identified issues.
A resident with Alzheimer’s disease, severe cognitive impairment (low BIMS score), and communication difficulties was care planned for supervision with toileting and partial assistance with bathing, yet was observed ambulating independently to a shared bathroom where the emergency pull-cord system was not functioning. Surveyors found that pulling the bathroom emergency cord did not activate lights or an alert at the nurse’s station, and a CNA was unaware whether the cord signaled at the station. This confirmed that a working emergency call system was not available in the bathroom and bathing area used by the resident.
Facility staff did not maintain an effective training program for RNs, LPNs, CNAs, and other employees, with no documented education on behavioral health care or communication, including communication with a Spanish-speaking resident. Staff reported they had not been trained to communicate with this resident and instead relied on the family and a Spanish-speaking ADON to translate. The Staff Development Coordinator confirmed the absence of training records and there were no communication tools or established communication process in the resident’s room. Facility leadership was informed that required staff training, including communication training, was not effectively maintained or documented.
A cognitively intact resident with multiple medical conditions repeatedly reported that personal items such as soaps, lotions, clothing, and perfume were going missing and stated that she and her daughter had informed staff and prior administrators many times without action. CNAs acknowledged awareness of the resident’s allegations but were unsure whether these concerns had been reported, despite the DON’s stated expectation that a grievance be completed whenever items were reported missing, lost, or stolen. Only one grievance was documented, and when the findings were presented to the administrative team, they offered no comments or concerns.
Facility staff failed to complete required pre-employment screening, resulting in multiple employee files lacking sworn statements, state police criminal background checks, or verification of licenses/certifications. An internal audit had already identified missing documents, but no corrective action was taken and the issue was not brought to QA. One employee was hired and allowed to work before the criminal background report was obtained and reviewed; when the report was later received from a sister facility, it showed barrier crimes including assault of a family member, malicious wounding, and indecent exposure. The Regional HR Director reported prior problems with the state police online system and reliance on another facility’s HR staff to obtain background checks, and leadership offered no additional information during interviews.
Staff failed to maintain a safe environment by leaving kitchen floor tiles missing at the kitchen entrance and by not repairing a damaged dining room entry door. The removed tiles were stored on a pellet warmer near the exposed area, and the Director of Maintenance acknowledged that the missing tiles created a potential trip hazard. The dining room entry door was observed splitting apart with the bottom hinge detached, and the door was being kept propped open; the Director of Maintenance stated the door could fall if staff attempted to close it, identifying it as a hazard. Facility leadership reported no additional concerns when interviewed about these conditions.
The facility failed to maintain an effective pest control program, as multiple cognitively intact residents reported large flying roaches in their rooms, bathrooms, and shower areas, and a visitor also reported seeing roaches. Surveyors directly observed roaches on a bathroom floor in one resident’s room, along with standing water and roach bait houses, after the resident had previously complained to housekeeping about room cleanliness and roaches. Two residents in another room reported wasp nests by their window for several weeks, and surveyors confirmed two nests and a gap between the screen and window that allowed insect entry. Leadership was informed of an additional gap at a hallway-to-courtyard threshold that could admit insects, and it was determined that pest control services had lapsed for two months due to unpaid invoices, while pest control logs had been destroyed and left blank, omitting documentation of roach sightings and the wasp nests.
A Spanish‑speaking resident with dementia, severe cognitive impairment (BIMS 5/15), and multiple ADL assistance needs had a care plan identifying a communication problem, a preference for Spanish, and an intervention to provide a translator as necessary. The H&P documented a language barrier and noted that one of two nurses could speak Spanish, and the DON stated an interpretation document was kept at the nurse’s station. However, CNAs caring for the resident reported they were not aware of any interpreter services or interpreter information, demonstrating that interpreter services were not effectively available or communicated to staff to support this resident’s identified communication needs.
Facility staff did not ensure that residents knew where to find the list of contact names, addresses, and phone numbers for the ombudsman, adult protective services, and other State agencies. In a resident group meeting with the Resident Council President and four other residents, all five reported they did not know how to contact these agencies. The Activities Director later stated that residents are educated at each resident council meeting about the ombudsman and the location of the contact information, and that this is documented in council minutes. When these findings were presented to the Interim Administrator, DON, ADON, and Corporate Nurse Consultant, they did not offer comments or concerns.
A resident with intact cognition but extensive ADL dependence and multiple chronic conditions, including chronic respiratory failure and COPD, experienced an acute episode of hypoxemia with O2 saturations in the 70–80% range and chills, prompting an acute provider visit and respiratory treatments. Although facility policy required prompt notification of the resident’s representative and maintenance of current contact information after significant changes in condition, staff did not document any notification or attempted notification of the resident’s POA or secondary emergency contact at the time of the event. Subsequent surveyor calls showed that listed phone numbers were not working or could not receive voicemail, and the secondary contact reported not receiving any call, while the resident later supplied an updated number; the DON confirmed there was no record of contact attempts and that she had not been informed of the change in condition.
A resident with moderately impaired cognition and a history of malignant neoplasm of the colon reported that multiple personal items, including beverages, toiletries, and bifocals, had been missing for several months and that she had informed various staff, including the DON and nurse aides. However, only a single grievance form was found, documenting missing Ensure but not the other items, and the Social Worker stated she was unaware of the missing items until the surveyor’s inquiry. This reflects a failure by staff to properly initiate and document a grievance for all reported missing items and to ensure the resident’s grievance was fully recognized and addressed.
A resident with a history of stroke, aphasia, and anxiety, and with severely impaired cognition per BIMS, had a PRN Lorazepam 0.5 mg G-tube order written without a stop date and used for more than 14 days without documented prescriber re-evaluation. The clinical record lacked evidence that the physician or other prescribing practitioner assessed the ongoing appropriateness of this psychotropic medication, even though the care plan identified anti-anxiety drug use and outlined monitoring for adverse reactions.
Facility staff failed to timely report an allegation of abuse involving a resident with moderately impaired cognition and a diagnosis including malignant neoplasm of the colon. The resident reported being shoved back into bed by staff after nearly falling, and a facility synopsis documented that she was shoved twice by two staff members while being assisted to bed. The incident date and the report date in facility records showed a five-day delay before the allegation was reported to state agencies. Staff interviewed during the survey stated they were not aware of the incident, and leadership provided no additional information about the delay, resulting in a deficiency for failure to promptly report suspected abuse.
Facility staff failed to accurately complete an admission MDS when a resident was incorrectly coded as receiving an anticoagulant with a documented indication, despite no corresponding physician order, care plan entry, or physician progress note confirming anticoagulant use. The same MDS also recorded a BIMS score indicating intact cognition, but the primary deficiency involved the inaccurate documentation of high-risk drug class use.
Staff failed to follow a physician’s order for continuous O2 at 3 L/min via nasal cannula for a cognitively intact resident with chronic respiratory failure, COPD, and multiple comorbidities. Over at least three days, the resident was repeatedly observed in bed with the O2 concentrator set at 5 L/min, and the resident reported earlier breathing difficulty. An RN later verified the physician’s order for 3 L/min and acknowledged that the flow rate had been at 5 L/min for several days before adjusting it back to the ordered rate.
A resident with anxiety and moderately impaired cognition had a one-time order for Ativan 0.5 mg. During a medication pass, the ADON obtained a 1 mg Ativan tablet from the stat box for an RN to administer. The RN opened the single-dose package and, while wearing gloves, broke the 1 mg tablet in half by hand, wasting one half and giving the other half to the resident. Facility leadership later stated that policy requires use of a tablet splitter to ensure dose accuracy and minimize contact with the scored tablet, indicating that proper medication administration technique was not followed.
Facility staff failed to provide required discharge instructions and documentation to two residents who left AMA. One resident with multiple acute and chronic conditions and moderate cognitive impairment left shortly after admission, and nursing notes only recorded that the resident left with family and signed AMA paperwork, with no evidence of discharge instructions or a recapitulation of the stay being provided, consistent with the DON’s statement that discharge summaries are not given for AMA discharges. Another resident with a hip fracture and intact to moderately impaired cognition was discharged by staff after the son arrived unexpectedly, with non‑narcotic medications provided but no documented discharge orders, and the receiving facility reported that it received only a face sheet and PASRR because the discharging facility stated it would not send additional records due to the AMA status, leaving the admitting facility without an H&P, clinical notes, or a medication list.
A resident with a history of stroke, aphasia, anxiety, severely impaired cognition (BIMS 4/15), and total dependence for ADLs was not provided necessary nail care. The resident was observed in bed with fingernails approximately 1.75 inches beyond the fingertips, discolored, and with scratches on the thighs and right arm. A CNA later acknowledged that the resident’s nail care had been overlooked.
Failure to Conduct and Act on Monthly Pharmacist Drug Regimen Reviews
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a licensed pharmacist conducted and documented monthly drug regimen reviews (DRRs) for multiple residents and the facility’s failure to respond to pharmacist-identified irregularities according to established policies and procedures. For several residents, surveyors found no documentation in the clinical record of monthly pharmacist reviews or of the facility’s response to any identified irregularities. The Director of Nursing (DON) repeatedly stated that she did not know where the monthly DRRs were located, did not have them, and that the facility was unable to provide this information during the survey period. For one resident with diagnoses including a right femur neck fracture, alcoholic cirrhosis, hypertension, and depression, the quarterly MDS showed moderately impaired cognition. Review of this resident’s clinical record from late April revealed no documentation of the facility responding to irregularities identified by the pharmacist during monthly DRRs. When interviewed, the DON stated she did not know where the monthly DRRs were and could not provide them, and no additional information was produced by the end of the survey. Another resident with type 2 diabetes, chronic kidney disease, muscle weakness, and hypertension, and with severely impaired cognition per the admission MDS, also had no documented facility response to pharmacist-identified irregularities in the progress notes, and the DON again reported that the monthly DRRs could not be located or provided. For two additional residents, one with a stroke and aphasia and another with cataracts and anxiety, surveyors found that no monthly pharmacy reviews were documented in their clinical records over a 12‑month period. In the first of these cases, the resident had severely impaired cognition and active orders for PRN lorazepam via G‑tube and multiple PRN morphine doses for varying levels of pain or distress, which were frequently administered without documented pharmacy reviews or recommendations. The last pharmacy review in this resident’s record was dated more than a year earlier, and the last recommendation several months earlier. For the resident with cataracts and anxiety, no monthly pharmacy reviews were documented for the same 12‑month period, with the last review and recommendation both dated in the prior year. The DON acknowledged that she had only recently started a pharmacy review and recommendation binder and could not provide further information. The facility also failed to implement and follow policies and procedures for responding to pharmacist-identified irregularities, including those requiring urgent action, for two other residents. One resident with severe cognitive impairment and multiple psychiatric and neurologic diagnoses, including non‑Alzheimer’s dementia, seizure disorder, bipolar disorder, schizophrenia, and psychotic disorder, had no documentation in the progress notes of the facility responding to irregularities identified by the pharmacist during monthly DRRs. Another resident with extensive medical conditions, including chronic respiratory failure with hypoxia, diabetes with autonomic polyneuropathy, lymphedema, cirrhosis, NASH, hepatic fibrosis, COPD, morbid obesity, ventral hernia with obstruction, gastroparesis, panic disorder, chronic kidney disease, major depressive disorder, and anxiety disorder, similarly had no documentation of facility responses to pharmacist-identified irregularities. In both cases, the DON stated she did not have a process for responding to pharmacist-identified irregularities and had not developed a system since beginning employment, and the facility was unable to provide the missing DRRs or additional information before the survey concluded.
Failure of Governing Body to Implement Effective QAPI, Oversight, and Reporting Systems
Penalty
Summary
The governing body failed to ensure an effective QAPI (Quality Assurance Performance Improvement) program and overall management systems, despite being legally responsible for establishing and implementing facility policies and appointing a properly licensed administrator. Surveyors identified multiple deficient practices across environmental services, sanitary and clean building conditions, infection control practices, and medication storage and administration, which affected all residents’ quality of life. The facility had no documentation of a Performance Improvement Plan and had not held QAPI meetings for three of four quarters. Resident Council minutes and grievance logs showed that residents and families had repeatedly raised concerns, including inadequate linens and delays in washing and returning personal clothing, and these issues continued for several months without resolution. During the survey period, the facility was undergoing significant administrative turnover, with a newly hired DON, Social Services Director, Human Resources Director, and Maintenance Director, and several new managers employed for a month or less. Long-term residents complained about facility conditions, and staff interviews confirmed ongoing laundry problems. Observation of the laundry department revealed mounds of clean, dry laundry waiting to be folded and other unsatisfactory conditions. Review of maintenance and pest control logs revealed additional unresolved issues. The facility also failed to notify the State survey and certification agency when a fire watch was initiated after trouble alarms on the fire control panel, even though a fire watch was conducted and later lifted once the system was repaired. Surveyors determined that the facility lacked an effective training program for employees on required topics, including QAPI, effective communication, and behavioral health, and that the governing body should have been made aware of the issues identified during survey debriefings.
Failure to Maintain Effective QAPI Program and Staff Training
Penalty
Summary
The facility failed to implement and maintain an effective QAPI program and QAA activities for three of four quarters reviewed, affecting all residents. Surveyors found no documentation that multiple identified system issues, including those related to maintenance and pest control, were being discussed during QAPI meetings. There was no documentation of a Performance Improvement Plan and no QAPI team meetings for most of the review period. Review of Resident Council minutes and grievance logs showed that administration was aware of ongoing issues and concerns voiced by residents and families, yet these issues continued for several months without resolution. Substandard quality of care was identified, prompting an extended survey. During interviews, the Assistant Administrator reported having no information about QAPI activities prior to January 2026 and stated that the current administrative staff could not locate any QAPI documentation from the previous administrator. She indicated that the facility was expected to meet monthly for Quality Assurance and quarterly for QAPI, but confirmed there was no current Performance Improvement Project in place. The extended survey also determined that the facility did not have an effective training program, with failures in required staff training on QAPI, effective communication, and behavioral health. These findings demonstrated that the facility did not have an operational, documented, or effective QAPI and staff training system in place during the review period.
Failure to Maintain Comprehensive QAPI Program and Performance Improvement Projects
Penalty
Summary
The facility failed to implement and maintain a comprehensive QAPI (Quality Assurance Performance Improvement) program, including performance improvement projects, for at least three of four reviewed quarters, affecting all residents. During a survey in which substandard quality of care was identified and an extended survey was initiated, surveyors determined that the facility did not have evidence of ongoing QAPI activities or current performance improvement projects. In an interview, the Assistant Administrator reported having no information about QAPI prior to January 2026 and stated that the current administrative staff could not locate any documentation of QAPI activities from the previous administrator. She also stated that the facility was expected to meet monthly for Quality Assurance and quarterly for QAPI meetings, but four quarters of records were reviewed and three had no information. The Administrator and other leadership staff were informed of the substandard quality of care findings during end-of-day debriefings on multiple days of the survey. No specific resident medical histories or individual clinical conditions were described in the report; the deficiency was systemic, involving the absence of documented QAPI processes and performance improvement projects intended to monitor and improve care for all residents.
Failure to Document Staff COVID-19 Vaccination Education, Offers, and Status
Penalty
Summary
Facility staff failed to document COVID-19 vaccination information for staff members, including education, offers of vaccination, and vaccination status. During the Infection Control task on 4/23/26 at approximately 1:05 PM, surveyors requested the facility’s Infection Control information for staff. At 3:38 PM, the Infection Preventionist (IP) reported that she had not been directed to maintain staff COVID-19 vaccination status and therefore had no records of staff vaccination information. The IP further stated she had no documentation that any staff had been provided education on the benefits and potential risks of the COVID-19 vaccine, nor that staff had been offered the vaccine or given information on how to obtain it, because she had not been instructed to perform these activities. On 4/28/26 at 3:30 PM, during a final interview with the Administrator, Assistant Administrator, DON, Regional Nurse Consultant, and Regional MDS Consultant, the facility’s leadership team did not provide comments or additional information regarding staff COVID-19 data. No specific residents or their medical histories were mentioned in relation to this deficiency, and the report focuses solely on the lack of staff COVID-19 vaccination documentation and associated education and offering processes.
Failure to Maintain Effective QAPI Training Program for Staff
Penalty
Summary
The deficiency involves the facility’s failure to develop, implement, and maintain an effective training program for all staff on its Quality Assurance and Performance Improvement (QAPI) program. During an extended survey triggered by findings of substandard quality of care, surveyors determined that required QAPI training was not consistently provided to staff, including RNs, LPNs, and CNAs. Interviews with staff and review of training records for five sampled nursing staff members showed no documentation of QAPI education, and those staff members reported they could not recall receiving such training. The facility’s orientation materials, which covered topics such as employee benefits, health and safety, resident rights, infection control, and competencies, did not include QAPI. The Staff Development Coordinator stated she did not provide QAPI training and believed it was handled by Human Resources, while the Human Resources Director confirmed that QAPI was not part of new-hire orientation. The annual education calendar used by the Staff Development Coordinator was from 2017 and did not list QAPI as a topic. Later, the Staff Development Coordinator produced limited documentation of computer-based QAPI training, showing that 14 employees from various disciplines received QAPI in-service education in one month and that 117 employees had completed QAPI training assigned on a prior date; however, she was unsure if this list included all employees. There was no evidence of ongoing QAPI training after new QAPI goals were established, and no additional education documents were available for the sampled staff.
Failure to Maintain Effective Behavioral Health Training Program for Staff
Penalty
Summary
The deficiency involves the facility’s failure to develop, implement, and maintain an effective training program that included required behavioral health care and services education for all staff, as identified during a survey that resulted in a finding of Substandard Quality of Care and an extended survey. During the survey, the survey team requested training schedules and documentation from the Staff Development Coordinator, who reported she had no evidence that behavioral health training had been provided to all staff, stating only that some staff had received training on the computer. A list of employees, including RNs, LPNs, CNAs, and other disciplines, was requested for review. Review of the educational records for five sampled nursing staff members (two RNs, one LPN, and two CNAs) showed no documentation of behavioral health training. When these staff members were interviewed, they reported they could not remember receiving behavioral health training and stated that some trainings were done in person and some on the computer, without being able to identify behavioral health content. The Staff Development Coordinator confirmed she did not have documentation of any employees receiving behavioral health care training. During end-of-day debriefings, facility leadership, including the Administrator, Assistant Administrator, Regional Nurse Consultant, and Director of Nursing, were informed that the facility lacked an effective training program regarding required topics, including behavioral health, and that education/training documents were maintained by the Staff Development Coordinator.
Widespread Environmental, Pest, and Cleanliness Failures Across All Units
Penalty
Summary
Facility staff failed to maintain a safe, clean, comfortable, and homelike environment across all three units, as evidenced by widespread pest infestations, environmental disrepair, and unclean resident care areas. Multiple cognitively intact residents reported large flying roaches in their rooms and throughout the building, including on walls and ceilings, making it difficult to sleep and causing some to question whether they should avoid showering. Residents also reported that pest control had not treated their rooms. Surveyors directly observed roaches in resident bathrooms and rooms, including live and dead roaches on floors, and facility leadership acknowledged that a gap at a courtyard threshold served as an entry point for bugs. A wasp nest with egg sacs and a live wasp was observed between a resident room window and screen, with a gap allowing air and insects into the room; residents stated the nest had been present for about three weeks and that staff were aware. The physical environment on the Fine Unit and other areas was in disrepair and not maintained in a clean or homelike condition. Numerous ceiling tiles in halls and resident rooms were stained, bulging, loose, or missing, including heavily stained tiles over residents’ beds. Walls, doors, and thresholds were damaged, including a wall in disrepair between rooms, a resident room door with frayed and swollen edging, and a courtyard threshold removed in a way that left a gap and uneven flooring. Bathrooms had leaking toilet cisterns with pans catching actively dripping water, heavily stained and loose tiles, and containers under valves collecting standing water that staff acknowledged likely attracted roaches. In several rooms, floors were described and observed as filthy, sticky, and covered with trash, food debris, and accumulated brown or yellowish substances on floors, walls, and cove bases. In at least two rooms, staff and the Housekeeping Director stated that residents frequently spit on the floor, and that encrusted brown substances could not be removed with current cleaning methods. Resident rooms on the Fine Unit were small, with many semi-private rooms having one bed abutted directly against the wall near the door, leaving no space on one side of the bed. Residents were observed lying in beds with body parts resting on the walls, and stains were noted on walls where residents’ heads rested. Staff, including CNAs and housekeeping, reported difficulty providing care and cleaning around beds placed against walls, and a family member reported feeling cramped and lacking privacy when visiting a loved one in such a room. Visitors and residents commented that the Fine Unit rooms were much smaller and older than rooms on other units and that they had seen roaches in the building. The State Life Safety Inspector stated that beds should not be abutted against the wall, that the rooms were small, and that there should be enough room for stretchers to enter to assist either resident in an emergency. Shared and unit shower rooms were observed to be cluttered and unclean. On one unit, the shower room bathroom contained multiple shower chairs, a pair of shoes on the floor, a toilet covered in black plastic with a sign indicating it needed repair or replacement, and used latex gloves on the plastic and floor. A commode bucket with dried brown-looking substance and used items was found on a commode chair, and the shower area had brown substances on walls and floors, wet hair near the drain, and a wet washcloth on a shower bed. On another unit, the shower room was full of clutter, including shower chairs with bags of soiled clothing, and a bathtub filled with incontinence products, towels, shirts, dust, and sheets. The shower floor and tiles appeared soiled and dusty, water was constantly dripping from the shower head, and a used saturated dressing with pink and yellow secretions was observed at the shower drain. The water closet in that shower room was extremely cluttered, and the toilet was sealed with plastic and tape with an “out of order” note. Hallways and common areas were not maintained free of clutter and obstructions. On the Fine Unit, furniture, equipment, and supplies were stored on both sides of a hallway near resident rooms, including a mattress, rollator, multiple cardboard boxes, pallets of boxed items, a large trash can, and a rolling hamper. On another hall, wheelchairs, a shower bed, chairs, oxygen concentrators, mats, positioning devices, a laundry cart, a Hoyer lift, and a wheelchair were stored in the corridor across from resident rooms and near a shower room. A family member reported concern that hallway clutter would make it hard to evacuate a resident in an emergency and that her visually impaired loved one, who ambulates and may wander, could fall or be injured due to the clutter. Emergency call systems were not consistently functional in resident-accessible bathrooms. In a shared bathroom used by several rooms, including one resident who ambulated independently to the bathroom, the emergency alarm pull cord did not light up or send an alert to the nurse’s station when tested on two separate days. A CNA at the nurse’s station stated he was not aware whether the emergency pull-cord alarm sent an alert. This non-operable emergency call system remained in use by a resident who was observed throughout the survey ambulating independently to that restroom. Individual resident rooms showed repeated failures to maintain cleanliness and a homelike environment. One resident’s room was repeatedly observed with a filthy floor, trash debris, and an exposed outlet with sharp edges near the HVAC unit; a reddish substance resembling vomit was seen on the floor until housekeeping was called to clean it. Another resident’s room had a sticky floor, food accumulated around the perimeter, dark yellow/brown substances on the floor, and copious brown drippage behind the headboard down to the floor; the resident stated she had informed housekeeping about the dirt and roaches in her room and bathroom. In another room, a resident was observed with a fall mat between beds that had debris and footprints, a soiled glove on the floor, and a floor that was noticeably dirty and in need of mopping. In yet another room, the wall under the window was dirty and needed painting, and crusty material was present on the floor, wall, and baseboard behind the bed; the resident stated staff never cleaned the room and that she had to look out at the “nasty mess.” Support service areas were also not maintained in a clean, orderly condition. The laundry room contained washed clothing left in washers, dryers full of clothing waiting to be folded, and tables piled halfway to the ceiling with unfolded clothing. Shelves held many plastic bags of clothing identified by the laundry aide as personal belongings to be donated. The laundry room floors were grossly soiled, and a large bin of soiled laundry contained pillows with yellowish-brown substances mixed in with soiled bed linens. In the kitchen, floor tiles were missing at the entrance, and the removed tiles were placed on a pellet warmer next to the missing area. The Director of Maintenance stated the tiles had been removed a couple of months earlier and acknowledged that the missing tiles could be an area where staff could trip and fall. Throughout the survey, residents, family members, visitors, and staff consistently reported concerns about roaches, room size and layout, clutter, and cleanliness. Residents described roaches crawling on ceilings and walls, flying roaches present day and night, and worsening infestations since construction began. Staff interviews confirmed difficulty providing care and cleaning in cramped rooms with beds against walls and acknowledged environmental issues such as gaps at thresholds that allowed insect entry and leaking plumbing that contributed to standing water. Despite these observations and reports, during multiple debriefings and final interviews, the administrative team either made no comments, voiced no concerns, or did not provide additional information regarding the identified environmental and cleanliness deficiencies.
Failure to Maintain Accurate Resident Room Clocks for Orientation Needs
Penalty
Summary
Facility staff failed to reasonably accommodate the needs of four residents by not ensuring that the large wall clocks in their shared bedrooms were working and displayed the correct time. For one resident with anemia, hypertension, anxiety, and depression, the clock in the room consistently displayed 5:51 over multiple days and times, with the second hand not moving. This resident was observed in the room on several occasions, either in bed or in a wheelchair, while the clock remained incorrect. Staff members entered the room repeatedly to pick up food trays, deliver ice and water, and provide care, but no staff member addressed or corrected the non-functioning clock. A second resident with severe cognitive impairment had a wall clock that continuously displayed 4:20 over several days and at various observation times, with the hands not moving. This resident was observed lying in bed or sitting in a wheelchair while the clock remained inaccurate. As with the first resident, staff were seen entering the room for routine tasks such as tray pickup, ice and water delivery, and care provision, yet no one intervened to fix or report the incorrect clock. The unit manager later stated that clocks in residents’ rooms should be accurate for resident orientation and that staff should have noticed the problem. A third resident with severe cognitive impairment had a wall clock that showed varying, incorrect times across multiple observations, including 10:50, 1:38, 4:20, 11:34, and 2:02, without corresponding to the actual time. This resident was observed in the room in a wheelchair or in bed while the clock times changed inconsistently. During one interaction, when asked what time lunch was being served, the resident looked at the clock and stated she did not know. Staff were again observed performing routine tasks in the room without addressing the inaccurate clock. A fourth resident, with diagnoses including diabetes, cerebral infarction, hemiplegia, and aphasia and a BIMS score indicating severe cognitive impairment, had a wall clock that remained fixed at 2:47 over several days and times, with the hands not moving. This resident, observed both in bed and in a wheelchair, stated that the clock was wrong and did not work, yet staff entering the room for care and services did not correct or report the issue. Facility leadership and the DON acknowledged during interviews that clocks in residents’ rooms should be accurate and that staff should have observed that the clocks were not working.
Residents Unaware of Access to Survey Results Binder
Penalty
Summary
Facility staff failed to ensure that residents knew where the survey results binder was located or that they had access to it. During a resident group meeting held with the Resident Council President and four other residents who regularly attend, all five residents reported they were unaware they could review the survey book or had access to it, and none could identify its location; the council president speculated it might be behind the nurse’s station. A subsequent interview with the Director of Activities revealed that the facility’s position was that residents were educated at every resident council meeting on where to locate the survey results binder, and this education was documented in the resident council minutes, but no suggestions were offered on how residents would be updated going forward. In a final interview with the Interim Administrator, DON, Assistant DON, and Corporate Nurse Consultant, the surveyor conveyed these findings, and the administrative team made no comments and voiced no concerns.
Failure to Involve Resident/Family in Care Planning and to Update Care Plans After Status Changes
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a cognitively impaired resident and her family were invited to and able to participate in person-centered care plan meetings. The resident, who had Type 2 diabetes and Alzheimer’s disease, was assessed on a quarterly MDS with a BIMS score of 5/15, indicating severely impaired decision-making. Her care plan, revised on 1/28/26, documented dementia, a primary language of Spanish, and detailed communication interventions, including use of a translator as necessary and discussion of concerns with the resident and family. Despite this, her daughter reported never receiving an invitation to or attending a care plan meeting, and review of the medical record showed two care plan meetings with no documentation that the resident or family were present. A second deficiency concerns the facility’s failure to review and revise another resident’s person-centered care plan when her status changed. This resident had a history of stroke with aphasia and anxiety, and a Significant Change MDS with a BIMS score of 4/15, indicating severely impaired decision-making, and was coded as dependent for all ADLs. Observation on 4/21/26 found the resident in bed without a bedside drainage bag, and a CNA stated that the resident had not had an indwelling catheter for at least two months and was incontinent of urine, confirming this by examining the peri area. Medication and treatment orders showed an indwelling Foley catheter order from 8/03/25 that was discontinued on 10/23/25, with no rationale documented for the discontinuation. Despite the discontinuation of the catheter order months earlier, the resident’s care plan still contained an active problem dated 6/12/25 stating that she currently had a 16 French indwelling catheter with a 10 ml balloon for end-of-life care, with related goals and interventions for catheter management. Additionally, the care plan included a hospice problem dated 9/08/25 with goals and interventions related to hospice services, while a hospice certification note dated 2/18/26 documented that hospice services would end on 2/21/26 because the resident was no longer considered terminal and would be discharged from hospice. These discrepancies show that the care plan was not reviewed and revised to reflect the resident’s current status regarding catheter use and hospice enrollment.
Failure to Post Daily Nurse Staffing Information in Accessible Locations
Penalty
Summary
Facility staff failed to ensure that daily nurse staffing information was posted in a prominent and readily accessible location for residents, staff, and visitors. During multiple days of survey observations, surveyors did not see any daily nurse staffing postings on the nursing units or at the receptionist’s desk. Group and individual interviews with alert and oriented residents revealed that they did not know where to find information about daily nurse staffing or how to determine how many staff members were working. A visitor who reported visiting regularly also stated she did not know where the nurse staffing information was located and had not seen it posted. When interviewed, the Administrator was unsure where the nurse staffing information was posted and referred the surveyor to the Assistant Administrator. The Assistant Administrator indicated that staffing information was posted on a bulletin board in the Human Resources hall and showed an “as worked” schedule for a single shift and date, and then acknowledged that the posting at the receptionist’s desk should include the facility name, shift, nursing positions, and census. The receptionist produced an empty picture frame from under the desk, stating they were replacing the frame where the posting was usually kept. The Assistant Administrator did not know if postings were retained for 18 months. The staffing coordinator stated she usually posted the nurse staffing daily and that prior postings were available, but was unsure if they covered the past 18 months. Records provided showed postings only from late August to early March, with numerous missing dates and incomplete information, including missing census data and blank RN time slots on certain shifts, despite facility policy requiring daily posting for each shift of the number of nursing personnel providing direct care.
Expired Humulin R Insulin Found on Medication Carts
Penalty
Summary
Facility staff failed to provide appropriate pharmaceutical services when two bottles of Humulin R insulin remained in use on medication carts beyond the 28-day discard period after opening. During a medication cart audit on the [NAME] unit Front Hall cart at approximately 2:05 p.m., surveyors and an LPN identified a bottle of Humulin R, 100 units of insulin, with an open date indicating it should have been discarded after 28 days; the LPN acknowledged it should have been discarded. In a separate audit on the Fine Unit Cart #2 at approximately 2:27 p.m., surveyors and another LPN found a bottle of Humulin R insulin with an open date showing it was also past the 28-day discard timeframe, and the LPN stated that it was no longer good and needed to be discarded. A final interview with the Administrator, Assistant Administrator, DON, Regional Nurse Consultant, and Regional MDS Consultant did not yield any additional information about these findings. No specific residents, their medical histories, or conditions at the time of the deficiency were identified in the report, and the deficiency centers on the presence of expired insulin on two of three medication carts as observed and confirmed by facility nursing staff.
Failure to Conduct and Document Required QAPI Activities and Oversight
Penalty
Summary
The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) program met regulatory requirements, including conducting QAPI meetings at least quarterly and maintaining documentation of QAPI activities. Surveyors reviewing four quarters of records found no QAPI documentation for three of the four quarters in 2025, with only one quarter in 2026 having documentation. The Assistant Administrator reported having no information about QAPI prior to January 2026 and stated that the current administrative staff could not locate any QAPI documentation from the previous administrator. She also stated that the facility was expected to meet monthly for Quality Assurance and quarterly for QAPI, but there was no current Performance Improvement Project in place. During the survey, which was extended after substandard quality of care was identified, surveyors reviewed maintenance logs, pest control logs, Resident Council minutes, and grievance logs. These records showed that administration was aware of ongoing issues and concerns voiced by residents and families that continued for several months without resolution. The survey also determined that the facility did not have an effective training program, including required training on QAPI, effective communication, and behavioral health. Despite the identification of substandard quality of care and other issues by the survey team, there was no documentation that the governing body was aware of or acting on these findings.
Non-Functional Bathroom Emergency Call System for Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a functional emergency call system in a resident bathroom and bathing area used by a cognitively impaired resident. Resident #16, who has Type 2 diabetes without complications and Alzheimer’s disease, was assessed on a recent quarterly MDS as having severely impaired cognitive abilities, with a BIMS score of 5/15. The resident’s care plan identified communication problems related to dementia, a primary language of Spanish, and the need for various communication supports and monitoring of her ability to express needs and discomfort. Functionally, the resident required supervision or touching assistance for toileting hygiene and partial-to-moderate assistance with showering/bathing, but was observed during the survey to ambulate independently to the shared bathroom. On an initial bathroom tour on 4/21/26, surveyors observed that the emergency pull alarm in the bathroom shared by specified rooms on Unit 1 appeared non-functional, as it would not light up or be heard at the nurse’s station. This same bathroom was used by Resident #16, who was repeatedly observed ambulating independently to this restroom despite the non-operable emergency call system. On 4/24/26, the emergency pull cord was tested again and, when pulled, did not send an alert to the call enunciator at the nurse’s station. When asked, CNA #3 stated he was not aware whether the emergency pull-cord alarm sent an alert while at the nurse’s station. These observations and staff interviews confirmed that a working emergency call system was not available in the bathroom and bathing area used by Resident #16.
Failure to Maintain Effective Staff Training on Behavioral Health and Communication
Penalty
Summary
Facility staff failed to develop, implement, and maintain an effective training program for all staff, specifically lacking required education on behavioral health care and communication. During an extended survey conducted after substandard quality of care was identified, surveyors interviewed the Staff Development Coordinator, who stated she had no evidence that behavioral health training had been provided to all staff and acknowledged that some staff only received computer-based training. Review of educational records for five nursing staff members (two RNs, one LPN, and two CNAs) showed no documentation of training on behavioral health care. Staff interviews further revealed that these employees had not received training on communication with a Spanish-speaking resident. Staff reported that they relied on the resident’s family to translate and on the Assistant DON, who spoke Spanish, rather than on any formal training or structured communication process. The Staff Development Coordinator confirmed there was no documentation of any employees receiving training on communication with a Spanish-speaking resident, and surveyors observed that there were no communication tools in the Spanish-speaking resident’s room and no developed or implemented process for communicating with that resident. Facility leadership, including the Administrator, Assistant Administrator, Regional Nurse Consultant, and DON, were informed that required training, including communication training, was not being effectively maintained or documented.
Failure to Address Resident’s Repeated Reports of Missing Personal Belongings
Penalty
Summary
Facility staff failed to honor a resident’s right to be treated with respect and dignity and to retain and use personal possessions by not appropriately addressing repeated reports of missing personal items. The resident, who had diagnoses including cancer, hypertension, and hyperlipidemia, was cognitively intact for daily decision-making as evidenced by a BIMS score of 12/15 on a recent MDS assessment. During an interview, the resident reported that personal belongings such as soaps, lotions, clothes, and a bottle of perfume (reported as broken) were being stolen on a weekly basis. The resident stated that both she and her daughter had reported these issues many times to staff, prior administrators, and nursing, but nothing had been done. The resident and her daughter again reported the missing items during a care plan meeting. Staff interviews showed that CNAs were aware of the resident’s allegations of missing items but did not consistently report them according to facility expectations. CNA #7 stated that if a resident reported missing items, they would look for the items and/or report it to the charge nurse or DON, but CNA #7 was not aware whether this resident’s missing items had actually been reported. CNA #3 recalled that the resident had previously alleged missing items but was unsure whether this had been reported to anyone. The DON stated that the expectation was that a grievance be completed whenever a resident reported missing, lost, or stolen items; however, only one grievance, dated 4/22/26, was provided, despite the resident’s reports that the problem had occurred many times. When the findings were presented to the Interim Administrator, DON, Assistant DON, and Corporate Nurse Consultant, they made no comments and voiced no concerns.
Failure to Complete Pre-Employment Background Checks and Credential Verification
Penalty
Summary
Facility staff failed to thoroughly investigate prospective employees' histories before hiring, resulting in incomplete personnel files and delayed identification of disqualifying criminal backgrounds. A review of 25 employee records hired over the last 2 years on 4/22/26 showed that 11 files were missing at least one required document: a sworn statement, a state police criminal background search, or verification of a certificate or license. The Human Resources (HR) Director reported that an in-house audit had already identified missing documents in employee records, but no action had been taken to correct the problem or to refer the issue to the Quality Assurance committee. The HR Director further stated that an employee hired on 4/7/26 began employment before the facility received and reviewed the state police criminal background report. The background check was requested on 4/8/26, and the report was not received until the evening of 4/21/26 from a sister facility, at which time it was discovered that the employee had barrier crimes, including assault of a family member, malicious wounding, and indecent exposure. The employee was terminated on 4/22/26 before clocking in that day. The Regional HR Director explained that the facility’s process was to obtain background checks and ensure all required documents were completed, and stated that it was their policy not to hire employees with past criminal prosecutions. She also reported that the in-house HR Director had experienced issues with the state police online system and had relied on a sister facility’s HR Director to obtain the documents. During subsequent interviews with the Administrator, Assistant Administrator, Regional President of Operations, DON, Regional Nurse Consultant, and Regional MDS Consultant, no additional information was provided and staff voiced no comments.
Environmental Hazards from Damaged Flooring and Dining Room Door
Penalty
Summary
Facility staff failed to maintain an environment free from accident hazards in the kitchen by not replacing missing floor tiles at the kitchen entrance. During an observation, surveyors noted that several floor tiles were missing at the point of entry into the kitchen, and the removed tiles were placed on a pellet warmer next to the area where the tiles were missing. In an interview, the Director of Maintenance stated that the tiles had been removed a couple of months earlier and acknowledged that the area with missing tiles could cause staff to trip and fall, identifying it as a hazard. The facility also failed to address a damaged dining room entry door that presented an accident hazard. During an observation of the dining room, the entry door was seen splitting apart, and the bottom door hinge was not attached to the door. In a subsequent interview, the Director of Maintenance reported that the door was being replaced and explained that it was currently propped open because the bottom hinge was broken. The Director of Maintenance further stated that if staff attempted to close the door, it could fall, and acknowledged this condition as a hazard. In a final interview, the Administrator, Assistant Administrator, DON, Regional Nurse Consultant, and Regional MDS Consultant had no further comments or concerns regarding these findings.
Failure to Maintain Effective Pest Control and Document Pest Activity
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective pest control program to prevent and address roaches and other pests, resulting in multiple resident complaints and direct observations of pests by surveyors. During a Resident Council meeting with the President and four other regular attendees, all participants agreed the facility was not a safe, clean, comfortable, and homelike environment. Several cognitively intact residents, as evidenced by Brief Interview for Mental Status (BIMS) scores of 14–15, reported seeing large flying roaches throughout the facility, including in their rooms and shower areas, and described the shower room as unclean. One resident stated roaches crawled on ceilings and walls and made it difficult to sleep and reported not seeing pest control treat their room. Another resident, who had a BIMS score of 0 but was described by staff and through interviews as alert and oriented times four, reported that flying roaches were present during the day and night and that the problem had worsened since construction began. A visitor in the dining room also reported seeing roaches in the building and expressed concern that the older section of the facility needed attention. In one resident’s room and bathroom, surveyors directly observed four roaches on the bathroom floor (two dead and two alive on their backs), and the Maintenance Director did not remove them during the observation. The same room contained two roach bait houses and a plastic container under the toilet’s on/off valve that had collected standing water, which the Maintenance Director acknowledged was related to a flooding bathroom and likely attracted roaches. The resident reported having told housekeeping about how dirty the room was and that roaches crawled and flew around the room and bathroom; when the surveyor and housekeeper re-entered the bathroom later, roaches were again observed and then removed by the housekeeper. Additional pest-related issues were identified on another unit, where two residents in a shared room reported the presence of wasp nests by the window and stated the nests had been there for about three weeks and that staff were aware. Visual inspection revealed two wasp nests between the screen and glass, one with multiple round, greyish-white egg-like sacs and a live wasp on an empty cell, and a second smaller nest, along with a quarter-inch gap between the outside screen and the window that allowed outside air to be felt and contained what appeared to be a dead wasp. During the end-of-day debriefing, facility leadership was informed that a gap at the threshold from the hallway door to the courtyard could be a point of entry for insects and roaches. It was also noted that contracted pest control services were not completed for two months due to a lapse in vendor payment processing, and that the Maintenance Director had destroyed pest control logs across all units, leaving them blank and failing to document the roach sightings and the wasp nests reported by residents and observed by surveyors.
Failure to Ensure Access to Interpreter Services for Spanish-Speaking Resident
Penalty
Summary
Facility staff failed to ensure language interpreter services were available to allow effective communication for a Spanish‑speaking resident. The resident had Type 2 diabetes without complications and Alzheimer's disease, and a recent MDS assessment showed a BIMS score of 5/15, indicating severely impaired cognitive abilities for daily decision‑making. The MDS also documented that the resident required varying levels of assistance with oral hygiene, dressing, eating, toileting hygiene, footwear, personal hygiene, and showering/bathing. The person‑centered care plan identified a communication problem related to dementia, noted that Spanish was the resident’s primary language, and stated that the resident preferred to communicate in Spanish, although she understood and spoke some English. The care plan included multiple communication interventions, including providing a translator as necessary to communicate with the resident. The resident’s History and Physical documented a language barrier and indicated that assistance was available from one of two nurses, with one able to speak Spanish. The DON reported that an interpretation document was kept at the nurse’s station on the resident’s unit. However, during interviews, CNAs assigned to care for the resident stated they were not aware of any interpreter services or interpreter services information at the facility. These staff interviews, combined with the clinical record review and the resident’s identified communication needs, showed that interpreter services were not effectively made available or known to direct care staff, resulting in a failure to implement the care‑planned intervention to provide a translator as necessary for this Spanish‑speaking resident.
Residents Unaware of How to Access Ombudsman and State Agency Contact Information
Penalty
Summary
Facility staff failed to ensure that residents knew the location of the list of contact names, addresses, and phone numbers for State agencies, the ombudsman, and adult protective services, resulting in 5 of 5 residents attending a resident group meeting being unaware of how to contact these entities. During a resident group meeting held with the Resident Council President and four regularly attending residents, all participants reported they did not know how to contact the ombudsman, adult protective services, or other state offices. A subsequent interview with the Activities Director revealed that she stated residents are educated at every resident council meeting about the ombudsman and where to find the contact information, and that this education is documented in the resident council minutes. In a final interview with the Interim Administrator, DON, ADON, and Corporate Nurse Consultant, the surveyor conveyed these findings, and the administrative team made no comments and voiced no concerns. No additional medical history or clinical conditions of the residents were provided in the report, and the deficiency centers on residents’ lack of awareness of how to access posted or available contact information for external advocacy and protective agencies.
Failure to Notify Resident Representative and Maintain Updated Contact Information After Change in Condition
Penalty
Summary
Facility staff failed to notify a resident’s representative of a significant change in condition and did not maintain updated contact information, contrary to facility policy. The resident, who was cognitively intact per an annual MDS (BIMS score 15/15) but functionally dependent in most ADLs, had a care plan noting ADL self-care deficits related to impaired balance, weakness, and shortness of breath with exertion. The facility’s policy, revised 12/01/22, required staff to promptly inform the resident, consult the physician, and notify the resident’s representative when there is a significant change in physical, mental, or psychosocial condition, including life‑threatening conditions or clinical complications, and to record and periodically update contact information for the resident’s legal representative or family. On 4/21/26, a physician progress note documented that the resident was seen for an acute visit due to hypoxemia, with oxygen saturation dropping into the 70–80% range and associated chills. The note described a significant medical history including morbid obesity, hypoventilatory syndrome, functional quadriparesis, bedbound status, chronic respiratory failure with oxygen dependence, COPD, hypertension, CAD, chronic pain syndrome, GERD, asthma, anemia, and neuropathy. The physician coordinated DuoNeb treatments with nursing staff, after which the resident’s oxygen saturation improved to 89%, chills subsided after increasing room temperature, and vital signs remained stable; the resident denied respiratory and other systemic symptoms at that time. Diagnostic tests (CBC, CMP, CXR) were ordered to further evaluate the hypoxemia and chills. Earlier that day, during the initial tour, the resident was observed in bed under covers in a very warm room and reported not feeling well. The resident’s face sheet listed one family member as Emergency Contact #1 and POA, and another family member as Emergency Contact #2. Surveyor calls to these contacts on 4/21/26 and 4/22/26 revealed that one phone number did not allow a voicemail, another was not working, and the second contact reported not having received any call about the change in condition. The resident later provided an updated phone number for Emergency Contact #2. A review of the medical record showed no documentation that either emergency contact was notified or that attempts to notify them were made on 4/21/26 regarding the change in condition. In interviews, the DON stated she was not informed of the change in condition, believed the resident to be her own responsible party, and acknowledged there was no note in the record indicating the son was contacted on 4/21/26 during the change in condition.
Failure to Properly File and Address Resident Grievance on Missing Personal Items
Penalty
Summary
Facility staff failed to honor a resident’s right to voice grievances and have them promptly addressed when they did not ensure a grievance was filed regarding multiple missing personal items. Resident #12, who had a diagnosis including malignant neoplasm of the colon and was assessed on the MDS with a BIMS score of 12 indicating moderately impaired cognitive abilities for daily decision making, reported during the initial tour on 04/22/2026 that she had been missing two cases of cranberry juice, one case of Ensure Clear, body wash, perfume, baby powder, and her bifocals for approximately four months. She stated she had reported these missing items to multiple staff members, including the DON and nurse aides. Despite these reports, the Social Worker later stated she was not aware of the missing items until 04/28/2026. Review of the facility’s grievance/complaint documentation showed only a single Grievance/Complaint form dated 04/21/2026, which recorded the resident’s report of only two boxes of Ensure being missing and indicated reimbursement for those two boxes, with no documentation of the other missing items the resident had reported over the preceding months. This sequence of events demonstrates that the facility did not consistently initiate or document a grievance for all of the resident’s reported missing items, and key staff, such as the Social Worker, were unaware of the full scope of the resident’s concerns despite her statements that she had reported them to various staff members over an extended period.
Failure to Re-Evaluate Prolonged PRN Lorazepam Order
Penalty
Summary
The deficiency involves the facility’s failure to prevent the prolonged use of an as-needed psychotropic medication without appropriate time limits or documented re-evaluation. One resident with diagnoses including stroke with aphasia and anxiety had a Significant Change MDS assessment showing a BIMS score of 4/15, indicating severely impaired cognitive abilities for daily decision-making. A physician order dated 4/06/2026 directed Lorazepam 0.5 mg via G-tube every 4 hours as needed for anxiety, but the order did not include a stop date. Review of the clinical record showed no documentation by the physician or prescribing practitioner that the resident had been evaluated regarding the appropriateness of continued PRN Lorazepam use. As of 4/28/2026, the resident had been continuously prescribed this PRN Lorazepam for 22 days without a documented reassessment of its ongoing necessity. The resident’s care plan, dated 01/19/2026, identified the use of anti-anxiety medications and listed goals and interventions focused on monitoring and reporting adverse reactions and side effects such as drowsiness, confusion, impaired thinking, and unexpected behavioral changes. However, despite this care plan, there was no evidence in the record that the prescriber had reviewed or justified the continued PRN psychotropic therapy beyond 14 days, and facility leadership acknowledged that the medication should have been re-evaluated or the ongoing need documented.
Failure to Timely Report Allegation of Resident Abuse to State Agencies
Penalty
Summary
Facility staff failed to timely report an allegation of abuse to the appropriate state agencies for one resident. The resident, who had a diagnosis including malignant neoplasm of the colon and a BIMS score of 12 indicating moderately impaired cognitive abilities for daily decision making, reported that she had almost fallen out of bed and was shoved back into bed by staff. During the survey’s initial tour, the resident stated she had informed Veterans Administration staff about this incident, that she had not experienced such treatment since, and that she felt safe. A Facility-related Synopsis documented that the resident had an incident in which she was shoved twice by two staff members while being assisted back to bed, with the employees’ names unknown. The Facility-related Synopsis showed an incident date of 08/28/25 and a report date of 09/03/25, indicating the allegation was reported five days after the alleged incident. The report was sent to various state agencies and concluded that the resident could not provide specific dates or times of the alleged incident and that the allegation of abuse was unfounded, while also noting that the resident felt safe in the facility. Current staff interviewed during the survey stated they were not aware of the incident. During a final interview with the Administrator, Assistant Administrator, DON, Regional Nurse Consultant, and Regional MDS Consultant, no further information was provided regarding the delay or circumstances of the reporting, confirming that the allegation of abuse was not reported to the appropriate state agencies within the required timeframe.
Inaccurate MDS Coding of Anticoagulant Use
Penalty
Summary
Facility staff failed to ensure an accurate Minimum Data Set (MDS) assessment for Resident #39. The resident was admitted with diagnoses including liver cirrhosis, diabetes, and status post right foot trans metatarsal amputation. The admission MDS with an assessment reference date of 4/6/2026 documented that the resident completed the Brief Interview for Mental Status (BIMS) and scored 15/15, indicating intact cognitive abilities for daily decision-making. In section N0415 (High-Risk Drug Classes: Use and Indication), the MDS coded that the resident was receiving an anticoagulant and that an indication for its use was documented. However, review of the Physician’s Order Summary, the resident’s care plan, and a physician progress note dated 4/7/2026 did not show any order, documentation, or care plan entry indicating that the resident was actually receiving an anticoagulant. During an interview, the MDS Coordinator acknowledged that the 4/6/2026 admission MDS was not coded accurately because the resident had not been taking an anticoagulant.
Failure to Follow Physician’s Oxygen Flow Rate Order
Penalty
Summary
Facility staff failed to follow a physician’s order for oxygen flow rate for one resident with multiple chronic conditions, including chronic respiratory failure with oxygen dependence, COPD, morbid obesity, hypoventilatory syndrome, functional quadriparesis, and other comorbidities. The resident was cognitively intact per a recent MDS (BIMS score 15/15) and was care planned for ADL self-care deficits related to impaired balance, weakness, and shortness of breath with exertion. The March 2025 Physician Order Summary specified that the resident was to receive continuous oxygen at 3 L/min via nasal cannula for COPD. Despite this order, during the initial tour on 4/21/26 around 12:30 p.m., the resident was observed in bed with the oxygen concentrator set at 5 L/min via nasal cannula, and the resident reported having had trouble breathing earlier that morning. On 4/22/26 at approximately 4:45 p.m., the resident was again observed in bed receiving oxygen at 5 L/min via nasal cannula. On 4/23/26 at about 5:10 p.m., an RN stated she would need to verify the physician’s orders regarding the oxygen flow rate. After reviewing the orders, the RN confirmed the resident should be receiving 3 L/min of oxygen and was informed that the oxygen flow rate had been set at 5 L/min for three days. The RN then checked the concentrator in the resident’s room and stated she changed the flow rate back to 3 L/min. These observations and interviews showed that the resident had been receiving oxygen at a higher flow rate than ordered for at least three days, constituting a failure by staff to follow the physician’s order for oxygen administration.
Improper Technique Used to Split Ativan Tablet for One-Time Dose
Penalty
Summary
Facility staff failed to follow proper medication administration technique when preparing and administering a one-time dose of Ativan for Resident #23. The resident, who had diagnoses including cataracts and anxiety and a BIMS score of 9/15 indicating moderately impaired cognitive abilities for daily decision-making, had a physician’s order dated 4/23/2026 for Ativan 1 mg, to give 0.5 tablet by mouth one time only for anxiety. During the morning medication pass on 4/23/2026, the ADON obtained a single-dose package of Ativan 1 mg from the stat box for administration by RN #4. RN #4 opened the package and, while wearing gloves, broke the 1 mg tablet in half by hand, wasted one half, and administered the remaining 0.5 mg to the resident. A nurse’s note documented that a one-time authorization had been obtained from the pharmacy to remove one Ativan 1 mg tablet from the stat box to fulfill the 0.5 mg one-time order. In a subsequent interview, the DON stated that the 1 mg Ativan tablet should not have been broken by hand, as facility policy requires the use of a tablet splitter to ensure dose accuracy and minimize contact with the scored tablet. The failure to use a tablet splitter and instead manually break the tablet constituted improper technique in achieving the ordered dose of medication for the resident.
Failure to Provide Discharge Instructions and Transfer Documentation for Residents Leaving AMA
Penalty
Summary
Facility staff failed to provide required discharge information and documentation for two residents who left the facility against medical advice (AMA). One resident was admitted with multiple acute and chronic conditions, including sepsis, hypertension, diabetes, pneumonia, and COPD, and had a BIMS score of 12/15 indicating moderate cognitive impairment. The resident left AMA within three days of admission. The facility’s transfer and discharge policy, including AMA, required that residents and families be informed of the risks and benefits of staying, alternatives, and that these discussions be documented, as well as completion of a discharge summary and post‑discharge plan of care for anticipated transfers or discharges. Nursing documentation on the day of discharge only noted that the resident left with his daughter, signed AMA paperwork, and was stable, with no signs of distress, and there was no documentation that any discharge instructions, recapitulation of the stay, or other written information were provided. Interviews with facility staff confirmed that discharge summaries and related information were only provided for planned or anticipated discharges and not for residents leaving AMA. The discharge planner stated that nursing staff would provide discharge summaries at the time of discharge, while the DON stated that discharge summaries were provided only for planned discharges and that no information was given to residents who left AMA. The DON further stated that no recapitulation of the stay would be given to residents at the time of discharge if they signed out AMA, and that the facility’s practice was to limit discharge summaries to anticipated transfers or discharges. Surveyors informed facility leadership that no effort had been made to assist this resident to adjust to the new living arrangement because the resident signed out AMA. For the second resident, who had a displaced intertrochanteric fracture of the left femur and intact to moderately impaired cognition based on MDS BIMS scores, the facility failed to ensure that the admitting facility received necessary admission documents when the resident left AMA. Progress notes showed that the resident’s son arrived to take the resident home, staff noted there were no discharge orders in the chart, and an on‑call supervisor authorized discharge and instructed staff to give non‑narcotic medications to the son. The discharge summary documented discharge to an assisted living setting with improvement in condition, but it lacked signatures from the resident or family. Interviews revealed that facility staff considered the departure AMA, notified the VA caseworker of the AMA status, and did not send clinical documentation beyond a face sheet and PASRR. The admitting facility’s AD reported receiving only those two documents, stated that the discharging facility said they would not send paperwork because the resident left AMA, and reported not receiving an H&P, clinical notes, or a medication list, which delayed the resident’s admission to the new facility.
Failure to Provide Necessary ADL Assistance and Nail Care
Penalty
Summary
Facility staff failed to provide necessary assistance with activities of daily living (ADLs) for one resident who was completely dependent on staff for all ADL care. The resident had a history of stroke with aphasia and anxiety, and a Significant Change MDS with an ARD of 2/24/2026 documented a BIMS score of 4/15, indicating severely impaired cognitive abilities for daily decision-making, and coded the resident as dependent in section GG0130 for all functional abilities. On 4/21/26 at approximately 2:40 PM, the resident was observed asleep in bed with fingernails extending about 1.75 inches beyond the fingertips and appearing discolored, and with scratches noted on the thighs and right arm. In a subsequent interview, a CNA acknowledged that the resident’s nail care had been overlooked.
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.
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What surveyors actually found near you
We read the 157 citations issued within 25 miles in the last 12 months — including the 4 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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Virginia Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Birchwood Park Rehabilitation | 0.5 mi | ★★★★★ | 0 | 0 |
| Rosemont Health & Rehab Center, Llc | 1 mi | ★★★★★ | 0 | 0 |
| Our Lady Of Perpetual Help | 2.3 mi | ★★★★★ | 0 | 0 |
| Bayside Health & Rehabilitation Center | 2.5 mi | ★★★★★ | 0 | 0 |
| Cypress Pointe Rehabilitation And Nursing | 3.4 mi | ★★★★★ | 14 | 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 July 2026) and official state health department websites.