Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Auburn Post Acute during CMS and state inspections, most recent first.
The facility failed to submit complete and accurate PBJ staffing data to CMS for Q4. Review of the PBJ discrepancy report showed the payroll system underreported total nursing hours by 1,606.80 hours because extra break time was deducted and one employee lacked a CMS job title code, so those hours were not counted. The Administrator stated the software did not correctly carry over LPN and CNA hours and that accurate coding would have met the 3.4 HPRD and produced correct census and staffing hours.
Call lights on the North and South Units were not fully functioning, with missing room buttons at the nurse station panel and repeated delays in staff response reported by residents; one resident in pain waited at least 30 minutes for help while staff observed the malfunctioning system. The first floor bathroom pull cords were also too short and the bathrooms were locked, leaving the emergency call system inaccessible to a resident lying on the floor.
Kitchen sanitation and food handling practices were not maintained during meal service. The ceiling above the dishwasher area had water stains, a missing panel, and exposed pipes with dust and spider webs; several cabinets holding clean utensils would not fully close; and uncovered trash bins contained food scraps and debris. During tray line service, a cook used contaminated gloves while handling chicken, touched a clean plate with residue on the gloves, and allowed meat juices and liquid from pans to drip onto other uncovered foods, with the dietary supervisor acknowledging the improper glove use and cross-contamination.
The facility failed to designate a qualified IP for the infection prevention and control program. The Wound Nurse/IP had only been in the role for one week after the prior IP left and did not have the required infection prevention and control certification, and the Interim DON confirmed this oversight.
The facility failed to keep the main entrance safely accessible when the ADA door operators did not work, leaving residents using wheelchairs unable to open the twin doors independently and sometimes needing staff help or to force the doors open. The facility also failed to complete timely and complete fall assessments for two residents with significant medical issues, including one resident with a faulty walker after a fall and another resident with MS, brain injury, weakness, memory impairment, and a later bed-related fall. In addition, three sharps containers on LTC nurse carts were observed filled past the fill line, and staff confirmed they should have been changed before becoming overfull.
Unsafe and Unhomelike Environment: A resident’s room had broken blinds at eye level, another resident’s room had stained ceiling tiles after a leak, and hallway/room areas had missing thresholds and broken hand sanitizer dispensers. The main floor bathrooms also lacked emergency pull cords, and staff gave conflicting directions about whether residents could use them, while the Administrator confirmed the bathrooms were intended to be available to all residents.
The facility failed to provide bed hold notifications to 3 residents during hospital transfers and a surgical hospitalization. Records showed no documentation that the bed hold policy was reviewed with the residents or, for one resident with memory impairment and a DPOA, with the representative. Staff confirmed the nursing staff were responsible for offering the notice, but no supporting documentation was found.
Late Completion of Comprehensive MDS Assessments: The facility failed to complete admission and annual MDS assessments within required timeframes for multiple residents. Admission assessments for some residents and annual assessments for others were completed several days late, and the MDS Nurse verified the delays while the DON stated the RN Coordinator was expected to complete assessments on time.
Care plans were not comprehensive or followed for multiple residents with catheter care, diarrhea, ADL, dressing, and pressure relief needs. A resident with an indwelling catheter lacked care plan directions for emptying the bag, another resident with diarrhea and a probiotic order had no care plan for that issue, and other residents were observed without planned privacy, grooming, dressing assistance, or repositioning/pressure relief. Staff stated the interventions should have been included and implemented as part of the residents’ CPs.
The facility failed to provide required ADL assistance for three residents who needed help with dressing and personal hygiene. One resident was observed wearing the same clothing across days and staff said the resident was not changed when gotten up from bed. Two other residents were observed with unkempt hair and facial hair, and one resident stated they needed help shaving and wanted a haircut. MDSs and care plans showed each resident required substantial staff assistance with these ADLs, but staff described no clear process for grooming or haircut services.
Urinary catheter care was not maintained for two residents with indwelling catheters. One resident’s care plan and Kardex did not direct staff to empty the bag or keep it off the floor, and observations showed the bag repeatedly full and resting on the floor. Another resident had an order to empty the bag every shift due to high UTI risk, but the bag was observed half full and later full on the floor without a privacy cover, and staff confirmed it had not been emptied or properly positioned.
A resident with chronic pain had inaccurate narcotic count documentation, including a corrected count written over the original entry instead of using a single-line strike-through, and the MAR lacked notes explaining the discrepancy and refusal. Staff also found expired and undated meds and biologics in the med room and on the Medicare South and LTC South med carts, no refrigerator temp log was available, and the treatment cart’s bottom drawer could be opened even when locked.
Failure to educate residents and family on outside food policy: A resident's son brought restaurant food into the room without staff checking it, and he said he had not received the policy or known the resident's diet restrictions. Two other residents had outside food or snacks in their rooms and stated they were not informed of the facility's food storage practices or given the policy. Staff reported educating residents as they encountered them, but did not know how family members were educated.
Staff failed to follow EBP for three residents with wounds or indwelling catheters by entering rooms and providing high-contact care without the required gown and gloves. The facility also had a wheelchair with torn armrest covers exposing foam, and a laundry machine whose temperature had not been logged for months even though staff stated it should be checked and documented daily.
A facility failed to implement its Antibiotic Stewardship Program for a resident who received an ABO for a bilateral leg skin infection. The resident had redness, warmth, and tenderness, but review of updated McGeer's criteria showed the condition did not meet infection criteria, and the Wound Nurse/IP stated it should have been reported to the provider for review.
A facility failed to obtain timely informed consent for psychotropic and off-label medication use for three residents. One resident with TBI, anxiety, and depression had an antianxiety med started and increased without consent, another resident with PTSD and hallucinations began an antipsychotic before consent was signed, and a third resident with moderate cognitive impairment and PTSD received an off-label BP med for months before consent was completed; the DON and RCMs confirmed the missing or late consents.
Grievances were not properly logged, investigated, or communicated back to residents. One resident with anxiety, depression, chronic pain, and limited mobility voiced concern about care in pairs and later filed a grievance about pain management after an outside clinic visit, but the facility did not fully address the allegations or enter the concerns on the grievance log. Another resident with depression and bipolar disorder reported multiple concerns about a CNA, yet the grievance form was left incomplete and the issue was not logged or resolved with the resident.
MDS assessments did not accurately reflect resident status for three residents. One resident’s admission MDS omitted documented pressure ulcers despite hospital discharge and skin assessment records showing wounds, another resident’s quarterly MDS left the routine and activity preferences section blank even though the resident could be interviewed, and a third resident’s admission and quarterly MDSs omitted a bipolar disorder diagnosis documented in the physician record. Staff confirmed the MDS entries were incorrect or incomplete.
A resident with anxiety, depression, and later documented bipolar disorder had no PASRR initiated at admission, and the later Level I PASRR omitted the bipolar diagnosis. The record also showed delirium and significant behavioral symptoms, use of care in pairs, behavior agreements, and a transfer notice after ongoing verbal and physical aggression toward staff.
Missed Routine Care Conferences: The facility failed to provide routine care conferences for two residents sampled for care planning. One resident had moderate cognitive impairment, a fracture, blood sugar disorder, poor nutrition, depression, and a psychotic disorder, and wanted discharge back to the community; the record showed no care conference on admission or during the first quarterly period. Another resident with HTN, CVA, and a seizure disorder reported the first care conference occurred only recently, despite the expectation for quarterly and as-needed conferences.
Failure to Follow Ordered Monitoring and Medication Parameters: The facility did not consistently carry out ordered weight checks, medication parameters, skin assessments, respiratory care, bowel care, or chart updates. One resident had significant weight loss without timely physician notification, another had missing weight documentation despite weekly orders, a resident received pain meds without pain-level parameters in the orders, and a resident received a BP med without required SBP/HR checks. Staff also missed weekly skin checks for a resident with a pressure injury, did not follow ordered oxygen tubing/humidifier changes or flow rate, failed to give PRN stool softeners after several days without a BM, and left a completed hospice referral order active in the chart.
Failure to provide RNP services for a resident with CVA, HTN, and left-sided weakness. The care plan called for restorative exercise to both arms and legs 3 to 6 times weekly, but documentation showed no services in one month and only 3 sessions the next month, less than weekly. The resident did not recall receiving restorative care, and the DON confirmed the services were not provided as outlined.
A resident with MS, diabetes, seizure disorder, and quadriplegia had a tube feeding order for 1620 CC of low-sugar formula daily, but observations found the pump off at times, formula and saline bags disconnected from the pump, and bags not consistently dated or timed. The MAR repeatedly documented only 270 CC provided daily instead of the ordered amount, and the DON stated the record did not show the resident received the prescribed nutrition.
Failure to assess and provide adaptive eating equipment and utensils for a resident with a brain injury, impaired mobility on the right dominant side, and loss of verbal communication. During dining, the resident struggled to cut food and scoop it with a teaspoon, and an interpreter stated the resident wanted adaptive utensils and a plate to help with independent eating. The DOR later confirmed the resident should have been assessed for adaptive feeding equipment use but was not.
Multiple residents experienced sexual, physical, and verbal altercations that staff documented but did not treat as reportable abuse allegations. A resident with dementia and intrusive behaviors repeatedly grabbed and touched other residents, including spanking a cognitively intact resident’s buttocks and grabbing another resident’s breasts, yet earlier incidents were neither logged nor investigated, and the later investigation did not incorporate the prior events. Two cognitively intact roommates reported a physical altercation that caused scratches, but documentation showed no protective actions, reporting, or abuse investigation, and the abuse log contained no entry. In another case, a resident verbally demeaned a roommate with derogatory comments about odor and incontinence; staff arranged a room change but did not document notifications, reporting, or an investigation, contrary to facility abuse policy.
Surveyors identified that the facility failed to assess and manage smoking and elopement risks for multiple residents, including individuals with cognitive impairment, dementia, traumatic brain injury, and mobility limitations. Several residents smoked in their rooms, shared bathrooms, an indoor atrium, and a garage area despite a written no-smoking policy, and many had no smoking safety assessments or care-plan interventions. One resident, assessed as unsafe to smoke independently, repeatedly smoked indoors and was later observed outside picking up cigarette butts and lighting them in their lap, while other residents shared lit cigarettes in the parking area. Another resident sustained a cigarette burn to the leg without documented reassessment or reporting. A cognitively impaired resident with a Wander Guard and an elopement care plan eloped multiple times to nearby stores and was later observed near an elevator without required 1:1 supervision, with inconsistent Wander Guard alarm function. Smoking and elopement incidents were frequently not entered on the incident log or investigated, and staff and leadership interviews confirmed that facility policies for smoking, incident reporting, and elopement were not followed.
Surveyors found that the facility failed to follow its own pressure injury prevention policy and professional standards for three residents at risk for or with pressure ulcers. One resident admitted with bilateral arm fractures and no PUs was identified as at moderate risk but received only one Braden assessment, had no skin or wound care plan, and later developed facility-acquired elbow ulcers that were incompletely assessed, poorly documented, and not treated with dressings for several days. Another high-risk resident with moisture, immobility, and friction/shear issues had a documented gluteal shearing wound and later a back wound that was repeatedly charted without provider notification, wound measurements, or formal wound evaluations; on hospital transfer, four wounds were present, but on readmission only one received treatment orders, and the resident was observed with an uncovered painful buttock wound, an undersized brief sitting in the wound area, and a soiled month-old dressing on the back that had not been changed or reassessed. The DON acknowledged that required Braden assessments, care planning, wound documentation, and provider/dietician notifications were not completed as expected.
Facility administration did not effectively oversee abuse prevention, incident reporting, smoking safety, elopement procedures, or staff training and competency. The administrator, who also served as abuse coordinator, did not ensure consistent review of resident progress notes or that all incidents of abuse, smoking, or elopement were reported and investigated. Despite a prior citation for unsafe smoking, multiple residents known to be smokers repeatedly smoked inside the building without required smoking assessments or care plans, and two residents assessed as unsafe to smoke independently continued to smoke indoors. The interim administrator acknowledged that smoking and elopement policies were not properly implemented. Additionally, the staff development coordinator reported there was no system to schedule, document, track, or monitor required orientation, annual mandatory education, or competency evaluations for staff, and the facility lacked an implemented policy governing staff training and competency.
The facility failed to implement and maintain a clear and safe smoking policy, resulting in residents using an unsafe smoking area in a parking garage that was littered with cigarette butts and had blocked or improperly placed fire safety equipment. Although the written policy prohibited on-premises smoking and required certain residents to smoke off premises under supervision, it did not define the premises, a designated smoking area, or rules for residents admitted before a specified date. The administrator and DON identified multiple resident smokers, allowed some to be grandfathered to smoke in the garage, and reported that smoking supplies were kept on the med cart and checked out by residents, but both acknowledged the policy was unclear and not followed, and that there was a breakdown in the system for managing resident smoking.
The facility failed to maintain an effective in‑service training and competency evaluation system for CNAs, as required by its facility assessment and regulations. Residents with psychiatric, cognitive, behavioral, and complex care needs required staff trained in communication, resident rights, abuse/neglect prevention, infection control, ADLs, behavior management, trauma‑informed care, and substance use disorders. Three CNAs actively assigned to resident care had no documented annual mandatory training, performance evaluations, skills competency assessments, or evidence of completing the required 12 hours of in‑service education. The staff development process relied on corporate video modules and staff meetings without any tracking of participation, no system to ensure the 12‑hour annual CNA in‑service requirement, and no integration of performance reviews to identify and address training needs, and leadership confirmed that no such systems or documentation were in place.
A resident with a history of sexual and physical assault, who was cognitively intact and required moderate ADL assistance, reported that another resident in the hallway made unwanted physical contact with their breasts and only stopped when told to do so, after which the resident sought staff help. The resident who engaged in the touching had Alzheimer’s disease, confusion, wandering, and documented sexually inappropriate and intrusive behaviors, including prior incidents of slapping and grabbing other residents, with care plans noting grabbing private areas and entering others’ spaces. Progress notes for these prior incidents did not document staff responses or protective actions for other residents, and observations showed this resident without 1:1 supervision for extended periods, while the facility’s investigation ultimately ruled out abuse and neglect, characterizing the event as behavioral rather than intentional despite its own abuse policy defining non-consensual sexual contact as sexual abuse.
The facility failed to submit complete and accurate PBJ staffing and census data to CMS for a quarterly reporting period. PBJ records showed a total census count that did not match the facility’s own monthly census records, resulting in a discrepancy of hundreds of census days. The administrator reported that PBJ and census reporting were handled at the corporate level and acknowledged prior issues with timely and accurate MDS submissions. Corporate staff later identified a different "accurate" census total after re-review, confirming that the original PBJ submission was not correct, which affected the accuracy of CMS nursing home staffing level data.
A deficiency was cited due to the facility not ensuring an area was free from accident hazards and not providing adequate supervision to prevent accidents. The report does not specify the individuals involved or the exact circumstances leading to the deficiency.
The facility failed to maintain a safe, clean, and homelike environment, with issues such as cluttered hallways, damaged doorways, and lack of room personalization. Observations included tripping hazards, stained ceilings, and rust marks under sinks. The administrator acknowledged the need for timely maintenance.
The facility failed to provide required written notices to residents and their representatives during transfers or discharges, affecting five residents. This included a lack of notification to the LTCO, preventing advocacy and education for residents. Staff interviews revealed unfamiliarity with regulations, and the facility's practice did not include sending written notices during hospital transfers.
The facility failed to provide written notice of its bed-hold policy to residents or their representatives during hospital transfers. This affected multiple residents, including one with moderate memory impairment and complex medical diagnoses, and another with stroke and heart failure. Staff interviews confirmed the lack of documentation and communication regarding bed-hold options, placing residents at risk of not being informed of their rights and associated costs.
The facility failed to conduct timely care conferences and update care plans for several residents, leading to potential unmet care needs. A resident expressed frustration over not having a care conference for eight months, while another had not had one for over ten months. Additionally, a resident's care plan was not updated to reflect their current condition, as they were not participating in a walking program due to leg pain, contrary to what was documented.
The facility failed to prepare resident meals according to the dietician-approved menu, serving all residents from the same pan of orange chicken instead of providing diet-specific preparations. This oversight was confirmed by the Dietary Supervisor and highlighted by the Registered Dietician, who noted the nutritional differences between the regular and diet preparations.
The facility failed to maintain comprehensive medical records and ensure resident privacy. A resident's dialysis notes and lab results were not scanned into their medical record, and another resident's hospice documentation was incomplete. Several residents' pharmacy recommendations were missing from their records, and an LPN left a computer screen open, compromising privacy. Staff acknowledged these issues, citing a backlog in the medical records department.
The facility failed to ensure proper infection control and hygiene practices, including hand hygiene and PPE protocols, as observed with a resident and in the dining room. Staff did not perform hand hygiene between tasks or properly sanitize equipment, increasing the risk of infection. Uncleanable surfaces and unsanitized equipment further contributed to the deficiencies.
The facility failed to maintain resident dignity by not providing privacy bags for catheter bags, not ensuring residents were fully covered during transport, and not knocking before entering rooms. A resident's catheter bag was visible from the hallway, and others were exposed during transport. Staff also removed items from residents' rooms without permission.
The facility failed to obtain informed consent for a tilt-in-space wheelchair for a resident with a history of stroke and dementia, as the consent form did not identify potential risks. Additionally, several residents receiving psychotropic medications lacked documentation of informed consent, placing them at risk of losing their right to be informed and to refuse treatment. Staff acknowledged the absence of consent documentation and the importance of informed consent for medication use.
The facility failed to ensure that residents' Advance Directives (ADs) were included in their records and that assistance was offered to those without ADs. A resident with moderate memory impairment had no AD or documentation of assistance offered, and another resident had no AD discussions since admission. Staff interviews confirmed these deficiencies, which were contrary to the facility's policy.
The facility failed to investigate incidents involving three residents, leading to unaddressed injuries and safety concerns. A resident using a power wheelchair had multiple accidents resulting in a fracture, another resident reported feeling threatened by a nurse without follow-up, and a third resident's fall was not logged or investigated. These deficiencies highlight a lack of communication and documentation, compromising resident safety.
The facility failed to ensure accurate MDS documentation for several residents, leading to potential risks for unmet care needs. A resident's MDS did not reflect antianxiety medication use, while another's inaccurately recorded influenza vaccination dates. Two residents lacked cognitive assessments, and another's dental status was misrepresented. Staff acknowledged these inaccuracies, highlighting the importance of accurate MDS for care planning.
The facility failed to complete necessary PASRR assessments for several residents, leading to potential risks of inappropriate placement and unmet mental health needs. Inaccuracies and omissions in PASRR documentation were identified for residents with serious mental disorders, with staff confirming the lack of required evaluations.
The facility failed to clarify and follow physician orders for several residents, leading to potential risks for ineffective treatments and medication errors. A resident's IV antibiotic order lacked a specified flow rate, and another resident's bowel management protocol was not followed, resulting in duplicated laxative administration. Two residents received blood pressure medications outside of prescribed parameters, and pain medication orders were not clarified. Staff interviews confirmed these deficiencies.
The facility failed to provide adequate nail care and shaving assistance for residents dependent on staff for ADLs. A resident with moderate memory impairment had long, dirty nails due to lack of documented care. Another resident with severe cognitive impairment also had long nails despite care plan directives. Two residents requiring extensive assistance were observed with long chin hairs, indicating inconsistent shaving practices. Staff interviews confirmed that shaving should be part of daily care, but this was not consistently done.
The facility failed to properly assess and treat skin conditions for two residents, did not implement nonpharmacological pain interventions for a resident with frequent pain, and neglected to monitor another resident for latent injuries after a fall. These deficiencies highlight lapses in communication, documentation, and adherence to facility policies.
A facility failed to reassess a resident's power wheelchair use after hospitalizations and cognitive changes, leading to accidents and a fracture. Additionally, two residents had their beds placed against the wall without safety assessments, risking entrapment. These oversights violated facility policies and compromised resident safety.
Incomplete and inaccurate PBJ staffing submission
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to CMS for Q4 PBJ reporting. Review of the June 2022 CMS Long-Term Care Facility PBJ Policy Manual showed that facilities are required to electronically submit direct care staffing information based on payroll and other auditable data, including direct care staff, job categories, resident census data, and direct care staff turnover and tenure by the required deadline. Review of the facility’s October 2025 through December 2025 HPRD discrepancy report showed the total nursing hours reported by the payroll system were inaccurate by 1,606.80 hours. The discrepancy was attributed to extra break times being deducted from employee hours and to one employee who did not have a CMS job title code, causing those hours not to be counted. During interview, the Administrator stated the payroll software did not correctly carry over licensed nurse and CNA total hours and that, if the codes had carried over correctly, the facility would have met the 3.4 HPRD and would have reported correct census and staffing hours.
Call system failures and inaccessible bathroom pull cords
Penalty
Summary
The facility failed to ensure the communication system was functioning and accessible in resident rooms and in the first floor bathrooms. The facility policy required call lights to alert staff to a centralized work area, required staff to report call light problems immediately, and required the system to be accessible to a resident lying on the floor at each toilet and bath/shower area. During observation, the audible call system was on, but the nurse station panel did not show resident room lights for several rooms on the North and South Units, and staff were observed looking at the panel without responding while a room call light remained on for more than half an hour. Staff also stated that one room’s call light button was missing from the panel and that the system had been malfunctioning for months. Resident interviews described repeated delays in staff response to call lights. One resident with abdominal pain, observed bent over and grimacing while on supplemental O2, stated staff took at least half an hour or longer to answer the call light. Other residents stated it often took 30 to 40 minutes or longer for staff to respond, that nights were the worst, and that staff sometimes walked past their rooms multiple times without coming in. One resident said they had asked a roommate to use the call light from the other side of the room because their own call light did not seem to work. Staff interviews confirmed the malfunctioning system was a safety concern, and the maintenance director stated the issue required a third-party vendor and that no work order had been entered for one resident room’s malfunctioning call light. The first floor bathrooms were also not properly equipped for resident use. Both bathrooms were locked, had no door handles from inside or outside, and the pull cords were only about half an inch long, making them inaccessible to a resident lying on the floor. Staff stated residents could not use the main floor bathrooms because the call lights were non-functional and posed a safety risk, while the administrator stated residents were allowed to use them but acknowledged the pull strings were not accessible as required. One resident reported being told to use the bathroom in their room instead of the main floor restrooms, which affected their ability to attend meals and activities on the main floor.
Kitchen Sanitation and Cross-Contamination During Meal Service
Penalty
Summary
The facility failed to keep the kitchen environment sanitary and to follow safe food handling practices during meal service. During observation, the kitchen ceiling above the dishwasher area had dry, brown-stained water marks, and a ceiling panel was missing, exposing mechanical drains and pipes with dust build-up and spider webs while clean and sanitized utensils were stored below. Multiple kitchen cabinets that held clean utensils had drawers and doors that did not fully close because of failed magnetic locks and worn drawer tracks, and two food waste bins in the dishwashing area were half-filled with food scraps and garbage without lids or covers while scattered food debris was present on the floor. During lunch tray line service, a cook handled chicken with gloved hands, used the same contaminated gloves after touching fallen chicken pieces and a garbage can, and smeared chicken residue onto a clean plate without removing the gloves, washing hands, or changing the plate. The cook also picked up chicken with tongs and allowed meat juice to drip across uncovered foods and into a macaroni and cheese pan, and lifted a metal pan containing blended broccoli in a way that caused liquid underneath the pan to drip across other uncovered foods. The dietary supervisor stated the gloves should have been removed and hands washed between tasks, that contaminated plates should not be used, and that dripping foods and steam table pans should be handled carefully to avoid cross-contamination.
Unqualified Infection Preventionist Assigned
Penalty
Summary
The facility failed to ensure that a qualified staff person was designated to serve as the Infection Preventionist for the infection prevention and control program. During an interview, the Wound Nurse/Infection Preventionist stated they had been in the IP role for one week after the previous IP left, and that they did not have the required infection prevention and control certification. The Interim DON confirmed oversight of the IP role and also confirmed that the current IP did not have the required certification.
Unsafe Entrance Access, Overfilled Sharps Containers, and Incomplete Fall Management
Penalty
Summary
The facility failed to ensure the main entrance was safely accessible for residents using mobility devices. Observation showed the twin front doors did not open when the ADA operators were pressed from either the interior or exterior side. Staff stated the ADA operator had been broken for weeks, that residents in wheelchairs or with other mobility needs were sometimes helped through the entrance by staff, and that some residents could squeeze through when no one was at the front desk. Residents using wheelchairs reported difficulty using the entrance independently, including one resident who stated the door no longer worked and another who had to physically push the door open because the automatic operators did not function. The maintenance record reviewed did not show the issue had been logged. The facility also failed to provide sufficient fall management for two residents. One resident had diagnoses including a fracture, uncontrolled blood sugar, stroke, and upper extremity impairment, and had a documented fall on 12/31/2025 while walking with a walker when staff assisted the resident to the ground. The fall investigation noted the resident reported the walker was faulty and the brakes were not working, but there was no documentation that staff reassessed the resident’s fall risk after the fall. Staff confirmed a new fall assessment should have been completed after each fall, but it was not completed for this resident. Another resident had multiple sclerosis, a brain injury with one-sided weakness, memory impairment, limited range of motion, and required substantial to maximum assistance with bed mobility. The resident was identified as high fall risk on admission, but the fall risk assessment was not consistently completed, including when the resident had a significant change in condition and entered hospice care. After a later fall in which the resident rolled out of bed during repositioning, the facility’s safety devices assessment did not capture the resident’s recent history of rolling out of bed as a fall risk factor. Staff acknowledged the identified risk factors should have been captured, but they were not. The facility also had three sharps containers on nurse carts that were filled past the fill line. One overfilled sharps container was observed on the North LTC nurses’ cart, and two overfilled sharps containers were observed on the South LTC nurses’ cart. Staff verified each container was overfilled and stated the containers should have been changed before becoming overfull. Staff also stated the overfilled containers created infection control and staff safety concerns.
Unsafe and Unhomelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment on the North Unit and South Unit, and failed to ensure safe accessible use of the first-floor public bathrooms. On the North Unit, Resident 15’s room blinds had broken slats, and the resident stated the broken blinds affected sleep because the break was at eye level when lying in bed. The Maintenance Director identified the broken blinds and stated they should be replaced. On the South Unit, a dark stain covered two ceiling tiles above Resident 6’s window, and Resident 6 stated there had been a leak in the ceiling. The stain remained on a later observation, and missing flooring thresholds were noted between the hallway and resident rooms 245 and 247, along with missing push levers from wall-mounted hand sanitizer dispensers across from the second-floor elevator and inside a resident room. For bathrooms 1 and 2 on the main floor, the emergency pull cords were missing from the wall-mounted call light devices. One resident stated staff told them to use the bathroom in their room because the main floor restrooms were for staff and visitors only, while staff later stated the bathrooms were unavailable to residents due to non-functional call lights. The Administrator later stated the bathrooms were available to all residents, but the call light pull cords were absent and the call lights were not clearly audible.
Failure to Provide Bed Hold Notifications During Hospital Transfers
Penalty
Summary
The facility failed to follow the required discharge process for 3 of 6 residents reviewed for hospitalizations by not informing them, or their representatives, of the facility’s bed hold policy. The facility policy dated 04/28/2025 stated that residents and/or their representatives were to receive a bed hold notice as soon as practical for emergent discharges and at the time of therapeutic leave for scheduled procedures, and that residents could choose to pay a daily rate to ensure return to the same bed upon readmission. For Resident 84, records showed a hospital transfer and return to the facility, but there was no documentation that the bed hold policy was discussed; Staff C stated there had been an issue with bed holds at the time and it was likely the process did not occur. For Resident 55, records showed a hospitalization for surgery and return to the facility, but no documentation showed the bed hold policy was reviewed. For Resident 8, the MDS showed discharge to a short-term general hospital, with memory problems and impaired daily decision-making, and the resident’s family member was the DPOA for financial/healthcare decisions; the resident was sent to the ED after being observed very weak, sluggish, and with delayed responses, but there was no documentation that the bed hold policy was offered to the resident or the DPOA.
Late Completion of Comprehensive MDS Assessments
Penalty
Summary
The facility failed to complete comprehensive admission and Annual MDS assessments within the required regulatory timeframes for 10 of 14 residents reviewed. The affected residents were Residents 15, 84, 18, 11, 2, 35, 38, 44, 55, and 6. The report states that admission MDS assessments were completed late for Residents 15, 18, 11, and 44, and Annual MDS assessments were completed late for Residents 84, 2, 35, 38, 55, and 6. The delays ranged from 1 to 9 days past the required timeframe, and the facility policy and RAI Manual both identified the admission and annual assessments as comprehensive assessments used to identify care needs and support care planning. During interview, the MDS Nurse stated the RAI Manual was used as the guide for completing MDS assessments and verified that the listed residents’ comprehensive assessments were completed late. The MDS Nurse stated timely completion was important because it was a federal regulatory requirement and allowed the interdisciplinary team to identify significant changes needed for care planning. The DON stated the RN Coordinator was expected to complete comprehensive MDS assessments timely as required.
Care plans were not comprehensive or implemented for multiple residents
Penalty
Summary
The facility failed to develop and implement comprehensive, resident-specific care plans for 5 of 19 sampled residents. The report identified deficiencies in care planning for residents with urinary catheters, diarrhea and probiotic use, ADL and grooming needs, dressing assistance needs, and repositioning/pressure relief needs. Facility policy required a comprehensive, person-centered care plan for each resident to meet medical, nursing, mental, and psychosocial needs and all services needed. For Resident 35, the quarterly MDS showed diagnoses including a history of stroke, a nerve condition affecting bladder control, and urinary tract blockage, with an indwelling urinary catheter and partial toileting assistance needs. Although there was an order to change the catheter as needed, the catheter care plan and Kardex did not include directions for staff to empty the catheter bag. The resident was observed in bed with the catheter hung on the bed frame and stated they needed more consistent catheter care, including emptying the catheter. Staff stated aides were responsible for emptying the catheter bag and that this direction should have been included in the care plan and Kardex. For Resident 55, the MDS showed dependence on staff for toileting assistance and bowel incontinence, and the resident stated they frequently had diarrhea. The resident had a physician order for a probiotic supplement twice daily for diarrhea, but the care plan did not address the diarrhea or probiotic use, aside from one mention of diarrhea as a possible medication side effect. For Resident 15, the MDS showed an indwelling urinary catheter and substantial assistance needs with personal hygiene, but the catheter care plan called for a privacy cover that was not in place when observed, and the ADL care plan directed staff to assist with grooming and hygiene even though the resident was observed with matted hair and unkempt facial hair and stated staff had not provided the planned assistance. For Resident 9, the MDS showed Vietnamese as the primary language and moderate to maximum assistance needs with dressing, but the resident was repeatedly observed wearing the same clothing without the dressing assistance directed in the care plan. For Resident 48, the MDS showed significant mobility assistance needs and risk for pressure ulcers, and the skin care plan directed repositioning and pressure relief, but the resident remained in the same tilted wheelchair position for more than two hours without observed repositioning or pressure relief assistance.
Failure to Provide Required ADL Assistance
Penalty
Summary
The facility failed to ensure dependent residents received the ADL assistance they were assessed to require, including dressing assistance and personal hygiene/grooming care. The deficiency involved Residents 9, 15, and 1, who were each documented in MDS assessments and care plans as needing substantial staff help with these needs. The report states the failure left residents at risk for body odors, unmet care needs, diminished feeling of self-worth, and a decreased quality of life. Resident 9’s MDS showed the resident primarily spoke Vietnamese, was rarely understood by others, and had weakness, joint pain, and memory impairment. The resident was assessed to need moderate to maximum staff assistance with dressing, and the care plan directed one-person physical assistance with dressing and undressing. On observation, Resident 9 was seen in the same yellow t-shirt on consecutive days, and later in a brown long-sleeved top that had been put on the prior day. A CNA stated the resident was not changed when gotten up from bed, and the Resident Care Manager stated staff were expected to provide morning and evening care, including changing clothing. Resident 15’s admission MDS showed clear speech and intact memory, with medical conditions including paralysis of the lower body after a motor vehicle accident, and the resident was assessed to require substantial to maximum assistance with personal hygiene, including shaving. The care plan directed one-person physical assistance with personal hygiene needs. The resident was observed with matted, disheveled hair and a long beard and mustache with debris woven into dry facial skin, and stated they felt like a caveman and needed help shaving safely and wanted a haircut. Resident 1’s quarterly MDS showed heart failure and a history of stroke, with substantial to maximum assistance needed for personal hygiene including combing hair and shaving. The care plan required one-person physical assistance, but the resident was observed with greasy, long, unkempt hair and a beard extending several inches past the chin, and stated they wanted a haircut and had not had one since admission. The facility had a barber shop area, but the resident’s name was not on the haircut list, and staff stated there was no current barber or clear process for coordinating haircuts.
Urinary catheter bags not emptied or kept off the floor
Penalty
Summary
The facility failed to ensure urinary catheters were maintained according to professional standards of nursing for 2 of 3 residents reviewed for urinary catheter care. The report states that catheter bags were not consistently emptied as ordered and were not kept in the proper location, including being left on the floor. The facility policy required catheter bags to be emptied when half full and kept below bladder level to prevent backflow, and staff interviews confirmed they expected catheter bags to be kept off the floor for infection control reasons. Resident 35 had diagnoses including a history of stroke, a nerve condition affecting bladder control, and urinary tract obstruction, and required an indwelling urinary catheter. The resident’s care plan addressed infection prevention and catheter-related trauma, but did not direct staff to empty the catheter bag periodically or ensure it remained off the floor. The Kardex also did not include instructions to empty the catheter or keep it off the floor. Observations showed the catheter bag completely full with urine visible in the tubing and resting on the floor, and on multiple later observations the bag was again found on the floor. The resident stated concern about the frequency of catheter bag emptying and reported urine on the floor. Resident 15 had diagnoses including loss of mobility from the waist down, bladder control loss, urinary retention, and recurrent UTI, and also had an indwelling urinary catheter. The physician ordered the catheter bag to be emptied every shift because the resident was at high risk for UTI. However, observations showed the catheter bag hanging from a garbage can, halfway full, without a privacy cover, and later full and sitting on the floor without a privacy cover. The resident stated there were several instances when the bag was full and staff did not empty it, and nursing staff verified the bag was full, on the floor, and without a privacy cover.
Inaccurate narcotic accounting and unsecured, expired medications
Penalty
Summary
Narcotic documentation for a resident with chronic pain was not maintained in a clear and accurate manner. The archived January/February 2026 narcotic ledger for the resident showed a liquid opioid with a starting quantity of 400 mL. On 02/15/2026, an LPN documented administration of 18 mL with 10 mL remaining. On 02/16/2026, another LPN documented administration of 18 mL and wrote a corrected count of 15 mL directly over the original remaining quantity in darker handwriting, obscuring the initial entry rather than using a single-line strike-through. The ledger also showed the word discard with 0 mL remaining, and the disposition section documented disposal of 15 mL into a drug buster by staff. The resident’s February 2026 MAR showed the narcotic was ordered daily, and the record showed administration on 02/16/2026 and refusal on 02/17/2026. No progress notes were documented to explain the administration discrepancy, the count correction, or the refusal. During interview, staff stated the bottle had arrived from the pharmacy with more medication than reflected on the label and that the remaining quantity should have been reconciled to 15 mL, but the correction was not documented in a way that preserved the original entry. The Interim DON stated narcotic count corrections should be completed with a single-line strike-through and that the resident’s refusal documentation was inaccurate. Medication storage observations also showed expired and undated medications and biologicals in the medication room and medication carts. The medication room refrigerator contained an opened bottle of tuberculin testing solution, 10 influenza vaccines expired on 03/16/2026, and no temperature log was available. A drawer in the medication room contained an anticonvulsant expired on 12/24/2025 and opened glucose tablets without an expiration date. The Medicare South medication cart contained opened antibiotic eye drops and expired water pills, and the LTC South medication cart contained opened respiratory medication solution cartridges and eye drops without open dates, plus prescription eye drops expired on 2/26/2026. The treatment cart was observed locked, but the bottom drawer could be opened without a key on multiple observations, and staff stated the cart was not secured because supplies behind the drawer prevented it from closing all the way.
Failure to Educate Residents and Family on Outside Food Policy
Penalty
Summary
The facility failed to ensure that residents and a family member were educated and provided the facility policy regarding the use and storage of foods brought in from outside sources, including safe food handling practices. The facility policy stated that foods brought in by family and visitors would be safely stored and handled, checked by food and nutrition staff or licensed nursing staff for diet compatibility, and that residents and families would be given a copy of the policy and a handout on safe food handling practices. The admission agreement packet did not include this policy. Resident 31 had a regular diet with easy-to-chew texture and a nutritional assessment noted cognitive and behavioral problems, including altered mental status affecting food intake. During observation, the resident's son entered the room with restaurant-bought Mexican food in a plastic bag, and the nurse standing nearby did not check the food. The son stated they had been bringing outside food for a while, had not had it checked, did not know the resident's dietary restrictions, and had not been given a copy of the policy. Resident 32 had a cardiac diet and had a half-eaten meal next to a DoorDash bag on the bedside table; the resident stated they had not been informed of the facility's food storage practices or given the policy. Resident 5 had a regular diet after signing a risk agreement to liberalize the diet and had several snacks and canned beverages in the room, including an open snack bag; the resident stated staff did not assist with airtight storage and they were not informed of the facility's food storage practices or given the policy. Staff stated they educated residents as they encountered them, but did not know how family members were educated on the policy.
Failure to Follow EBP and Maintain Cleanable Equipment and Laundry Temperature Logs
Penalty
Summary
The facility failed to adhere to Enhanced Barrier Precautions for three residents who had orders requiring staff to wear gowns and gloves during high-contact care. One resident had a wound and was ordered to have staff wear gown and gloves for bathing, dressing, transfers, and handling linens, but two CNAs entered the room without that PPE and transferred the resident back to bed after a shower. Another resident had an indwelling urinary catheter and was ordered for gown and gloves during high-contact care, but a restorative nursing assistant entered the room without gown or gloves, transferred the resident back to bed, and emptied the catheter drainage bag. A third resident also had an indwelling catheter and an order for appropriate PPE, but a CNA entered the room, put on gloves, and emptied the catheter bag without wearing a gown. The facility also had an observation of a resident's wheelchair with torn and tattered armrest covers exposing foam padding, and the wound nurse/infection preventionist stated that exposed foam was not cleanable and could pose an infection risk. In the laundry room, one washing machine was connected to low-temp detergent, chlorine sanitizer, and laundry softener, but the temperature log showed the last recorded temperature was from nearly 10 months earlier. Staff stated temperatures should be documented daily, and the interim DON confirmed the washing machine temperatures were not being monitored or logged as they should be.
Failure to Use Antibiotic Stewardship Criteria
Penalty
Summary
The facility failed to establish an infection prevention and control program that included implementation of an Antibiotic Stewardship Program to promote appropriate use of antibiotics and reduce unnecessary antibiotic use for 1 of 5 residents reviewed for unnecessary medications. Resident 1 was admitted with diagnoses including high blood pressure, a respiratory infection, and a traumatic brain injury, and the health record showed an antibiotic ordered on 02/05/2026 to be given twice daily for 10 days for a bacterial skin infection affecting both legs. Provider notes documented redness, warmth, and tenderness to the affected areas, but review of the updated McGeer's criteria showed the condition met only three of four criteria used to define an infection. During interview, the Wound Nurse/Infection Preventionist stated the infection did not meet criteria and should have been reported to the provider for review.
Failure to Obtain Timely Informed Consent for Psychotropic and Off-Label Medications
Penalty
Summary
The facility failed to obtain informed consent and document the risks, benefits, and alternatives before initiating or increasing psychotropic medications for 3 residents reviewed for unnecessary medications. The facility policy stated that prior to starting or increasing a psychotropic medication, the resident and/or representative must be informed of the benefits, risks, and alternatives, and that consent should be documented in advance. The policy also stated that medications used as an alternative to a psychotropic medication are subject to the same requirements. Resident 1 had diagnoses including traumatic brain injury, anxiety disorder, and depression, and was receiving an antianxiety medication that was started and later increased, but no informed consent was obtained for either order. Resident 84 had PTSD, an adjustment disorder, and hallucinations, and resumed an antipsychotic medication; consent was obtained 15 days after treatment began. Resident 40 had moderate cognitive impairment and PTSD, and was prescribed a blood pressure medication for off-label treatment of PTSD; consent was not obtained until over six months after the medication was started. Staff interviews confirmed the consents were not completed prior to treatment for these residents.
Grievances Not Logged or Thoroughly Investigated
Penalty
Summary
The facility failed to initiate, log, and complete thorough grievance investigations for two residents who voiced concerns. One resident, who had diagnoses including anxiety, depression, chronic pain, and muscle weakness and required a wheelchair with limited lower body mobility, expressed dissatisfaction with being placed on care in pairs after asking why two staff came to assist with a requested transfer. The resident’s concern was not entered on the March grievance log, and staff later acknowledged that a grievance form should have been completed when the concern was voiced but was not. The same resident also filed a grievance about not being assessed for pain after returning from an outside clinic and alleged being left without adequate pain management, resulting in extreme pain and vomiting. The grievance response addressed outside provider requirements but did not evaluate the facility’s role in continuity of care, pain management on return, or the resident’s reported distress. Another resident, who had depression and bipolar disorder and could communicate needs, reported multiple concerns about a CNA, including a broken phone, feeling like a bother when asking for help, and waiting for assistance at the front door. The grievance form for those concerns had blank investigation and resolution sections, the grievance was not logged, and staff confirmed it was not thoroughly investigated or communicated back to the resident.
MDS assessments did not accurately reflect resident status
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) accurately reflected the status of 3 of 19 sampled residents. For Resident 1, the 07/01/2025 admission MDS indicated the resident was at risk for pressure ulcers but had no current pressure ulcers, even though the 06/27/2025 hospital discharge summary documented two pressure ulcers at discharge. The 06/27/2025 Admit/Readmit Assessment also noted the nurse made several attempts to complete an admission skin check because the resident declined, and documented a known wound to the bilateral buttocks. On 04/29/2026, the resident was observed lying in bed on an air mattress and stated they had wounds on their legs and hips. Staff O confirmed the admission MDS was coded incorrectly and required modification, and stated admission pressure ulcer status should be based on hospital documentation and a physical assessment. For Resident 4, the 02/13/2026 Quarterly MDS showed unclear speech and intact cognition, but the section for routine and activity preferences was left blank, with the resident interview portion marked with dashes and no staff assessment completed. Staff O stated that if a resident could answer for themselves, the resident interview should be completed, and if not, the staff assessment should be completed; Staff O also stated the section should have been completed. For Resident 18, both the 12/20/2025 admission MDS and the 03/22/2026 Quarterly MDS listed anxiety and depression, but did not include bipolar disorder. A 12/29/2025 physician progress note documented bipolar disorder with current episodes of mild to moderate depression. During observation on 04/29/2026, Resident 18 was in bed with multiple belongings within reach and appeared visibly distressed about behavior contracts and a notice of forced discharge to an adult family home. Staff O confirmed the bipolar disorder diagnosis was missing from both MDS records and stated it should have been included.
Inaccurate and Late PASRR Screening
Penalty
Summary
The facility failed to ensure a Pre-admission Screening and Resident Review (PASRR) assessment was accurate for one resident with mental health conditions. The resident’s admission MDS listed anxiety and depression, and the record showed no PASRR was initiated at admission. Later documentation identified bipolar disorder with current episodes of mild to moderate depression, and the care area assessment noted delirium with inattention and disorganized thinking, along with behavioral symptoms including screaming, babbling, cursing, repetitive questioning, pacing, kicking, and scratching. The resident’s record also showed care in pairs was implemented and two behavior agreements were used. A 30-day notice of transfer was initiated because the facility stated the resident’s ongoing verbal and physical aggression endangered the safety of others. The Level I PASRR was completed later by the Social Services Director and listed depression, anxiety, homelessness history, and polysubstance use disorder under SMI indicators, but it did not include the resident’s bipolar diagnosis. The Social Services Director stated the PASRR should have been completed adequately and before admission, and that the bipolar diagnosis should have been included when the PASRR was submitted late.
Missed Routine Care Conferences
Penalty
Summary
The facility failed to provide routine care conferences for 2 of 3 residents sampled for care planning, including a resident with a fracture, blood sugar disorder, poor nutrition, depression, and a psychotic disorder, and another resident with high blood pressure, stroke, and a seizure disorder. For the resident with moderate cognitive impairment and a goal to discharge back to the community, the record showed a discharge preference care plan with interventions for staff to hold interdisciplinary care conferences with the resident and family to address discharge planning and to review the plan of care initially and quarterly or as needed. However, the resident stated they had not had a care conference since admission and wanted to know when they could go home. Record review showed no documentation that the resident was offered or provided a care conference on admission or during the first quarterly assessment period, and only one care conference assessment was completed about six months after admission. For the other resident, the record showed care conferences were conducted annually, and the resident stated the first care conference occurred about a month before the interview and that it would have been nice to have had one earlier to communicate and address needs. Staff stated care conferences should have occurred quarterly and as needed, and confirmed the facility was behind on care conferences for residents.
Failure to Follow Ordered Monitoring and Medication Parameters
Penalty
Summary
The facility failed to monitor and document weights for residents with ordered weekly weight checks and significant weight changes. One resident with memory deficits, unstable blood sugar levels, painful finger joints, and assistance needs for meals had a physician order for weekly weights, but the record showed an 8-pound loss over 9 days and a 9-pound loss over one month without documentation that the resident was re-weighed to confirm the change or that the physician was notified when the significant loss was identified. Staff later stated the software did not flag the loss as significant and that nursing staff did not notify the physician because it was not ordered. Another resident had an active order for weekly weights on Tuesdays, but the last recorded weight was months earlier; the April TAR showed checkmarks indicating weights were obtained on several dates, yet no weights were entered, and one note only stated the resident could not be weighed without documenting refusal, another attempt, handoff to the next shift, or physician notification. The facility also failed to follow medication parameters and ordered monitoring for several residents. One resident had three pain-relieving medication orders, but none included pain-level parameters, and staff administered the medications at varying pain scores, including use of a narcotic pain medication for pain levels ranging from 5/10 to 8/10. Staff stated the orders should have included parameters and that the orders should be clarified. Another resident had an order for a blood pressure medication to be held if systolic blood pressure was below 100 mmHg or heart rate below 60 bpm, but the April MAR showed the medication was given multiple times without checking or documenting those parameters before administration. Additional failures involved ordered skin, respiratory, bowel, and hospice-related care. A resident with an unhealed full-thickness pressure injury and dependence on staff for all cares had an order for weekly skin evaluations, but no weekly skin evaluations were completed after 04/01/2026. Another resident on oxygen had orders for oxygen at 2 L/min and for tubing and humidifier changes weekly, but observation showed the humidifier was not connected, the tubing was undated, and oxygen was being delivered at 2.5 L/min; the resident stated the dry oxygen irritated the throat. A different resident’s oxygen tubing remained dated 11 days earlier than the observation date despite an order to change and date it weekly. The same resident also had PRN stool softeners ordered if no bowel movement occurred for three days, but the April ADL documentation showed five days without a bowel movement and no PRN stool softener was administered. Finally, a resident had a hospice referral order, was evaluated, and was found not appropriate for hospice care, yet the order remained active in the chart.
Failure to Provide Ordered Restorative Nursing Services
Penalty
Summary
The facility failed to provide Restorative Nursing Programs (RNP) for 1 of 1 residents reviewed for restorative services. The facility policy stated that residents needing restorative services after therapy was no longer indicated would be assessed, a plan would be developed for the needed activities and frequency, and Certified Nursing Assistants would complete and document the restorative services offered and completed. Resident 7 was admitted with diagnoses including stroke, high blood pressure, and weakness affecting the left side of the body. The resident's care plan included restorative services three to six times a week to exercise both arms and both legs. However, the March 2026 restorative documentation showed no restorative services were provided that month, and the April 2026 documentation showed services were provided only on 04/09/2026, 04/17/2026, and 04/23/2026, which was less than once a week. The resident stated they did not remember having restorative services since the beginning of the month, and the DON reviewed the record and stated the restorative services should have been provided as outlined in the RNP but were not.
Tube Feeding Not Provided and Documented per Order
Penalty
Summary
The facility failed to ensure that Resident 4’s enteral feeding was provided in accordance with physician’s orders and accurately documented. Resident 4 was dependent on staff for all care and had diagnoses including multiple sclerosis, a seizure disorder, diabetes, and quadriplegia. The physician’s order required a low-sugar formula to be infused at 90 CC per hour for 18 hours for a total of 1620 CC and 1944 calories daily, with tube placement checks before feedings or flushes and tube feeding supplies changed nightly. Facility policy stated feeding tubes should be used according to physician’s orders, including the type and caloric value of the formula, volume, duration, and amount of water flushed through the tubes. Observations showed the feeding pump was not running at times, with formula and saline bags hung but disconnected from the pump, and the formula bags were not consistently dated or timed to match the ordered feeding schedule. On multiple days, the MAR documented only 270 CC of formula provided daily instead of the ordered 1620 CC. Staff reviewed the MAR and stated it did not show the correct amount of nutrition was provided, and the DON stated the MAR did not show the resident received the amount of formula ordered. The DON also observed a formula bag in the resident’s room containing 950 CC and stated there was no documentation showing the bag was refilled during the feeding.
Failure to Assess and Provide Adaptive Eating Equipment
Penalty
Summary
The facility failed to assess and provide special/adaptive eating equipment and utensils for a resident who needed them. Resident 70 had a brain injury with loss of verbal communication and impaired function and mobility on the right dominant side, was Samoan, understood most conversation, preferred American Sign Language, and wanted an interpreter during communication. The resident’s MDS indicated independence with eating, and the revised ADL care plan identified self-care performance deficits related to the resident’s medical conditions and limited mobility. During a dining observation, Resident 70 was seen struggling to cut up the meal while using a teaspoon with the left hand, and some cut-up food fell off the plate as the resident tried to scoop it up. An Activity Aide who interpreted for the resident stated the resident said adaptive utensils and a plate would greatly help with eating independently, and the resident indicated OT had not evaluated them for adaptive utensils. The Director of Rehabilitation reviewed the therapy notes and stated the resident should have been assessed for adaptive feeding equipment use, but was not.
Failure to Investigate and Report Resident-to-Resident Sexual, Physical, and Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to identify, report, investigate, log, and respond appropriately to multiple resident-to-resident altercations, including alleged sexual, physical, and verbal abuse. Facility policy required immediate investigation of any suspicion or report of abuse, thorough documentation, and reporting to the state survey agency, with an Abuse Prevention Coordinator designated to oversee these processes. Despite this, the facility did not treat several documented incidents as reportable allegations of abuse and did not initiate investigations or protective measures as required. For one resident with dementia, confusion, wandering, and intrusive behaviors, progress notes documented that this resident was grabbing and touching various staff and residents, hitting staff and residents, touching another resident’s buttocks, and grabbing another resident’s coat as they walked by. These notes did not indicate what was done to protect other residents, whether staff identified who the affected residents were, whether notifications were made, or whether the incidents were reported or investigated. The facility’s abuse log for the relevant month contained no entries for these events. Another cognitively intact resident reported that this same resident spanked their buttocks while they were bending over to get condiments from a coffee cart; the nurse’s note documented the report and that it was relayed to the DON, but again did not show any protective actions, notifications, reporting, or investigation. A later incident involved another cognitively intact resident who reported that the same behaviorally impaired resident grabbed their breasts near an elevator. An investigation was completed for this single event, including interviews, and concluded that the behavior was related to dementia and was considered behavioral rather than intentional abuse, with abuse ruled out. However, this investigation did not identify or incorporate the prior documented inappropriate touching incidents, and those earlier events were not logged, reported, or investigated as abuse allegations. The deficiency also includes unaddressed physical abuse between roommates. One cognitively intact resident reported to an LPN that they had a physical altercation with their roommate, resulting in scratches on their left arm. The nurse documented the report, the presence of scratches, the offer of a room move, and provider notification, but there was no documentation of actions taken to protect either resident, prevent further abuse, or any indication that the incident was reported, logged, or investigated. Progress notes for the roommate over the same period contained no documentation of the altercation or staff response, and the facility’s abuse log for that month had no entries related to this physical altercation. Additionally, the facility failed to address resident-to-resident verbal abuse as an allegation of abuse. One cognitively intact resident was documented as being verbally aggressive and demeaning toward their roommate, calling them derogatory names, stating the roommate smelled, and expressing disgust that the roommate needed to be changed in bed. The nurse documented that the verbally aggressive resident was offered and accepted a room change and had no further concerns, but the note did not indicate who was notified, nor whether the verbal abuse was reported, logged, or investigated as required by facility policy. Across these events, the facility did not follow its abuse, neglect, and exploitation policy to treat these incidents as allegations of abuse requiring reporting, investigation, and preventive measures.
Removal Plan
- Conducted resident and staff interviews
- Ensured residents with sexual behaviors were placed on one-on-one supervision
- Re-educated all staff regarding abuse policies/procedures
- Ensured an effective system was in place to safeguard, protect and prevent residents at risk for abuse
Failure to Manage Resident Smoking and Elopement Risks Under F689
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment free from accident hazards related to smoking and elopement, and to provide adequate supervision to prevent accidents. Surveyors found that the facility did not timely or accurately assess multiple residents’ ability to smoke safely, did not develop or implement resident-specific smoking care plans, did not secure smoking supplies, and did not maintain a safe designated smoking area. The facility’s own smoking policy prohibited smoking on the premises and required new admissions to smoke off premises under direct supervision by a non-staff responsible party, with smoking supplies stored off premises. Despite this, the designated smoking area in the parking garage was littered with hundreds of cigarette butts, had a fire extinguisher lying on the ground, and another extinguisher and a smoking blanket blocked by trash cans, a chair, and a bed frame, making safety equipment inaccessible. One resident admitted for skilled services with impaired mobility and dependence on staff for care signed the non-smoking agreement but was later documented smoking or vaping in their room and in an indoor atrium. A smoking assessment identified this resident as wishing to smoke, having impaired short-term memory, and being unsafe to smoke independently, yet this was the only evaluation in the record. Their comprehensive care plan contained no information about smoking preferences, the failed smoking assessment, prior indoor smoking events, or interventions for smoking safety or nicotine dependence. Progress notes documented repeated indoor smoking, refusal to surrender a lighter, and use of a cigar in the room, but there was no evidence of incident logging or investigation. Observations showed this resident independently in the road outside, picking up cigarette butts, lighting them in their lap while wearing thin pants and a disposable brief, and obtaining lit cigarettes from other residents in the driveway of the parking garage. The receptionist stated the resident frequently went out to smoke, should sign out but did not, and staff were not informed that the resident was unsafe to go out or smoke independently. Another resident with moderate cognitive impairment, dementia, traumatic brain injury, severe mental illness, and dependence on a wheelchair had no documentation of being informed of the non-smoking policy and no smoking safety assessment, despite multiple documented incidents of smoking inside the facility. Progress notes showed this resident smoked in their restroom, in a shared bathroom where smoke filled the room and disturbed a roommate, and in the atrium, and was reported by other residents to have smoked marijuana with others in the atrium. These events were not entered on the incident log, and there was no documented investigation or new interventions. A cognitively intact resident observed on camera smoking an unknown substance in the garage with another resident also had no smoking assessment or care plan, and the incident was not logged or investigated beyond a note that it would be discussed at a staff meeting. Another resident with mild cognitive impairment and a roommate on oxygen was associated with a strong smell of smoke and ash on the floor in their room, but there was no documentation of locating or removing smoking materials, implementing protective interventions, or logging and investigating the incident. Additional residents who smoked were not properly assessed or care planned. One cognitively intact resident with wandering behaviors had an outdated and incomplete smoking assessment indicating they were not a smoker, with no subsequent assessments despite later documentation of the resident smoking outside and refusing nicotine cessation. This resident was later observed off facility property in a power wheelchair, with coats, bags, and a blanket on the chair, smoking a cigarette. Two other residents observed smoking in the driveway of the parking garage had no smoking safety assessments or care plans. Staff interviews confirmed that 17 residents were known smokers, that three were grandfathered under a prior policy allowing smoking in a designated area, and that active smokers were supposed to be assessed and have smoking-focused care plans, but the DON acknowledged that the reviewed residents lacked such assessments and that there was a breakdown in the system for managing resident smoking. The facility also failed to reassess a resident’s ability to smoke independently after a cigarette burn and did not report or investigate the injury. A progress note documented that this resident told a shower aide they had accidentally burned their leg with a cigarette while smoking outside, but the note did not describe how the burn occurred or any new interventions to prevent future burns. The state tracking and reporting system showed the burn injury was not reported. In interviews, leadership stated that a resident burn was expected to be reported, logged, investigated, and followed by nursing assessment, provider notification, treatment orders, reassessment of independent smoking ability, and consideration of protective equipment and cessation support, none of which were documented for this resident. The deficiency further includes failures related to elopement prevention and supervision for the cognitively impaired resident with dementia, traumatic brain injury, and severe mental illness who used a wheelchair and a Wander Guard device. This resident had an elopement care plan identifying them as a wanderer at risk for elopement, with interventions including frequent monitoring, safety interventions, and use of a Wander Guard. Progress notes documented exit-seeking behavior, agitation, and multiple episodes where the resident left the facility unassisted and went to nearby stores or was found several blocks away. Some events involved staff following and returning the resident, and one involved police notification and initiation of 1:1 supervision, but several elopements were not entered on the incident log or investigated, and there was no documentation of why the Wander Guard system did not alarm during at least one elopement. Later observation showed the resident near an elevator with a Wander Guard device on the wheelchair; the system did not alarm until the elevator button was pushed, and the resident expressed intent to go to the store, while no 1:1 staff were present despite a written 1:1 supervision guideline and staff sign-in logs indicating such supervision should have been in place. Throughout these events, the facility did not consistently follow its own policies for smoking, incident reporting, and elopement. Smoking incidents inside the building, in resident rooms, shared bathrooms, the atrium, and the garage were not reliably reported to administration, entered on the incident log, or investigated. Elopement events for the high-risk resident were similarly omitted from the incident log and not investigated as required. Leadership interviews confirmed expectations that such incidents be reported, logged, and investigated, and acknowledged that the smoking policy was unclear and not followed by residents or staff, and that the elopement policy was not followed for the resident who repeatedly eloped.
Failure to Provide Pressure Ulcer Prevention, Assessment, and Treatment for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary pressure ulcer (PU) prevention and treatment services consistent with its own policy and professional standards, affecting three residents reviewed for pressure ulcers. The facility’s Pressure Injury Prevention and Management policy required Braden Scale risk assessments on admission, weekly for four weeks, quarterly, and as needed, weekly licensed nurse skin inspections, prompt reporting of open areas or dressing issues by CNAs, development of care plans with measurable goals and interventions, and provider notification of new or worsening PUs. Surveyors found that these processes were not followed: Braden assessments were not completed as required, skin and wound assessments were incomplete or missing, care plans lacked appropriate skin and wound interventions, and there was a failure to notify the provider and dietician of new wounds. For one resident with bilateral humerus fractures, moderate cognitive impairment, and total dependence on staff for all ADLs, the admission MDS and admission collection tool documented no PUs on entry, only surgical wounds and bruising. A Braden assessment shortly after admission identified this resident as at moderate risk for PUs, but no further Braden assessments were documented and no skin or wound care plan or preventive interventions were added to the comprehensive care plan. Later, skin and wound evaluations documented new open lesions on both elbows as facility-acquired, but key fields such as the exact date of onset, wound stage, who staged the wounds, and whether the dietician was notified were left blank. Progress notes over the period when these wounds appeared contained no documentation of the new PUs, no description of staff response, and no evidence that the DON or dietician were notified. Dressing changes for the elbow wounds were not initiated and documented until several days after the wounds were first recorded, and subsequent wound evaluations were incomplete and contained wound measurements that did not match the wound provider’s assessment. The resident later reported elbow pain and stated that elbow protectors were provided only after a delay. For a second resident who was cognitively intact, dependent on staff for several ADLs, and assessed as high risk for PUs with constant moisture, bedfast status, complete immobility, and friction/shear problems, the care plan identified a right gluteal fold shearing wound and directed staff to avoid friction and shearing, assist with repositioning, and monitor and document skin injuries. A nurse documented skin breakdown to the posterior thoracic fold and repeatedly charted on this back wound over several months, describing it at one point as open and fleshy, but the notes did not indicate that the provider was informed, what type of wound it was, or any wound measurements. No skin/wound evaluations were completed for this back wound. Later, hospital transfer orders listed four wounds present on admission, including a right gluteal fold PU and additional full and partial thickness wounds, but on readmission the RN left the skin integrity section of the assessment blank, and physician orders reflected treatment for only one of the four wounds. During observations, the resident reported pain from a right buttock wound, stated they had to ask staff for dressing changes and help with turning, and was found with no dressing over the open right gluteal fold area and wearing a brief that was too small and sitting in the wound area. A dressing on the resident’s back was dated nearly a month earlier, was soiled, emitted a strong odor when removed, and no open area was found underneath, indicating the dressing had not been changed or the area reassessed during routine care. The DON later acknowledged that the first resident was at risk for PUs due to bilateral arm fractures, limited mobility, and potential nutritional problems, and confirmed that only one Braden assessment had been completed despite policy expectations for weekly assessments after admission and additional assessments with new skin issues. The DON also acknowledged that there was no skin/wound care plan with prevention and treatment interventions for this resident, that staff did not document progress notes or initiate an investigation or notifications when new facility-acquired PUs developed, and that skin/wound evaluations were not thoroughly completed or consistent with the wound provider’s assessments. For the second resident, the DON stated that the resident was followed by an outside wound provider and was on an air mattress with ointment and staff assistance for bed mobility, but also stated they were unsure how staff missed the long-standing dressing on the resident’s back if showers, skin checks, and care were being completed. The DON described expectations that staff notify providers of new wounds, obtain and implement treatment orders, document thorough wound assessments including measurements and pain, change dressings as ordered, and thoroughly assess skin during care, but survey findings showed these expectations were not met for the residents reviewed.
Systemic Administrative Failures in Abuse Oversight, Smoking Safety, Elopement, and Staff Training
Penalty
Summary
Facility administration failed to manage the facility in compliance with state and federal requirements by not ensuring effective oversight, monitoring, investigation, reporting, and prevention related to abuse, smoking, elopement, and staff training. The administrator’s job description, signed in October 2025, assigned responsibility for daily operations, effective use of resources, ensuring residents are free from abuse, ensuring adequate and competent staffing, and monitoring outcomes of all facility programs, policies, and procedures. The administrator also served as the abuse coordinator and stated that staff were educated on abuse policies upon hire, annually, and as needed. However, a regional market leader reported that management did not consistently review resident progress notes every 24–72 hours as expected to identify care concerns and incidents, and that not all incidents of abuse, smoking, or elopement were identified or reported to management, resulting in missed investigations and missed opportunities for prevention. Surveyors identified repeat issues related to accident hazards and supervision, particularly around resident smoking. A prior complaint survey in May 2024 had already cited the facility at F689 for failing to timely and accurately assess a resident’s ability to smoke safely, secure smoking supplies, and enforce the smoking policy when a resident repeatedly smoked inside the facility, which had risen to Immediate Jeopardy at that time. During the current survey, the administrator provided a list of 17 known resident smokers and stated that residents who smoke were identified on admission, signed a non‑smoking policy, and were required to go off property to smoke. The DON stated that smokers should be assessed, have a smoking‑focused care plan, and have smoking supplies checked in and out from the med cart. Despite this, the administrator acknowledged knowing that two residents had recently smoked multiple times inside the facility, including one resident who smoked indoors three days before the interview, and the DON confirmed that seven identified smokers had no smoking assessments in their medical records. The survey determined an Immediate Jeopardy at F689 beginning in late December 2025 due to repeated indoor smoking by two residents who were assessed as not safe to smoke independently. One resident was identified smoking inside the facility on multiple dates in December 2025 and January 2026, and another resident smoked inside on several dates in December 2025 and again in February 2026. Additionally, the interim administrator later stated that the administrator is responsible for resident safety and that staff are required to report incidents so interventions can occur, but acknowledged that the facility did not implement a smoking policy that supported resident rights and safety and that the elopement policy was not followed for one of the residents. Separately, the staff development coordinator reported that there was no system in place to schedule, document, track, or monitor required staff training and competency, and could not provide documentation of orientation, mandatory training, annual evaluations, or training described in the facility assessment. The interim administrator confirmed that the facility lacked and did not implement a policy for training, documentation, or tracking of required training and competency, contributing to deficiencies cited under F600, F610, F689, and F947.
Failure to Implement and Maintain Safe Smoking Policy and Area
Penalty
Summary
The facility failed to implement and effectively maintain a smoking policy in accordance with Federal, State, and local laws and regulations, resulting in unsafe smoking practices for resident smokers, non-smokers, and staff. The written smoking policy prohibited residents from smoking cigarettes, marijuana, tobacco products, e-cigarettes, and vaping devices anywhere on the premises and required residents admitted after 04/18/2024 to smoke off premises under direct supervision of a non-staff responsible party, with all smoking supplies stored off premises. The policy stated that staff would assess smokers for smoking safety, handling of smoking materials, and use of mobility devices outside, and that residents would sign out to smoke and sign back in upon return, with a section for residents to acknowledge and comply with the policy. However, the policy did not define where the premises ended, did not identify a designated smoking area, did not define smoking safety, and did not address rules for residents admitted prior to 04/18/2024. Surveyor observation showed that the designated smoking area used by residents was in the back of the parking garage, where the ground was littered with hundreds of cigarette butts. A fire extinguisher was found lying on the ground in the gravel, and a fire blanket and a second fire extinguisher were mounted on the wall but blocked by two large trash cans, a chair, and a bed frame, making them inaccessible. A maintenance assistant confirmed that certain residents were allowed to smoke in this area, acknowledged the large number of cigarette butts, and identified the fire extinguisher on the ground as unsafe. The administrator and DON reported that 17 residents were known smokers, that residents signed a non-smoking policy on admission, and that three residents were grandfathered under a prior policy allowing them to smoke in the parking garage while other residents were required to go off property to smoke. The DON stated that active smokers were assessed as independent, with assessments and smoking-focused care plans in their records, and that smoking supplies were kept on the med cart and checked out by residents who then signed out to smoke. When asked if the policy was being followed, the administrator stated the policy was unclear and not followed by residents or staff, and the DON stated there was a breakdown in the system of residents smoking. An interim administrator later stated that the facility did not implement or maintain a smoking policy that supported resident rights and safety.
Failure to Maintain Required CNA In‑Service Training and Competency Evaluation System
Penalty
Summary
The deficiency involves the facility’s failure to develop, implement, and permanently maintain an in‑service training program for nurse aides that was appropriate and effective based on nurse aide performance reviews and the facility assessment. The facility assessment identified that residents had psychiatric, mood, and substance use disorders, cognitive impairment, memory deficits, dementia, traumatic brain injury, and behavior issues, and that they required assistance with skin and wound care and activities of daily living such as bathing, dressing, oral care, eating, transfers, and ambulation. The assessment also specified that staff required training in multiple areas, including communication, resident rights, abuse/neglect identification, reporting and prevention, infection control, resident‑centered care, cultural competency, ADLs, disaster planning, vital signs, care for residents with cognitive and mental/psychosocial disorders, non‑pharmacological behavior management, trauma‑informed care, and care for residents with substance use disorders. Despite this, the facility did not have systems in place to ensure nurse aides received the minimum 12 hours of annual in‑service training, nor did it conduct or use performance reviews to identify and address training needs. Interviews and record review showed that nurse aides were actively providing resident care, but there was no documentation of required training or competency evaluation. Staff X, Y, and Z, all CNAs hired between October 2024 and January 2026, were assigned to resident care on the day and evening shifts, yet the facility could not provide documentation of their annual mandatory training, performance evaluations, skills assessments for competency, or completion of the required 12 hours of in‑service education. The Staff Development Coordinator reported that staff received video training on a corporate portal before orientation on topics such as abuse/neglect, resident rights, infection control, and dementia, and that these topics were discussed at staff meetings; however, there was no tracking system to ensure participation in annual required training, no system to track the 12‑hour nurse aide in‑service requirement, and no process to assess competency through skills evaluation. The Staff Development Coordinator also stated there was no support from the Administrator to implement tracking or competency systems and no involvement in nurse aide performance reviews. The Interim Administrator confirmed that there were no systems or documents in place to meet the training and competency requirements identified in the facility assessment.
Failure to Prevent Resident-to-Resident Sexual Contact and Inadequate Response to Prior Behaviors
Penalty
Summary
The facility failed to protect a resident’s right to be free from abuse when a cognitively intact resident experienced unwanted and unconsented touching of their breasts by another resident. The facility’s abuse, neglect, and exploitation policy defined sexual abuse as non-consensual sexual contact of any type with a resident and required the establishment of a safe environment to prevent sexual abuse and protect all residents from abuse. Despite this policy, the resident reported that while passing a snack closet near the nurse’s station on the way to their room, another resident positioned in the hallway made unwanted physical contact with their chest area, and the resident had to tell the other resident to stop and then sought staff assistance. The resident who experienced the touching had an admission MDS indicating they were cognitively intact, able to make their own decisions, and required moderate assistance with transfers, dressing, toileting, and personal hygiene. Their emotional/trauma care plan documented a history of sexual assault, physical assault with a weapon, and an unexpected sudden death of someone close, and identified them as at risk for decreased psychosocial well-being and emotional distress. The care plan directed staff to help identify triggers and attempt approaches to reduce anxiety and fear so the resident would feel safe and secure in the environment. Following the incident, the resident reported to social services that they felt safe in the facility provided the other resident was kept away from them. The resident who engaged in the inappropriate touching had an MDS showing confusion, memory loss, limited ability to understand or be understood, a non-English preferred language requiring an interpreter, and diagnoses including heart failure, Alzheimer’s disease, anxiety, and depression. This resident had documented physical, verbal, and wandering behaviors, as well as a care plan for sexually inappropriate behavior that included grabbing private areas and hitting buttocks, and another care plan for intrusive behaviors and wandering into other residents’ spaces. Progress notes documented three prior incidents of this resident sexually and inappropriately slapping and grabbing other residents, but the notes did not indicate what staff did in response or what actions were taken to protect other residents. On the day of the incident, observations showed this resident in their room without one-on-one supervision for extended periods, and the facility’s investigation concluded that abuse and neglect were ruled out, determining the incident to be behavioral rather than intentional, despite the history of similar behaviors and the facility’s abuse policy requirements.
Inaccurate PBJ Census Data Submitted to CMS
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to CMS through the Payroll Based Journal (PBJ) system for Quarter 2 of 2025. Review of the June 2022 CMS Long-Term Care Facility PBJ Policy Manual showed facilities are required to electronically submit complete and accurate direct care staffing information, including direct care staff, category of work, resident census data, and direct care staff turnover and tenure, by the required deadlines. For Q2 (April through June 2025), the PBJ data submitted by the facility showed a reported census total of 6988. However, review of the facility’s own monthly census records showed 2266 for April, 2242 for May, and 2238 for June, for a total of 6746, revealing a discrepancy of 242 census days. During an interview, the Administrator stated that PBJ submission and census reporting were completed at the corporate level and acknowledged that issues had been identified with prior MDS submissions being timely and accurate. In an email communication, corporate staff later stated that, after reviewing all PBJ submission documents, the accurate census for Q2 was 6789, which still differed from the originally reported PBJ census total. The Administrator stated they would expect complete and accurate PBJ information to be submitted as required. This failure affected the accuracy of nursing home staffing level data collected by CMS and had the potential to impact provisions of resident care and services.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to accidents occurring. Specific actions or inactions leading to this deficiency were not detailed in the report, nor were any particular residents or staff members mentioned.
Environmental Deficiencies in Resident Care Areas
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for residents across three units: Long Term 1, Short Term 1, and Short Term 2. Observations revealed multiple environmental deficiencies, including scuff marks, chipped and peeling paint, and exposed sharp edges on doorways. Hallways were cluttered with motorized scooters, wheelchairs, and other equipment, obstructing passage and creating potential hazards. Resident rooms lacked personalization, contributing to a less-than-homelike atmosphere. Specific incidents included a resident expressing a desire for a more personalized room and a nursing assistant tripping over detached floor trim. Additional issues were noted in the Short Term 1 and Short Term 2 units, where door frames were worn and chipped, and floor thresholds were separated, posing tripping hazards. Ceiling tiles were stained, and rust-colored drip marks were observed under shared sinks. The facility's administrator acknowledged the importance of maintaining a safe and comfortable environment and recognized the need for timely maintenance to address these deficiencies.
Failure to Provide Required Transfer/Discharge Notifications
Penalty
Summary
The facility failed to implement a system to ensure residents received required written notices at the time of transfer or discharge, or as soon as practicable. This deficiency was identified for five residents who were reviewed for hospitalizations. The facility did not provide written notifications to residents and/or their representatives in a language and manner they understood, which is necessary for making informed decisions about transfers or discharges. Additionally, the facility did not notify the Office of the State Long-Term Care Ombudsman (LTCO) about these transfers, preventing the LTCO from educating and advocating for residents regarding the discharge process. Specific instances included Resident 36, who was discharged to an acute care hospital on multiple occasions without receiving the required notifications. Resident 120, with moderate memory impairment and complex medical diagnoses, was transferred to the hospital without receiving a transfer notice. Resident 25, who had no memory impairment, was hospitalized several times without documentation of written transfer notifications. Resident 19 and Resident 52 also did not receive written notices of transfer with their rights. Interviews with staff revealed a lack of familiarity with the regulations regarding notifying the LTCO and providing residents with written notices, and the facility's current practice did not include sending written notices when residents were transferred to the hospital.
Failure to Provide Bed-Hold Policy Notification
Penalty
Summary
The facility failed to provide written notice of its bed-hold policy to residents or their representatives at the time of transfer to a hospital or within 24 hours, as required by their policy. This deficiency was identified for three current residents and one closed record. Resident 36 was transferred to an acute care hospital on two occasions, with no documentation of a bed-hold notice provided for the first transfer and incomplete documentation for the second. Resident 120, who had moderate memory impairment and complex medical diagnoses, was transferred to the hospital without being offered a bed hold. Similarly, Resident 19 was transferred to a hospital with no documentation of a bed-hold offer. Resident 25, who had no memory impairment and diagnoses including stroke and heart failure, was hospitalized twice without documentation of a bed-hold offer. In interviews, Resident 25 confirmed that the facility staff did not discuss bed-hold options with them. Staff F, a Resident Care Manager, acknowledged the importance of offering a bed hold with each hospitalization, while Staff O, the Business Office Manager, stated that staff should document the offer in nursing progress notes and complete an e-interact form. The failure to provide this information placed residents and their representatives at risk of not being informed of their rights and the cost associated with holding a bed during hospitalization.
Failure to Conduct Timely Care Conferences and Update Care Plans
Penalty
Summary
The facility failed to ensure that residents received and participated in care conferences, as well as failed to update and revise care plans to reflect person-centered care. Specifically, six residents did not have timely care conferences, which are essential for discussing care needs and making necessary adjustments to care plans. For instance, Resident 50 expressed frustration over not having a care conference for eight months, while Resident 57 had not had a care conference for over ten months, despite having significant health issues such as memory loss and chronic pain. Additionally, the facility did not maintain proper documentation of care conferences, as evidenced by Resident 38's case, where staff claimed a care conference was held but lacked documentation to support this. The absence of documentation and failure to conduct regular care conferences as per facility policy left residents without the opportunity to participate in their care planning, potentially leading to unmet care needs and inappropriate care. Furthermore, the facility failed to update care plans to reflect current resident conditions. For example, Resident 36's care plan indicated participation in a walking program, but observations and staff interviews revealed that the resident was not engaged in such a program due to leg pain. This discrepancy between the care plan and the resident's actual condition highlights the facility's failure to revise care plans as needed, which is crucial for providing appropriate and effective care.
Failure to Follow Dietician-Approved Menu for Resident Meals
Penalty
Summary
The facility failed to ensure that resident meals were prepared according to the dietician-approved menu, which placed residents at risk of unmet nutritional needs. During the lunch service on January 30, 2025, the menu indicated that residents on a regular diet should receive a regular preparation of mandarin chicken, while those on controlled carbohydrate and renal diets should receive a diet preparation. However, Staff Y, the kitchen cook, served all residents from the same pan of orange chicken, without providing a separate diet-specific main course. Staff X, the Dietary Supervisor, confirmed that only the diet version of the mandarin chicken was prepared and was unsure of the nutritional differences between the two preparations. Staff Z, the Registered Dietician, later stated that it was important to follow the menu due to the nutritional differences, which included 15 fewer kilocalories, 26 fewer grams of carbohydrates, and 33 fewer grams of sugar in the diet preparation. This oversight in meal preparation was observed and documented, highlighting a failure to adhere to the prescribed dietary requirements.
Deficiencies in Medical Record Maintenance and Resident Privacy
Penalty
Summary
The facility failed to maintain comprehensive and readily accessible medical records for several residents, leading to incomplete documentation and potential delays in treatment. For Resident 1, who was dependent on dialysis due to end-stage renal disease, the facility did not scan dialysis notes and lab results into the medical record. This included missing documentation of a significant drop in blood pressure and related inquiries from the dialysis center. Staff interviews confirmed that these records should have been promptly entered into the electronic medical record but were not, creating a risk of incomplete information for care providers. Resident 4, who was receiving hospice services due to a prognosis of less than six months, had only four hospice documents scanned into their record, despite regular visits from the hospice provider. Staff acknowledged a backlog in the medical records department, which delayed the scanning of important hospice documentation. Similarly, Resident 120's record lacked documentation of a prostate condition that justified the use of a urinary catheter, as noted in hospital discharge papers. Additionally, pharmacy recommendations for several residents, including Residents 44, 33, 25, and 49, were not scanned into their medical records. This included recommendations to adjust medications, which were addressed by staff but not documented in the residents' records. Furthermore, an LPN left a computer screen open to a resident's medication administration records, failing to secure resident privacy. Staff interviews confirmed that these lapses in documentation and privacy were not in line with facility expectations.
Infection Control and Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure proper hand hygiene and personal protective equipment (PPE) protocols were followed, as observed with Resident 269. Staff I, a Certified Nursing Assistant, did not remove gloves or perform hand hygiene before touching the resident's blankets and closet handle, and removed their gown improperly. This was confirmed by Staff J, the Infection Preventionist, who stated that staff should perform hand hygiene and change gloves when transitioning from dirty to clean tasks, and remove PPE in the correct order. In the dining room, Staff AA, an Activity Aide, did not perform hand hygiene between assisting different residents and handling clean and dirty dishes. Staff AA placed dirty trays on the same cart as clean trays, which was against the facility's infection control expectations. Staff J confirmed that staff should perform hand hygiene between handling clean and dirty items and not mix clean and dirty trays. The facility also failed to maintain clean and cleanable surfaces and equipment. Observations showed torn material on chairs and wheelchairs, which Staff J confirmed were uncleanable and increased infection risk. Additionally, a mechanical lift used for resident transfers had dried, brown splatter and was not sanitized after use, as observed with Staff V. Staff J and Staff H confirmed that assistive equipment should be sanitized after each use to prevent cross-contamination.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to uphold resident dignity for several residents by not providing privacy bags for catheter bags, not ensuring residents were fully covered during transport to the shower room, and not knocking before entering a resident's room. Specifically, Resident 52's catheter bag was repeatedly observed without a privacy cover, visible from the hallway, and similar issues were noted for Resident 12. Staff confirmed that catheter bags should have privacy covers to maintain dignity. Additionally, residents were not adequately covered during transport to the shower room, exposing them to other residents and family members. Resident 12 was observed with exposed body parts while being transported, and similar observations were made for Residents 17 and 29. Staff acknowledged that residents should be fully covered during such transports to prevent embarrassment and maintain dignity. Furthermore, staff entered Resident 1's room without knocking, and items were removed from the rooms of Residents 1, 26, 15, and 29 without permission. Resident 1 reported that staff took specially ordered incontinence bed pads from their closet without consent, and similar complaints were made by other residents. Staff confirmed that items should not be taken from residents' rooms without permission, as it is their home and belongings.
Failure to Obtain Informed Consent for Devices and Medications
Penalty
Summary
The facility failed to ensure informed consent was obtained for the use of a tilt-in-space wheelchair for Resident 48. The resident, who had a history of stroke, dementia, and muscle wasting, was observed using the wheelchair, which could potentially restrict their ability to walk independently. The consent form completed for the wheelchair did not identify any potential risks, such as the risk of restraint, and inaccurately stated that the wheelchair assisted with walking. Staff B, the Director of Nursing, acknowledged the inaccuracies and stated that the form should reflect the resident's inability to walk independently regardless of wheelchair positioning. Additionally, the facility did not provide informed consent for the use of high-risk medications for several residents. Resident 64, who had progressive neurological conditions and was on psychotropic medications, had no documentation of consent for these medications. Staff F, the Resident Care Manager, confirmed the absence of consent documentation, acknowledging the risk of loss of the resident's right to be informed and to refuse medication. Similarly, Resident 419, who had neurological conditions and was on psychotropic medications, also lacked documentation of informed consent, which Staff F confirmed. Resident 44, with complex medical diagnoses including anxiety, depression, and schizophrenia, was receiving multiple psychotropic medications without completed consent forms. The forms lacked signatures from the resident or their representative, indicating they were not informed of the risks and benefits. Staff F emphasized the importance of these consents for communication and acknowledgment of medication use. Resident 33, with severe cognitive impairment, was also receiving an antidepressant without a completed consent form, as confirmed by Staff B. The form did not indicate whether the resident or their responsible party was informed or consented to the medication.
Failure to Ensure Advance Directives for Residents
Penalty
Summary
The facility failed to implement an effective program to ensure that residents' Advance Directives (ADs) were included in their records and that residents without ADs were offered assistance to formulate one. This deficiency was identified for two residents, Resident 120 and Resident 49, out of six residents reviewed for ADs. Resident 120, who had a moderate memory impairment and medically complex diagnoses, did not have an AD in their record, and there was no documentation indicating that assistance to formulate an AD was offered. Additionally, there was no care plan addressing Resident 120's AD status. Staff interviews confirmed that the care conference documentation for Resident 120 did not address their AD status. For Resident 49, who had no memory impairment, the facility records showed an AD acknowledgment dated from their admission, but no further documentation of AD discussions or offers of assistance since then. Staff interviews revealed that Resident 49 was only offered assistance to formulate an AD once upon admission, contrary to the facility's policy of reviewing ADs quarterly at care conferences. This lack of adherence to the facility's policy placed residents at risk of not having their treatment goals met.
Failure to Investigate Incidents and Ensure Resident Safety
Penalty
Summary
The facility failed to thoroughly investigate an injury accident involving Resident 6, who used a power wheelchair and had a history of stroke and one-sided paralysis. Despite multiple nursing progress notes indicating bruising and pain in Resident 6's right ankle, the incident was not logged in the facility's September 2024 Incident Log. An observation later showed Resident 6 in pain after another accident with their wheelchair, leading to a hospital assessment revealing a right femur fracture. The Director of Nursing was unaware of the initial accident, indicating a lack of communication and investigation. Resident 38, who had some memory deficits and complex medical diagnoses, reported feeling threatened by a nurse. Despite describing the nurse and expressing fear, no follow-up was conducted to assess Resident 38 for psychosocial harm, and no interventions were put in place to ensure their safety. The facility's incident report indicated that alert charting should have been implemented, but only one progress note was found, showing a lack of documentation and follow-up. Resident 419 experienced a fall resulting in swelling and bruising, but the incident was not logged in the facility's incident log. A previous non-injury fall was recorded, but the injury fall was not, indicating a failure to investigate and ensure the resident's safety. Staff acknowledged the lack of an incident report and the importance of investigating such events to maintain resident safety.
Inaccurate MDS Documentation for Multiple Residents
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) accurately reflected the status of five residents, leading to potential risks for unmet care needs and diminished quality of life. For Resident 44, the MDS did not indicate the use of antianxiety medication, despite records showing administration three times daily. Additionally, the MDS failed to mark indications for high-risk drug class medications and inaccurately documented the resident's influenza vaccination status. Staff P acknowledged these inaccuracies during an interview. Resident 36's MDS incorrectly recorded the date of the influenza vaccine, listing it as the previous year instead of the current season, which was confirmed by a review of immunization records. Resident 4's MDS lacked a complete cognitive assessment, which was noted as the responsibility of the Social Services department. Similarly, Resident 6's MDS did not include a cognitive assessment, leaving their cognitive status undetermined. For Resident 25, the MDS inaccurately stated the resident had natural teeth, while records showed the resident had an upper denture and no natural teeth. Staff P confirmed these discrepancies, emphasizing the importance of accurate MDS documentation for appropriate care planning.
Deficiency in PASRR Assessments for Residents
Penalty
Summary
The facility failed to ensure that Pre-Admission Screening and Resident Review (PASRR) assessments were completed for five out of seven residents reviewed for PASRR screening. This deficiency was identified through interviews and record reviews, revealing that the necessary PASRR Level I and Level II evaluations were either missing or inaccurately completed. For instance, Resident 33, who had diagnoses of anxiety, depression, and a mood disorder, did not have a PASRR included in their record. Similarly, Resident 25, with multiple serious mental disorders, did not have a PASRR I completed prior to admission, and a Level II evaluation was not conducted as required. Additionally, the report highlights inaccuracies in the PASRR Level I assessments for Residents 44 and 64, where serious mental illness indicators were not identified, leading to a lack of necessary Level II evaluations. Staff interviews confirmed these oversights, with admissions processes failing to identify and correct errors in PASRR documentation. The absence of accurate and complete PASRR assessments left residents at risk of inappropriate placement and not receiving timely and necessary mental health services.
Failure to Clarify and Follow Physician Orders
Penalty
Summary
The facility failed to ensure physician orders were clarified and followed for several residents, leading to potential risks for ineffective treatments and medication errors. For Resident 38, the IV antibiotic order lacked a specified flow rate, and the IV tubing was not labeled with the date and time of change, which was against the facility's policy. Staff failed to clarify the order, and the tubing was not labeled, as confirmed by interviews with staff members. Resident 64's care plan indicated a need for bowel management due to constipation, but the MAR lacked a physician order for a suppository, which was part of the bowel protocol. Additionally, a powdered laxative was administered twice daily due to a duplicated order, leading to loose stools and diarrhea, increasing the risk of dehydration and skin breakdown. Staff interviews confirmed the lack of order clarification and the error in administration. Residents 44 and 50 were administered medications outside of the prescribed parameters for blood pressure management, with several instances of medication being given when the systolic blood pressure was below the specified threshold. Resident 44 also had pain medication orders that required clarification, as the parameters for administration were not followed. Resident 49's bowel management protocol was not initiated despite the absence of bowel movements, which could lead to severe complications. Staff interviews confirmed these deficiencies in following physician orders and protocols.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate nail care and assistance with shaving for residents who were dependent on staff for activities of daily living (ADLs). Resident 120, who had moderate memory impairment and complex medical diagnoses, required substantial assistance with personal hygiene. However, from January 9, 2025, to January 31, 2025, there was no documentation of nail care being provided, and observations showed the resident's fingernails were long, sharp, and dirty. Similarly, Resident 21, with severe cognitive impairment and chronic health issues, required substantial assistance with personal hygiene. Despite a care plan directive for weekly nail care, observations revealed long nails with debris, and staff admitted to forgetting to offer nail care. Residents 36 and 169, both requiring extensive assistance for personal hygiene, were observed with long chin hairs despite expressing a preference for shaving. Resident 36, who had no memory impairment, was observed with long chin hairs even after receiving a shower, which was when shaving was typically performed. Resident 169, admitted on January 23, 2025, had no documented bathing until January 30, 2025, and was also observed with long chin hairs. Staff interviews confirmed that shaving should be part of daily care, especially during showers, but this was not consistently done. The facility's failure to adhere to its ADL policy placed residents at risk for poor hygiene and diminished self-worth.
Deficiencies in Skin Care, Pain Management, and Post-Fall Monitoring
Penalty
Summary
The facility failed to ensure proper assessment, monitoring, and treatment of residents' skin conditions, as evidenced by the cases of two residents. One resident, who was cognitively intact, reported having a sore on their abdomen, which was observed to have a dressing with drainage. Despite this, there were no physician orders for treating the wound, and a weekly skin evaluation failed to identify any skin impairments. Staff interviews confirmed the absence of treatment orders and highlighted a lack of communication and documentation regarding the resident's wound care needs. Another resident reported a rash on their abdomen and thighs following a vaccination, which was not documented in the skin assessments. Although a provider's note indicated a plan to add medication and conduct daily skin checks, the facility records showed no daily monitoring of the resident's skin condition. Observations later confirmed the presence of a rash and scratch marks, indicating a failure to accurately document and monitor the resident's skin condition as expected by facility policy. Additionally, the facility did not implement nonpharmacological pain interventions for a resident with frequent pain due to a left leg amputation, relying solely on opioid medication. Furthermore, after a fall, another resident with neurological conditions and a risk for falls was not monitored for latent injuries as directed by the provider. The resident's health records lacked progress notes or skin assessments related to the injuries, demonstrating a failure to follow up on the resident's condition post-fall, as required by the facility's policies.
Failure to Reassess Power Wheelchair Use and Bed Placement Safety
Penalty
Summary
The facility failed to ensure proper assessment and reassessment of residents using power wheelchairs, leading to accidents and injuries. Resident 6, who had a history of stroke and one-sided paralysis, used a power wheelchair independently. Despite a policy requiring reassessment after hospitalizations or cognitive changes, Resident 6 was not reassessed after two hospitalizations, a change in cognition from intact to moderately impaired, or after an incident where they injured their ankle by running into a wall with their wheelchair. This lack of reassessment resulted in Resident 6 sustaining a fracture requiring surgery after another accident involving their power wheelchair. Additionally, the facility did not conduct safety assessments for the placement of beds against the wall for Residents 25 and 49. Resident 25, who had diagnoses including stroke and morbid obesity, had their bed placed against the wall without a safety assessment, as ordered by a physician. Similarly, Resident 49, who had a left leg amputation and other mobility issues, also had their bed placed against the wall without a safety assessment. Staff interviews confirmed that safety assessments should have been completed to prevent entrapment and ensure resident safety. The facility's failure to adhere to its own policies regarding the assessment and reassessment of residents using power wheelchairs and the lack of safety assessments for bed placements against the wall resulted in significant safety hazards. These oversights placed residents at risk of injury and demonstrated a lack of adequate supervision and hazard prevention in the facility.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Auburn
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Canterbury House | 0.7 mi | ★★★★★ | 22 | 0 |
| Lea Hill Rehabilitation And Care Center | 1.8 mi | ★★★★★ | 1 | 0 |
| North Auburn Care | 2.7 mi | ★★★★★ | 11 | 0 |
| Garden Terrace Healthcare Center Of Federal Way | 5.2 mi | ★★★★★ | 0 | 0 |
| Avalon Care Center Federal Way, L.l.c. | 5.2 mi | ★★★★★ | 26 | 0 |
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