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 August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avalon Care Center At Northpointe during CMS and state inspections, most recent first.
Failure to report and investigate abuse allegations: Staff reported concerns that an NA left the building and did not provide care to multiple residents, with two residents found soaked and one resident reporting a fall and arm injury that was not reported to the nurse. The DON and Administrator confirmed the allegations were not reported to administration or the SA as required, and the investigation did not address all of the allegations.
A facility failed to maintain a clean, comfortable, and homelike environment when multiple windows on the North Unit, including resident rooms and a common TV room, were repeatedly observed with a white hard-water film that made them blurry and blocked the view outside. A resident said the windows had been that way since admission, staff acknowledged the condition, and the Maintenance Director and Administrator confirmed the film was caused by sprinkler water hitting the windows.
Controlled lorazepam liquid was not fully included in shift-change narcotic counts in two med rooms, including refrigerated bottles for two residents and two unopened Omnicell-labeled bottles that were only counted monthly with pharmacy staff. In addition, two opened PPD vials were left in the refrigerator past the 30-day discard period, and staff acknowledged the PPD should have been discarded.
Staff failed to follow EBP and PPE requirements during resident care. An LPN flushed a resident’s g-tube and later administered IV antibiotics via a PICC without wearing a gown, another LPN gave an insulin injection without gloves, and NAs provided suprapubic catheter care without gowns. The residents involved had indwelling devices or received IV antibiotics, and staff acknowledged the gown and glove expectations.
Failure to Evaluate Resident for Self-Administration of Medications: A resident with COPD, chronic pain, and constipation kept OTC stool softeners, Lactaid, and Tums at the bedside and reported taking Lactaid nearly every day and stool softeners as needed. The MAR showed PRN constipation meds and an order for Lactase, but there was no provider order or documented evaluation authorizing self-administration, and the care plan did not show the resident was approved to manage their own meds.
PASRR Level II evaluation was not completed for a resident who later had diagnoses of bipolar disorder and depression after an initial PASRR Level I found no need for further review. The Social Services Director confirmed the missing Level II, and the Administrator and DON stated that a Level II was expected when a resident had a serious mental illness diagnosis.
A resident with dementia, weakness, and severe cognitive impairment had a care plan for ADL deficits and set up assistance for meals, but staff failed to revise the plan when the resident developed shaky hands and was given a lidded/spout cup for fluids. Observations showed the resident struggling to hold coffee, spilling drinks, and becoming soiled with coffee, while staff reported the adaptive cup was not on the Kardex/care plan and the DON stated there was no adaptive equipment listed.
A resident receiving IV antibiotics via PICC had ordered line care that was not consistently carried out or documented: the dressing change was not clearly recorded when due, an antimicrobial disk was not present under the dressing, and staff changed needleless caps without an order to do so. In a separate issue, a resident with Parkinson’s disease and a history of constipation did not have the bowel protocol implemented after prolonged periods without a BM, despite PRN laxatives being ordered.
A resident with quadriplegia and significant pressure ulcers had an order for an alternating pressure-relieving mattress, but repeated observations showed the mattress remained on Static and locked instead of Alternating. Although the TAR was initialed as completed, staff interviews showed they were only checking that the mattress was plugged in and inflated, and several staff believed the settings were already programmed or could not be changed.
Two residents with nutritional risk experienced significant weight loss while staff failed to respond appropriately to poor meal intake. One resident with dementia and a history of malnutrition had repeated low intake, refused meals on observation, and was not offered an alternate meal or supplement, while the NA did not notify the nurse. Another resident with diabetes, depression, malnutrition, and swallowing difficulty also had marked weight loss, stated they did not like the food, and was observed eating only part of meals without being offered an alternate meal or supplement or having the nurse notified.
Medications were not administered or held according to provider-ordered BP and HR parameters for two residents. One resident with HF and HTN received Lisinopril and Metoprolol ER three times when HR was below 60, with no charted explanation. Another resident with HTN and dementia received Clonidine, Hydralazine, and Losartan Potassium multiple times outside hold parameters, and staff confirmed meds should have followed the ordered VS limits.
Late MDS Encoding and Transmission: The facility failed to encode and transmit MDS assessments within required timeframes for two residents. One resident's admission MDS was completed but not yet submitted to CMS, and another resident's admission MDS was submitted late after the RN coordinator signed it much later than the ARD. The MDS Coordinator acknowledged both delays, and the Administrator stated staff were expected to submit MDS assessments on time.
A resident with opioid use disorder and a history of hepatitis received a lower methadone dose than prescribed by the OTP provider after a facility physician assistant changed the order based on recommendations from a hepatology clinic, without documented coordination with the OTP. The facility did not have a specific policy for OTP-managed residents and only reported the dosing discrepancy after being questioned by OTP staff.
A resident with opioid use disorder and chronic liver conditions experienced a change in methadone dosage by facility staff without documented coordination with the opioid treatment program (OTP) provider. The facility administered a lower methadone dose based on recommendations from a hepatology clinic, but did not consult the OTP, resulting in a discrepancy that was only discovered when unused medication was returned. Interviews revealed a lack of clear policy and confusion among staff regarding provider responsibilities for MOUD management.
Two residents experienced significant weight loss due to the facility's failure to maintain acceptable nutrition parameters. One resident lost 7.9% of their weight over three months, while another lost 8.51% in one month. Observations showed that residents were not offered alternate meals or nutritional supplements despite poor intake. Staff interviews revealed a lack of timely interventions and communication, contributing to the residents' weight loss.
The facility failed to follow professional standards for food safety, including improper storage and temperature monitoring of food items. Expired eggs were found in the refrigerator, and food temperatures were not consistently checked or documented during meal service, increasing the risk of contamination and bacterial growth.
The facility failed to submit MDS assessments to CMS within the required timeframe for four residents, affecting data accuracy and monitoring. The MDS Director and DON acknowledged the late submissions, confirmed by a validation report showing multiple late files.
The facility failed to administer bowel care medications as ordered for several residents, leading to prolonged periods without bowel movements. Despite physician orders for laxatives to be given after specific timeframes, the medications were not administered, and no documentation explained the omissions. Staff interviews revealed a misunderstanding of the protocol, contributing to the deficiency.
The facility failed to ensure proper respiratory care for three residents, lacking provider orders and documentation for oxygen and CPAP use. One resident used oxygen without orders, another had a CPAP machine without documented use or maintenance, and a third did not consistently use their CPAP despite having an order. These deficiencies risked respiratory complications and diminished quality of life.
The facility did not complete annual performance reviews for two nursing assistants, Staff P and Staff Y, as required. This was discovered through interviews and record reviews, which showed no documentation of completed evaluations. The administrator was unaware of the lack of a process for these evaluations, which posed a risk to residents' care quality.
The facility failed to administer medications as ordered for three residents, leading to significant medication errors. A resident with diabetes and high blood pressure missed insulin doses and had blood pressure medication administered against parameters. Another resident missed insulin and sevelamer doses during dialysis sessions, with no adjustments made. A third resident received blood pressure medication despite low readings. These failures risked medical complications.
The facility failed to maintain proper temperature controls for medication storage in two medication rooms and one refrigerator. In the West medication room, no thermometer was present, and in the East medication room, the absence of a thermometer was acknowledged by the DON. The refrigerator contained various medications, and the temperature logs were incomplete. The Administrator expected staff to monitor temperatures, but no policy was provided.
The facility failed to provide appetizing and palatable food, leading to dissatisfaction among residents. Complaints included mushy vegetables, processed chicken, inedible eggs, and overly salty meals. A test tray confirmed these issues, with food being bland and unappetizing. Despite residents expressing concerns, improvements were not made, and the dietary manager delayed addressing these issues.
The facility failed to ensure arbitration agreements were properly reviewed and explained to three cognitively impaired residents or their legal representatives. The agreements were signed by the residents themselves, despite their severe cognitive impairments, rather than by their legal representatives or POA. This oversight placed the residents at risk of being uninformed of their rights and losing legal protection.
The facility failed to implement enhanced barrier precautions for two residents with draining wounds, and staff improperly used N95 masks during a COVID-19 outbreak. Infection prevention policies were outdated, and the water management plan was incomplete, increasing the risk of infection spread.
Two residents in an LTC facility were not informed of medication changes, violating facility policy. One resident with cognitive impairment had their Seroquel and Ativan dosages increased without their POA's knowledge, leading to increased sedation and falls. Another resident experienced a decrease in pain medication without being informed. Staff interviews confirmed the need for notification and documentation of such changes.
The facility failed to notify the State Long-Term Care Ombudsman of hospital transfers and discharges for several residents, as required by policy. This deficiency was identified through interviews and record reviews, revealing that residents were transferred to the hospital without the necessary notifications. Staff interviews indicated a lack of awareness regarding the notification requirement, and the Ombudsman confirmed the facility's failure to notify them, except in cases of eviction notices.
The facility failed to provide timely bed-hold notices to five residents or their representatives during hospital transfers, risking their awareness of the right to retain their rooms. This deficiency was identified through interviews and record reviews, highlighting the lack of documentation and communication regarding bed-hold options.
The facility failed to timely and accurately complete MDS assessments for several residents, affecting data gathering and monitoring of residents' progress. Some assessments were completed weeks or months late, and inconsistencies were found in cognitive assessments. Staff acknowledged being behind on MDS completion, with 76 assessments overdue.
The facility failed to investigate falls and implement safety interventions for residents, leading to repeated falls and injuries. Two residents with substance use disorders were not assessed or managed properly, resulting in one resident eloping. Additionally, the facility did not ensure safe smoking practices, lacking supervision and safety measures for residents who smoked.
The facility failed to ensure proper monitoring and documentation of psychotropic medication use for residents, leading to potential chemical restraint and unmet care needs. A resident with dementia was administered increasing doses of Seroquel without consistent behavior monitoring or implementation of non-medication interventions. Similar issues were noted for two other residents with depression and anxiety, where documentation of behavior and side effects was incomplete.
A resident with bipolar disorder, high blood pressure, and cervical cancer was not evaluated for self-administration of medications, leading to unsupervised medication intake. The resident was found with loose pills and expressed uncertainty about them. An LPN admitted to possibly leaving the medications unattended, and the Resident Care Manager confirmed no assessment for self-administration had been conducted.
The facility failed to provide weekly and alternative menus to residents, denying them the right to choose their meals. Three residents, who were cognitively intact, reported not receiving menus or being unaware of their availability. Staff confirmed that menus were only given upon request, resulting in a low number of residents submitting meal choices. This deficiency potentially impacted residents' nutritional needs and quality of life.
The facility failed to provide complete information on services and charges not covered under the per diem rate for two residents. One resident received an incomplete SNFABN, while another resident's POA was informed of Medicare ending via phone but not given written notice of costs. The Business Office Manager confirmed the lack of documentation.
The facility failed to maintain a homelike environment and sanitation for residents, with drywall damage in several rooms and an unclean wheelchair for a resident. Observations over several days showed gauges and holes in the drywall of three residents' rooms, and a wheelchair with debris and a brown substance for another resident. Staff interviews indicated a lack of timely maintenance and cleaning responsibilities.
A facility failed to document and communicate a resident's transfer information to the receiving hospital. The resident, with cognitive impairment and conditions like diabetes and anxiety, was transferred for evaluation of agitation and psychosis. The transfer form lacked documentation of communication with the hospital, and staff confirmed the expectation to notify the hospital of the resident's condition.
A facility failed to complete a timely PASARR for a resident admitted after an exempted hospital stay. The resident, with depression and anxiety, was expected to stay for 30 days or less but remained beyond this period. A Level I PASARR indicated the need for a Level II, but it was not completed until 40 days after the expected discharge. The Social Service Director acknowledged the importance of timely PASARR completion for mental health care.
A facility failed to follow a physician-ordered podiatry referral for a resident with diabetes and Multiple Sclerosis, leading to delayed foot care. Despite a September note indicating the need for podiatry evaluation, the resident's toenails were not addressed until January by a nurse practitioner. Staff interviews revealed confusion and delays in arranging podiatry care, with uncertainty about sending residents out for appointments. The resident had not been seen by a podiatrist by the time of the survey exit.
A facility failed to ensure accurate communication and care planning for a resident receiving dialysis via a CVC. Despite the resident never having a fistula, the care plan inaccurately included interventions for a fistula, and staff documentation reflected this error. The Pre-Dialysis Assessment forms were inconsistently returned, and staff were initially unaware of the correct access site, leading to a deficiency in dialysis care.
The facility failed to provide adequate staffing, impacting resident safety and care. A resident with cognitive impairment experienced multiple falls due to insufficient supervision, while another resident with substance abuse history eloped due to lack of a care plan. Additionally, a resident reported long call light wait times, highlighting staffing challenges, especially during evenings and weekends.
A facility failed to consistently monitor a resident for adverse effects of a blood thinning medication, as required by provider orders. The resident, with heart failure and high blood pressure, was taking Xarelto. Documentation was incomplete across multiple shifts, as confirmed by interviews with a Registered Nurse and the Director of Nursing, who acknowledged the deficiency in monitoring.
The facility failed to maintain resident beds in safe operating condition, with four beds having exposed wires and peeling electrical tape on bed controls. Observations revealed these issues in multiple rooms, and the Maintenance Director admitted to not conducting regular inspections, relying instead on work orders to identify disrepair.
The facility failed to maintain functional call bell systems for two residents, leading to potential safety risks. A resident's call light was non-functional for weeks, and another resident's call light failed during an urgent need. Maintenance relied on work orders to address issues, lacking regular audits.
The facility failed to ensure personal refrigerators for two residents were clean, free of expired foods, and maintained at appropriate temperatures. One resident's refrigerator had a brown liquid spill and lacked a temperature log, while another's contained expired yogurt and pudding. Staff interviews revealed confusion over responsibility for monitoring these refrigerators.
The facility failed to investigate potential abuse allegations for two residents and falls for two others. A resident alleged their call light was removed, leading to a fall, while another had a scab allegedly caused by staff. Investigations were inadequate, lacking thorough staff interviews and specific incident details. Additionally, falls involving two other residents were not investigated, as required by facility policy.
The facility failed to provide adequate discharge planning and documentation for two residents, leading to potential risks of unsafe discharges. One resident with cognitive impairment was discharged without proper documentation, while another resident with mental health issues eloped and was not properly followed up. Staff interviews revealed inconsistencies in the discharge process and a lack of clarity regarding responsibilities.
The facility failed to provide necessary assistance to a resident during an outside appointment and did not adhere to the care plan for bathing another resident. A resident who was severely cognitively impaired and dependent on staff for ADLs was left without a caregiver at an appointment, leading to unmet needs. Another resident, who required assistance for bathing, did not receive consistent care as per their care plan, with several instances of missed or refused baths not being addressed.
A resident at risk for pressure ulcers due to immobility and health conditions developed a stage four pressure ulcer on the left heel, which the facility failed to identify and treat in a timely manner. Despite revisions to the care plan and interventions like an air mattress and heel floating, the ulcer was not promptly addressed, leading to delayed wound healing. Staff interviews revealed a lack of awareness and timely response to the resident's condition.
A resident reported an allegation of rough treatment by a staff member to Social Services, but the incident was not immediately documented in the facility's Incident Log. The Social Services staff member reported the allegation to unidentified staff, but the Administrator was only informed during a clinical meeting days later, leading to a delay in reporting to the State Survey Agency.
A resident with an open surgical wound requiring wound vacuum therapy did not receive the prescribed continuous treatment due to staff misinterpretation of the treatment schedule. The wound vacuum dressing was removed prematurely and replaced with a wet-to-dry dressing without proper documentation or notification to the medical provider. Staff were unfamiliar with the therapy's requirements, leading to a risk of delayed healing and infection.
Failure to Report and Investigate Abuse Allegations
Penalty
Summary
The facility failed to implement its Abuse and Neglect Prohibition Policies by not reporting allegations of abuse to facility administration and the State Agency within the required timeframe and by not completing thorough investigations for five sampled residents. The facility policy, revised 09/13/2022, required staff to report alleged abuse immediately, and no later than two hours when serious bodily injury was alleged, with all other allegations reported within 24 hours. It also required the facility to investigate the allegation and document evidence of the investigation. A handwritten note by a RN documented that NA staff reported concerns about another NA leaving the building at an unidentified time and not providing care to multiple residents, including residents 5, 38, 69, 117, and 131, for an unidentified period. The note also stated that residents 5 and 117 were completely soaked, food debris from the prior day was under resident 5, and resident 38 said they fell and hurt their arm and reported the fall to the NA, which was not reported to the nurse. Review of the facility incident logs showed no abuse allegations reported for these residents after the note was written. The DON stated the note was not received until the next day and that follow-up notes did not address all allegations or include all components of a thorough investigation. The Administrator confirmed the allegations were not investigated and reported as required.
Dirty Windows on North Unit
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment on Unit 1 - North Unit because several windows in resident rooms and a common television room had a white film, described as hard water residue or chalky mineral spots, that made the windows blurry and prevented a clear view outside. During multiple observations, both windows in one resident room, five of eight windows in the common television room, and the windows in another resident room were repeatedly noted to have the same white film on the outside of the glass. Resident council members stated the windows were too dirty to see outside. A resident in room 310 stated the windows had been blurry with a white film on the outside since admission in mid-April 2026 and was unsure whether housekeeping had cleaned them. Staff J, a nursing assistant, acknowledged the windows had a white film and was unsure how long they had been in that condition. Staff K, a housekeeper, stated the facility cleaned inside windows but said many windows on the North Unit had a hard water film from sprinkler water hitting the windows and that an attempt to clean the outside windows had only partially succeeded. The Maintenance Director also acknowledged the hard water film was caused by sprinkler water hitting the windows along the north side of the building, and the Administrator stated the windows were expected to be maintained in a clean, comfortable, and home-like condition.
Controlled Medication Counts and Expired PPD Vials
Penalty
Summary
The facility failed to ensure that lorazepam liquid, a controlled anti-anxiety medication, was monitored adequately to minimize the risk of loss or diversion in two medication rooms. In the West medication room, a locked box in the medication refrigerator contained lorazepam liquid for two residents; the amounts observed did not match the narcotic book, with one bottle showing 28 ml remaining while the book documented 29.5 ml, and another showing 8 ml remaining while the book documented 13.2 ml. Staff stated that controlled medications were counted at every shift change, but they had not been including refrigerated lorazepam in the count and had not been aware it was stored in the refrigerator. In the East medication room, the locked refrigerator box contained four bottles of lorazepam, including two unopened bottles labeled Omnicell that were not assigned to any resident and were not included in the shift-change count; staff stated those bottles were counted monthly with pharmacy staff instead of at each shift change. The facility also failed to discard two expired Tuberculin PPD vials in the West medication room refrigerator. One vial had been opened on 03/11/2026 and the other on 02/08/2026, both beyond the 30-day discard timeframe stated in the FDA package insert for opened multi-dose PPD vials. Staff acknowledged that the PPD testing solution should have been discarded 30 days after opening and that it had not been discarded.
Failure to Use EBP and Gloves During Resident Care
Penalty
Summary
The facility failed to ensure staff used Enhanced Barrier Precautions during high-contact care for residents with wounds or indwelling devices, and failed to ensure gloves were worn during an insulin injection. The report states that these failures placed residents and staff at risk of spreading infectious bacteria and exposure to blood or body fluids. Resident 112 had diagnoses including a brain bleed stroke, right-sided paralysis, and dysphagia, was severely cognitively impaired, had a urinary catheter, and received more than 51% of nutrition through a g-tube. The resident’s provider ordered EBP for care related to the urinary catheter and feeding tube. During observation, the resident’s room had EBP signage and PPE available, and Staff S flushed the g-tube while wearing gloves but no gown. Staff S stated they were not aware a gown was required for flushing the g-tube and believed gowns were for more in-depth care. Resident 144 had bacteremia and Streptococcal arthritis of the left hip and received antibiotics through a PICC line. During medication administration, Staff Q wore gloves, administered oral medications, and then connected IV cefazolin to the central line without wearing a gown. Staff Q stated they knew residents needing EBP from report or signage and acknowledged they should have worn a gown for the central line antibiotic administration. In another observation, Staff X administered an insulin injection to Resident 7 without gloves. For Resident 15, Staff W and Staff T both provided suprapubic catheter care while wearing gloves but not a gown, and both stated a gown should have been worn.
Failure to Evaluate Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure a resident was evaluated to safely self-administer medications. Resident 3 had diagnoses of COPD, chronic pain, and constipation, and was documented as alert, oriented, and able to make needs known. During interviews and observation, the resident stated they had bought stool softeners from Amazon and kept them in the nightstand drawer, and also took Lactaid from the bedside because it took a long time to get it from nurses. Lactaid packets were observed on the bedside table, and a bottle of Tums was visible in the partially opened top drawer of the nightstand. The resident stated they took Lactase every time they ate dairy and had not needed the stool softener for a couple of months, and acknowledged staff may not have been aware of the stool softeners. Review of the MAR showed orders for PRN constipation medications and an order for Lactase, three tablets every eight hours if needed for lactose intolerance, but no doses were marked as given. There was no provider order allowing the resident to take their own medications, no order for Tums was found, and no evaluation in the medical record showing the resident could safely self-administer medications. The care plan also did not show the resident was authorized to administer their own medications. Staff stated that a provider order and an evaluation were required for self-administration, and the Administrator and DON acknowledged the resident should have been evaluated and a provider order obtained.
PASRR Level II Evaluation Not Completed for Resident with Serious Mental Illness
Penalty
Summary
The facility failed to ensure that a PASRR Level II evaluation was completed timely for one resident who had been reviewed for PASRR. The resident’s annual assessment dated 04/30/2026 described the resident as cognitively intact and listed diagnoses of depression and bipolar disorder. A PASRR Level I screening had been completed prior to admission and indicated that no Level II evaluation was needed at that time because the resident did not have a diagnosis of serious mental illness. Record review showed that the resident was later diagnosed with bipolar disorder on 11/20/2025 and depression on 12/24/2025, which required a PASRR Level II evaluation. No documentation of a PASRR Level II was found in the electronic record, and no information was provided. In interview, the Social Services Director confirmed that no PASRR Level II had been completed for the resident as required and stated that the evaluation was important so the facility could care plan to address the resident’s mental health issues. The Administrator and DON also stated that a PASRR Level II was expected when a resident had a diagnosis of serious mental illness.
Failure to Update Care Plan for Adaptive Drinking Equipment
Penalty
Summary
The facility failed to revise Resident 65’s comprehensive care plan after the resident developed difficulty holding cups and was given adaptive drinking equipment. Resident 65’s quarterly assessment documented diagnoses of dementia and weakness, with severe cognitive impairment and the need for set up assistance for meals. The existing care plan from 11/27/2024 addressed an ADL self-care performance deficit related to weakness, loss of balance, and deconditioning, and included interventions for the resident to eat in the hallway near the nurse’s station and receive set up assistance for eating. Observations on 05/18/2026, 05/21/2026, and 05/26/2026 showed Resident 65 sitting in a wheelchair near the nurse’s station with a coffee mug in hand and visible shakiness, with difficulty holding and consuming the coffee. On 05/18/2026, the resident’s shirt and pants were visibly soiled with coffee, and the resident stated their pants were soaked and they spilled every cup of coffee they were given; the resident denied burns and discomfort. Staff T stated that when residents had difficulty holding cups, they notified the nurse and kitchen for adaptive equipment, and that Resident 65 had been given spout cups, but those cups were not on the Kardex. Staff G stated the cup with a lid needed to be on the care plan so staff would know to use it. Staff B stated there was no adaptive equipment on the resident’s care plan and that Resident 65 should have had an assessment and adaptive equipment added to the care plan.
PICC Care and Bowel Protocol Not Followed
Penalty
Summary
The facility failed to maintain a PICC line as ordered for a resident with dementia, a left hip fracture around an artificial joint, and Streptococcal arthritis of the left hip who was receiving daily IV antibiotics. The resident’s care plan identified the need for antibiotics via PICC, and the orders required flushing each tube before and after medication administration and every shift, monitoring the PICC site, dressing/date, and injection caps every shift, and completing a sterile dressing change every 7 days with an antimicrobial disk and transparent dressing. On observation, the PICC dressing was dated 05/12/2026, later documented as changed on 05/21/2026, and the insertion site was observed without an antimicrobial disk under the dressing. The resident’s PICC also had two capped tubes, and one tube became clogged and did not flush, requiring provider notification and alteplase. Documentation did not consistently show that the ordered PICC care was completed. The MAR/TAR showed the dressing change due on 05/19/2026 was marked with a code referring to a progress note, but the progress note did not document that the dressing change occurred. There was no MAR place to document needleless connector cap changes, and staff stated the caps were changed every four days even though the resident’s orders did not include instructions for changing them. Staff also acknowledged there was no order to change the end caps and no documentation showing the antimicrobial disk was applied as ordered. The RN and RCM stated the dressing and end caps were expected to be changed and documented, and confirmed the resident had no antimicrobial disk present under the dressing. The facility also failed to implement the bowel management protocol for a resident with Parkinson’s disease, kidney failure, and moderate cognitive impairment who was at risk for constipation and had a history of constipation. The care plan directed nursing staff to follow the facility bowel protocol, and provider orders included Miralax and Senna as needed for constipation. The bowel record showed no bowel movement for four days in one period and five days in another period. Staff stated the bowel protocol was to be initiated after 48 hours without a bowel movement, but the resident did not have bowel protocol orders in place, and staff acknowledged the PRN bowel medications should have been offered.
Pressure Mattress Not Set to Ordered Mode
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not maintained for a resident with quadriplegia who was totally dependent on staff for positioning in bed and had significant pressure ulcers on the coccyx and left ankle. The resident also had orders for moon boots and an air mattress, and an order written on 05/07/2026 specified an alternating pressure relieving mattress with instructions for the licensed nurse to check function and adjust the setting as needed every shift. Although the May 2026 TAR showed the alternating pressure mattress order and the instruction to check function and adjust the setting, staff documented the task as completed twice daily. Observations on 05/21/2026, 05/22/2026, 05/26/2026, and 05/27/2026 showed the mattress control panel was on Static and locked rather than Alternating. The resident stated they did not think the mattress ever inflated and deflated. Staff interviews showed nurses believed they only needed to confirm the mattress was on and inflated, some stated the settings were already programmed and locked, and the unit manager later acknowledged the mattress should have been on Alternating and did not match the provider order.
Failure to Address Poor Meal Intake and Weight Loss
Penalty
Summary
The facility failed to implement interventions to prevent weight loss for two residents with nutritional risk. Resident 11 had a history of malnutrition and dementia, and the revised nutrition care plan identified the potential for nutritional problems, but it did not direct staff on what to do when intake was poor at meals. Resident 11’s weights showed a decline from 214.2 lbs. to 197.8 lbs. over about six months, and meal records showed frequent low intake, including multiple meals with 0-25% or 26-50% consumed. During observations, Resident 11 was seen with meal trays in front of them and stated the food was below average and lacked flavor. On two separate occasions, the resident refused to eat, the tray was removed by an unidentified NA, and the resident was not offered an alternate meal or nutritional supplement. In both instances, the NA did not notify the nurse of the resident’s refusal to eat. The meal intake record did not match the observed intake on those occasions. Resident 62 had diagnoses including diabetes, depression, malnutrition, and swallowing difficulty, and the nutrition care plan also did not instruct staff on what to do for poor intake at meals. Resident 62’s weight decreased from 138.6 lbs. to 117.2 lbs. over six months, and the resident stated they were losing weight because they did not like the food. Multiple observations showed the resident eating only part of meals, with trays removed by NAs without an alternate meal or nutritional supplement being offered and without the nurse being notified. The meal intake record repeatedly documented higher intake than what was observed.
Medications Given Outside Ordered Vital Sign Parameters
Penalty
Summary
The facility failed to ensure medications were administered as ordered for 2 of 5 sampled residents reviewed for medication administration. Resident 5 had diagnoses of heart failure and high blood pressure and was alert and able to make needs known. The resident had orders for Lisinopril daily and Metoprolol ER daily, both to be held if systolic blood pressure was less than 110 or heart rate was less than 60 beats per minute. Review of the April and May 2026 MAR showed both medications were given three times when the heart rate was below 60, and there was no documentation in the chart explaining why the medications were administered outside the ordered parameters. Resident 11 had diagnoses including high blood pressure and dementia and was documented as having moderate cognitive impairment. The resident had orders for Clonidine daily, Hydralazine three times daily, and Losartan Potassium twice daily, each with hold parameters based on systolic blood pressure and heart rate. Review of the April 2026 MAR showed these medications were given seven times outside the ordered parameters, including instances when systolic blood pressure and/or heart rate were below the hold limits, and also showed two occasions when Losartan Potassium was not given even though the systolic blood pressure and heart rate were above the ordered parameters. Staff interviews confirmed that medications should have been administered or held according to the provider-ordered vital sign parameters.
Late MDS Encoding and Transmission
Penalty
Summary
The facility failed to routinely encode and transmit resident assessment data to CMS within the required timeframe for 2 of 25 sampled residents, Resident 132 and Resident 41, during review of MDS timeliness. The report states that nursing homes are required to submit OBRA-required MDS records for all residents in Medicare- or Medicaid-certified beds and transmit the data to CMS through iQIES after completion of the required assessment and tracking records. For Resident 132, the admission assessment showed an ARD of 01/27/2026, CAA care planning documentation completed on 02/04/2026, and the MDS signed by the RN coordinator as completed on 02/04/2026. During interview and record review, the MDS Coordinator acknowledged that Resident 132's admission MDS was completed on 02/04/2026 but was late and had not yet been submitted to CMS. For Resident 41, the admission assessment showed an ARD of 01/12/2026, CAA care planning documentation completed on 01/12/2026, and the assessment signed by the RN coordinator as completed on 05/08/2026. A final validation report showed a batch of 52 MDS assessments was submitted and accepted on 05/18/2026, including Resident 41's admission MDS; the MDS Coordinator acknowledged that this admission MDS was submitted late on 05/18/2026. The Administrator stated staff were expected to submit MDS assessments per the required timeframes.
Failure to Administer Methadone as Prescribed by OTP Provider
Penalty
Summary
The facility failed to administer methadone in accordance with the dosage prescribed by the Opioid Treatment Program (OTP) provider for a resident being treated for opioid use disorder (OUD). The resident, who had a history of Hepatitis B and C, was managed by the OTP for methadone dosing, with care plans indicating that the dosage was to be determined at weekly outpatient appointments. Following a hospital visit for an opioid overdose, the hospital coordinated with the OTP to temporarily reduce the resident's methadone dose, with a plan to gradually return to the previous dosage as directed by the OTP. Despite clear orders from the OTP to increase the methadone dose back to 70mg daily, facility staff administered only 50mg daily for several days. This change was made based on a verbal order from a physician assistant at the facility, who cited recommendations from the resident's hepatology clinic to reduce or eliminate methadone use. There was no documentation that the OTP was consulted or that care was coordinated between the OTP provider and the hepatology team regarding this change in methadone dosing. The facility did not have a specific policy for residents utilizing an OTP and relied on the OTP provider's orders for methadone administration. However, the facility did not report the deviation from the OTP's prescribed dose until questioned by OTP staff about unused medication. Interviews with facility staff revealed confusion about which provider was responsible for managing methadone dosing for OUD, and there was no evidence of direct coordination between the involved medical providers regarding the resident's methadone regimen.
Failure to Coordinate MOUD Dosage Changes with OTP Provider
Penalty
Summary
The facility failed to coordinate with the opioid treatment program (OTP) provider regarding changes to the medication dosage for opioid use disorder (MOUD) for a resident. The resident, who had a history of opioid use disorder and was being treated with methadone, also had diagnoses of Hepatitis B and Hepatitis C. After the resident experienced an opioid overdose and was hospitalized, the hospital coordinated with the OTP to temporarily reduce the methadone dose, with plans for the resident to return to the OTP for further dosing adjustments. Upon the resident's return, the OTP ordered a gradual increase of methadone back to the original dose. However, a physician assistant at the facility verbally changed the methadone dose to a lower amount based on recommendations from the resident's hepatology clinic, without documented coordination or consultation with the OTP provider. Facility staff administered the lower dose for several days, and the discrepancy was only discovered when the OTP noticed unused methadone in returned vials and questioned the facility. There was no documentation of communication with the OTP regarding the dose change or attempts to coordinate care between the OTP and the hepatology provider. Interviews with facility staff revealed a lack of clear policy regarding residents utilizing OTPs and confusion about which provider was responsible for managing methadone dosing for opioid use disorder. The medical director clarified that only the OTP should manage methadone dosing for opioid use disorder, but this protocol was not followed in the resident's case. The facility did not have documentation of proper coordination with the OTP, leading to the identified deficiency.
Failure to Address Nutritional Needs Leads to Significant Weight Loss
Penalty
Summary
The facility failed to maintain acceptable parameters of nutrition for two residents, leading to significant weight loss and potential harm. Resident 4 experienced a weight loss of 7.9% over approximately three months and 14.29% over six months. Despite being cognitively intact and able to eat with setup assistance, Resident 4's weight loss was not adequately addressed. Observations showed that Resident 4 was not offered alternate meals or nutritional shakes when they consumed less than 50% of their meals, contrary to the facility's policy. Staff interviews revealed that interventions for weight loss were not implemented in a timely manner, which could have mitigated some of the resident's weight loss. Resident 14, who was severely cognitively impaired, experienced an 8.51% weight loss in one month. The resident's weight loss was not reported to the dietician, and no evaluation was conducted to determine the need for further interventions. Observations indicated that Resident 14 was not offered alternate meals or nutritional supplements despite poor meal intake. Staff interviews highlighted a lack of communication and oversight, as the new Registered Dietician was not informed of the resident's weight loss, and interventions such as nutritional supplements were not put in place. The facility's failure to adhere to its nutrition and hydration policy placed both residents at risk for further decline in their weight and overall health. The lack of timely interventions and communication among staff contributed to the residents' significant weight loss and the potential for unintended consequences of poor nutrition. The report underscores the need for consistent monitoring and proactive measures to address nutritional deficiencies in residents.
Deficiency in Food Safety Practices
Penalty
Summary
The facility failed to adhere to professional standards for food safety, as evidenced by improper food storage, preparation, and temperature monitoring. During an observation, a crate of pasteurized eggs with an expired date was found in the walk-in refrigerator, which was acknowledged and disposed of by the Dietary Manager. This oversight in discarding expired food items poses a risk of bacterial growth and potential resident illness. Additionally, the facility did not consistently monitor or document food temperatures during meal service. Observations revealed that temperatures were not checked for all food items, such as a chef's salad served in the dining room, and there was no documentation of temperatures for the kitchen tray line. The Dietary Manager admitted that the facility did not check temperatures after the first tray line and only randomly checked temperatures during the second tray line without documentation. This lack of consistent temperature monitoring and documentation increases the risk of food contamination and bacterial growth, compromising food safety for residents.
Late Submission of MDS Assessments
Penalty
Summary
The facility failed to encode and transmit resident assessment data to the Centers for Medicare & Medicaid Services (CMS) within the required timeframe for four of eleven sampled residents. This deficiency involved the Minimum Data Set (MDS), an assessment tool used to gather information about residents' functional status, strengths, weaknesses, and preferences. The facility was required to submit MDS records for all residents in Medicare- or Medicaid-certified beds, and these records must be transmitted electronically within 14 days of the assessment completion date. However, the facility did not meet these requirements for Residents 7, 12, 86, and 90, as their assessments were submitted late. Resident 86 was discharged on August 25, 2024, but the assessment was completed on August 29, 2024. Resident 7 was discharged on October 25, 2024, with the assessment completed on October 29, 2024. Resident 12's quarterly assessment was completed on February 4, 2025, despite the observation end date being December 19, 2024, and the discharge assessment was also late. Resident 90's quarterly assessment was completed on February 1, 2025, with an observation end date of January 14, 2025. The facility's MDS Director and Director of Nursing acknowledged the late submissions, which were confirmed by a validation report showing 23 out of 79 files were submitted late, including those of the mentioned residents.
Failure to Administer Bowel Care as Ordered
Penalty
Summary
The facility failed to consistently monitor and provide timely bowel care for seven residents, leading to a deficiency in care. Residents 23, 36, 54, 62, 4, 39, and 46 were all affected by this oversight. Each resident had specific physician orders for laxatives to be administered if they had not had a bowel movement within a certain timeframe. However, the facility did not adhere to these orders, resulting in prolonged periods without bowel movements for the residents. Resident 23, who was cognitively intact and dependent on staff for activities of daily living, did not receive the prescribed laxatives despite not having a bowel movement for several days on multiple occasions. Similarly, Resident 36, also cognitively intact, went without bowel movements for five days without receiving the necessary medication. Staff interviews revealed a misunderstanding of the facility's protocol, with some staff believing bowel medication should be given after 72 hours, contrary to the physician's orders. Other residents, including Resident 4, 54, 39, 46, and 62, experienced similar issues, with their medication administration records showing that laxatives were not given as ordered. Interviews with staff, including the Director of Nursing, confirmed that the facility's expectation was to offer bowel care medication after 48 hours of no bowel movement unless otherwise specified by the physician. The lack of documentation for the omissions further highlighted the deficiency in care provided to these residents.
Failure to Ensure Proper Respiratory Care and Documentation
Penalty
Summary
The facility failed to ensure that respiratory treatments had provider orders, that these orders were carried out, and that care plan goals and interventions were developed for three residents. Resident 359, who had chronic obstructive pulmonary disease (COPD) and cardiomyopathy, was observed using oxygen therapy without any provider orders for its administration or maintenance. Despite having an oxygen concentrator and using oxygen via nasal cannula, there was no documentation in the care plan or medical records to support this treatment. Resident 358, diagnosed with heart failure and sleep apnea, had a CPAP machine in their room but lacked provider orders for its use, settings, or maintenance. The resident reported that their CPAP machine was not set up until three days after admission, and there was no documentation of its routine use or care in the medical records. Staff interviews confirmed the absence of necessary orders and care plans for the CPAP machine. Resident 71, with respiratory failure, COPD, and sleep apnea, had an active order to use a CPAP machine nightly. However, the resident reported not using the CPAP for several nights, contradicting the documentation in the medication administration record. Staff interviews revealed a lack of awareness about the resident's non-compliance with CPAP use, despite the presence of an order and care plan. These deficiencies placed the residents at risk for respiratory complications and diminished quality of life.
Failure to Conduct Annual Staff Performance Reviews
Penalty
Summary
The facility failed to conduct annual performance reviews for two nursing assistants, Staff P and Staff Y, as required by regulations. This deficiency was identified through interviews and record reviews, which revealed that there was no documentation of completed yearly performance evaluations for these staff members. During an interview, the facility's administrator admitted to being unaware of the lack of a process for conducting these evaluations and mentioned that the facility was in the process of initiating them. This oversight placed residents at risk of receiving care from inadequately trained or underqualified staff, potentially affecting their quality of life.
Medication Administration Failures in LTC Facility
Penalty
Summary
The facility failed to ensure that three residents received their medications as ordered by their physicians, leading to significant medication errors. Resident 22, who had diabetes and high blood pressure, did not receive insulin and blood sugar checks on multiple occasions, and their blood pressure medication, Metoprolol, was administered despite their heart rate being below the prescribed threshold. There was no documentation explaining these omissions or deviations from the physician's orders. Resident 71, who had end-stage renal disease and diabetes, missed several doses of insulin and sevelamer due to being out of the facility for dialysis sessions. The staff did not send medications with the resident to dialysis, and there was no communication with the physician to adjust medication timing or dosage. The resident confirmed they did not receive medications during dialysis sessions, and the staff entered a code indicating the resident was out of the facility without medications. Resident 46, who had high blood pressure, was given Metoprolol despite their systolic blood pressure being below the prescribed parameter on several occasions. There was no documentation explaining why the medication was not held, and staff interviews confirmed that the medication should have been withheld according to the physician's orders. These failures in medication administration and monitoring placed the residents at risk for medical complications.
Medication Storage Temperature Control Deficiency
Penalty
Summary
The facility failed to ensure proper temperature controls for medication storage in two of three sampled medication rooms and one of three medication storage refrigerators. In the West medication room, no thermometer was present to monitor the room temperature where various medications were stored. Similarly, in the East medication room, no thermometer was observed, and the Director of Nursing acknowledged the absence of a thermometer to monitor the room temperature. The refrigerator in the East medication room contained various insulins, intravenous medications, and concentrated oral antianxiety medications. The temperature log for the refrigerator showed only one entry for February 2025 and incomplete entries for January 2025, with the Director of Nursing acknowledging these omissions. During an interview, the Administrator stated that staff were expected to check the medication room refrigerator temperatures to ensure medication quality. However, no policy on medication storage was provided upon request. The lack of proper temperature monitoring and documentation placed residents at risk of receiving medications that may not be at their optimum efficacy, potentially leading to adverse side effects and diminished quality of life.
Facility Fails to Provide Palatable and Appetizing Food
Penalty
Summary
The facility failed to provide appetizing and palatable food for five residents, leading to dissatisfaction and potential risks for decreased nutritional intake and diminished quality of life. Residents reported issues such as mushy vegetables, processed chicken patties, inedible eggs, overly salty food, and unappetizing presentation. Despite expressing their concerns to dietary staff, residents did not see improvements. A test tray sampled by the survey team confirmed the residents' complaints, revealing unappetizing and bland food, with some items being lukewarm and lacking flavor. Resident 48, who had gastroesophageal reflux disease and an esophageal ulcer, also reported the food was sometimes too salty and lacked flavor. The dietary manager, Staff W, acknowledged the importance of tasting food to ensure palatability but had delayed attending Resident Council meetings to address these concerns. The State Ombudsman office confirmed multiple complaints from residents about the food, highlighting the facility's failure to address these issues promptly.
Failure to Ensure Proper Review of Arbitration Agreements
Penalty
Summary
The facility failed to ensure that the arbitration agreement was reviewed and explained in a form, manner, and/or language understood by the residents or their legal representatives for three sampled residents. This deficiency was identified for residents who were severely cognitively impaired and included those with diagnoses such as non-Alzheimer's dementia and Alzheimer's dementia. The arbitration agreements were signed by the residents themselves, despite their cognitive impairments, rather than by their legal representatives or power of attorney (POA). This oversight placed the residents at risk of being uninformed of their rights and losing legal protection. Interviews and record reviews revealed that the facility's process for offering arbitration agreements did not adequately assess the residents' cognitive abilities to understand and sign the agreements. Staff Z, the Admission Director, stated that they reviewed residents' records upon admission to determine their capacity to sign the agreement. However, this process failed in the cases of Residents 14, 60, and 90, who all had severe cognitive impairments. The facility's Administrator, Staff A, confirmed that arbitration agreements should have been offered to the residents' representatives or POA, acknowledging the oversight in these cases.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement enhanced barrier precautions for two residents with draining wounds, which is crucial to prevent the spread of multidrug-resistant organisms (MDROs). Resident 54 was observed with yellow drainage from a heel wound on their pillowcase, and there was no enhanced barrier sign or personal protective equipment (PPE) nearby. Similarly, Resident 46 had bloody drainage from a sore under their armpit, but there was no enhanced barrier sign or PPE available. These observations indicate a lack of adherence to infection control protocols, which are essential to prevent the spread of infections. The facility also demonstrated improper use of N95 respirators by several staff members during an active COVID-19 outbreak. Staff members were observed wearing N95 masks with straps incorrectly positioned, which compromises the mask's ability to form a proper seal and protect against airborne particles. Despite receiving training on PPE use, staff members cited reasons such as convenience and discomfort for not wearing the masks correctly. This improper use of N95 masks during a COVID-19 outbreak poses a significant risk to both staff and residents. Additionally, the facility's infection prevention and control policies were outdated and not reviewed annually as required. The water management plan was incomplete, lacking facility-specific information necessary for effective Legionella control. These deficiencies in infection prevention protocols and policy management further contribute to the risk of spreading infections within the facility.
Failure to Inform Residents and Representatives of Medication Changes
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were informed and consented to new medication changes, which affected two residents. Resident 90, who had severe cognitive impairment and multiple diagnoses including dementia and traumatic brain injury, was administered Seroquel and Ativan without the knowledge or consent of their power of attorney (POA). The facility increased the dosage of Seroquel multiple times and added Ativan to the treatment plan without notifying the POA, despite the resident experiencing increased sedation and falls. Interviews with staff confirmed that the POA should have been informed of these medication changes. Resident 54, who was cognitively intact but had a representative due to occasional confusion, experienced a decrease in their pain medication, Xtampa, without being informed. The representative was unaware of the medication change, and the facility failed to document any notification to the resident or their representative. Staff interviews revealed that the resident or their representative should have been notified of the medication change and a progress note should have been made. The facility's policy required that residents and/or their representatives be informed of changes in health status, including medication changes. However, the facility did not adhere to this policy, resulting in a lack of informed consent for medication changes for both residents. This failure prevented the residents and their representatives from making informed decisions regarding treatment and potentially impacted the residents' quality of life.
Failure to Notify Ombudsman of Hospital Transfers and Discharges
Penalty
Summary
The facility failed to ensure that the Office of the State Long-Term Care Ombudsman was notified of hospital transfers and discharges for five out of six sampled residents. This deficiency was identified through interviews and record reviews, which revealed that the facility did not provide the required notifications for residents who were transferred to the hospital. The facility's policy, dated July 2018, stated that notifications to the Ombudsman should occur before or as close as possible to the time of a facility-initiated transfer or discharge, with emergency transfer notifications sent at least monthly. Resident 4, who was cognitively impaired and unable to make decisions regarding their care, was transferred to the hospital due to increased behaviors, but there was no documentation of Ombudsman notification. Resident 46, who was cognitively intact, was sent to the hospital after a fall but also lacked documentation of Ombudsman notification. Similarly, Resident 71, who was cognitively intact, was transferred to the hospital for vomiting, fever, and high blood sugar without Ombudsman notification. Resident 90, with severe cognitive impairment, was transferred to the hospital twice after falls, yet no Ombudsman notification was documented. Resident 30, who was cognitively intact, was transferred to the hospital after a fall, but again, there was no documentation of Ombudsman notification. Interviews with facility staff, including the Administrator, Licensed Practical Nurse, Resident Care Manager, and Social Service Director, revealed a lack of awareness and practice regarding the requirement to notify the Ombudsman of hospital transfers and discharges. The Ombudsman confirmed that the facility had not been notifying them of such events, except when issuing a 30-day eviction notice. This oversight placed residents at risk of not having access to additional advocacy services from the State Long-Term Care Ombudsman.
Failure to Provide Bed-Hold Notices to Residents
Penalty
Summary
The facility failed to provide a bed-hold notice to residents or their representatives at the time of discharge or within 24 hours of transfer to the hospital for five sampled residents. This deficiency was identified through interviews and record reviews. For Resident 4, who was cognitively impaired, there was no documentation of a bed-hold notice being provided after being sent to the hospital due to increased behaviors. Similarly, Resident 46, who was cognitively intact, was not informed about the bed-hold until two days after their discharge following a fall. Resident 90, with severe cognitive impairment, was transferred to the hospital twice without any documentation of a bed-hold notice being offered. Resident 30, who was cognitively intact, was sent to the hospital after a fall, yet no bed-hold notice was documented. Resident 71, also cognitively intact, was sent to the hospital for evaluation due to vomiting, fever, and high blood sugar, but there was no record of a bed-hold notice being provided. Interviews with staff confirmed the lack of documentation and emphasized the importance of offering a bed-hold to ensure residents' rights to return to their rooms. The failure to provide timely bed-hold notices placed residents at risk of not being informed about their rights during hospitalization.
Failure to Timely and Accurately Complete MDS Assessments
Penalty
Summary
The facility failed to timely and accurately complete Minimum Data Sets (MDS) for 9 out of 11 sampled residents, which affected federal health information data gathering and placed residents at risk for inaccurate monitoring of their progress over time. The MDS assessments were not completed within the required time frames, as evidenced by several residents' assessments being signed off weeks or even months after the observation end dates. For instance, Resident 3's quarterly assessment was not signed as completed until over a month after the observation end date, and Resident 12's discharge assessment was completed over a month late. Additionally, there were inconsistencies in the MDS assessments for some residents, such as Residents 14, 109, and 90, where sections of the assessments conflicted regarding the residents' cognitive abilities and communication capabilities. These discrepancies were acknowledged by the Director of Nursing, who admitted that the assessments did not accurately reflect the residents' status as of the assessment reference date (ARD). Interviews with facility staff, including the MDS Director and the Administrator, confirmed that the facility was behind on completing MDS assessments as required. The MDS Director provided a list showing 76 MDS assessments were still in progress beyond the ARD, indicating a systemic issue with timely assessment completion. This failure to adhere to required timelines and ensure accurate assessments compromised the facility's ability to monitor residents' health data effectively.
Deficiencies in Fall Prevention, SUD Management, and Smoking Safety
Penalty
Summary
The facility failed to ensure proper investigation and implementation of safety interventions for residents who experienced falls. Four residents were identified as having sustained falls without adequate investigation or monitoring. For instance, one resident had multiple falls, including a major injury, but the care plan interventions such as placing a fall mat were not consistently implemented. Another resident was left alone in their room despite being at high risk for falls, and the care plan interventions were not followed, leading to repeated falls. The facility also failed to assess and manage risks associated with substance use disorders (SUD) for two residents. One resident with a history of methamphetamine and alcohol use eloped from the facility shortly after admission, and there was no care plan addressing their SUD. Staff interviews revealed a lack of training and understanding of how to assess and manage SUD risks. Another resident who used marijuana did not have a care plan addressing their SUD, and staff were unsure if counseling was offered. Additionally, the facility did not adequately assess residents' ability to smoke safely. One resident was identified as needing supervision to smoke safely, but the facility did not provide supervision or reassess the resident's smoking ability after a hospital visit. The facility's smoking policy was unclear, and there were no designated smoking areas or safety measures such as fire blankets or extinguishers in place, despite residents smoking on the property.
Inadequate Monitoring and Documentation of Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that residents were not given psychotropic medications unless necessary to treat specific conditions documented in the clinical record. This deficiency was observed in three residents, including Resident 90, who was admitted with diagnoses such as dementia and traumatic brain injury. Despite the absence of active orders for antipsychotic medications upon admission, Resident 90 was started on Seroquel due to reported agitation and impulsiveness. The facility did not implement the provider's recommendations for environmental treatment of agitation, and there was inconsistent documentation of behavior monitoring and non-medication interventions. Resident 90 experienced frequent falls and was administered increasing doses of Seroquel, along with Ativan for anxiety and agitation. However, the facility's documentation lacked specific details of the behaviors experienced by Resident 90, and there were significant omissions in behavior monitoring records. Interviews with staff revealed that behavior documentation was critical for determining medication adjustments, yet the records were incomplete and lacked sufficient detail to justify the medication changes. Similar deficiencies were noted for Residents 22 and 23, who were prescribed psychotropic medications for conditions such as depression and anxiety. The facility failed to consistently document behavior and adverse side effect monitoring as required. Staff interviews confirmed that documentation was incomplete, which is essential for monitoring the residents' mental health and the effects of psychotropic medications. The lack of proper documentation and monitoring placed residents at risk of being chemically restrained and having unmet care needs.
Failure to Evaluate Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident was evaluated for the ability to self-administer medications, which is a requirement for residents who are cognitively intact and capable of managing their own medication. Resident 74, who had diagnoses including bipolar disorder, high blood pressure, and cervical cancer, was observed with several loose pills on their overbed table, not in a medication cup, and expressed uncertainty about the identity of the pills. The resident mentioned that nurses usually watched them take their medications to prevent choking or dropping them, but acknowledged that this supervision was not consistent. Staff interviews revealed that the Licensed Practical Nurse (LPN) who administered the medications to Resident 74 did not recall leaving the medications unattended but admitted it was possible they were called away. The Resident Care Manager confirmed that nurses were expected to supervise medication administration unless the resident had been assessed and approved for self-administration, which had not been done for Resident 74. This oversight placed the resident at risk for missed doses or unintended health consequences, as the necessary assessment and approval process for self-administration had not been completed.
Failure to Provide Menus and Support Resident Meal Choices
Penalty
Summary
The facility failed to ensure that weekly menus and alternative menus were provided to residents, which denied them the right to choose their meal preferences. This deficiency was observed in three residents who were cognitively intact and capable of making decisions regarding their care. Resident 23 reported that menus were not handed out and had to be requested, often taking days to receive, which resulted in missed opportunities to choose meals. Staff interviews confirmed that menus were kept at the nurses' station and only provided upon request, with a low number of residents actually submitting their meal choices. Resident 36 expressed dissatisfaction with the food quality and was unaware of the availability of menus, indicating a lack of communication from the staff. Similarly, Resident 48, who had a medical condition requiring dietary considerations, stated that meals tasted the same and they were not offered alternative food choices or menus. Staff interviews revealed that the facility had not developed an effective solution to ensure residents could make their own food choices, with only a small fraction of residents submitting menus. This failure potentially affected the residents' nutritional needs and quality of life.
Failure to Provide Complete Advanced Beneficiary Notices
Penalty
Summary
The facility failed to provide complete information on services and charges for those services not covered under the facility's per diem rate for two residents, Resident 91 and Resident 14, who were reviewed for advanced beneficiary notices. Resident 91 received a Notice of Medicare Non-coverage (NOMNC) indicating that Medicare payment for physical therapy, occupational therapy, and skilled nursing care would end on January 2, 2025. Although Resident 91 was given a Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN), the notice was incomplete and did not inform the resident of the costs for continuing to reside in the facility. Similarly, Resident 14 received a NOMNC stating that Medicare payment for services would end on December 23, 2024. However, there was no documentation that a SNFABN or any other written notification was provided to Resident 14 or their power of attorney (POA) to inform them of the costs for continuing care after Medicare payment ceased. In an interview, Resident 14's POA confirmed that they were informed of the Medicare ending via a phone call but were not provided with or signed any documents regarding the daily cost for care. The Business Office Manager confirmed the lack of documentation of the facility's per diem rate on the SNF/ABN forms for both residents.
Failure to Maintain Homelike Environment and Sanitation
Penalty
Summary
The facility failed to provide a homelike environment for several residents, as evidenced by the poor condition of the drywall in the rooms of Residents 39, 46, and 83. Resident 39, who was severely cognitively impaired, had a room with gauges and a hole in the drywall behind their recliner and near the headboard. Similar damage was observed in Resident 46's room, who was cognitively intact, with gauges on multiple walls. Resident 83, also severely cognitively impaired, had drywall damage near their window and headboard. These observations were made over several days, indicating a lack of timely maintenance and repair. Additionally, Resident 14, who was severely cognitively impaired, was observed in an unclean wheelchair on multiple occasions. The wheelchair had white debris on the cushion and wheels, and a brown substance on the legs, which was not addressed over several days. Staff interviews revealed that everyone was responsible for cleaning wheelchairs, highlighting a failure in maintaining sanitation and dignity for the resident. These deficiencies were noted during observations and interviews with facility staff, including the Maintenance Director and Administrator.
Failure to Document and Communicate Resident Transfer Information
Penalty
Summary
The facility failed to ensure that a resident's medical record contained documentation of a hospital transfer and that the receiving hospital received information about the resident's condition. This deficiency involved a resident with cognitive impairment and diagnoses including diabetes, depression, and anxiety. The transfer form for the resident, who required a proxy for decision-making, indicated a transfer to the hospital for evaluation of behaviors such as agitation and psychosis. However, the section of the form that should have documented whether a report was called into the hospital was left blank, and there was no further documentation indicating that any information was relayed to the hospital at the time of transfer. Interviews with staff confirmed that it was expected for the hospital to be notified of the resident's condition, which was crucial for understanding the resident's status and history.
Delayed PASARR Completion for Resident After Exempted Hospital Stay
Penalty
Summary
The facility failed to ensure a timely completion of a Pre-Admission Screening and Resident Review (PASARR) for a resident who was admitted after an exempted hospital stay. Resident 46, who had diagnoses including depression and anxiety, was admitted to the facility directly from a hospital with an expected stay of 30 days or less. A Level I PASARR was completed prior to admission, indicating the need for a Level II PASARR due to the exempted hospital stay. However, the resident did not discharge within the expected 30 days and remained at the facility. A new PASARR was not completed until 40 days after the exempted stay period had expired. This delay in completing the PASARR was acknowledged by the Social Service Director, who stated that timely completion was important for implementing recommendations to care for the resident's mental health.
Failure to Follow Podiatry Referral for Resident
Penalty
Summary
The facility failed to ensure a physician-ordered foot care referral for a podiatrist was followed for Resident 54, who was reviewed for wound care. Resident 54 had diagnoses including diabetes, Multiple Sclerosis, and depression, and was cognitively intact. A provider progress note from September indicated the resident had long and thick toenails and required a podiatry referral for evaluation and treatment. However, the facility did not arrange for the resident to see a podiatrist, and the resident's toenails were not addressed until a nurse practitioner intervened in January. Interviews with facility staff revealed that there was confusion and delay in arranging podiatry care. Staff N, a Registered Nurse, mentioned that podiatry referrals depended on the resident's insurance, and appointments were to be arranged with an outside provider. Staff C, the Resident Care Manager, and Staff L, the Social Service Director, indicated efforts were being made to have a podiatrist visit the facility, but there was uncertainty about sending residents out for appointments. The Director of Nursing acknowledged that nail care could have been addressed sooner to prevent infections. At the time of the survey exit, Resident 54 had not yet been seen by a podiatrist.
Inaccurate Dialysis Care Plan and Communication
Penalty
Summary
The facility failed to ensure consistent communication and collaboration with the dialysis facility for a resident requiring dialysis services. The resident, who was cognitively intact and had diagnoses including diabetes and end-stage kidney disease, received dialysis via a central venous catheter (CVC). However, the facility's care plan inaccurately included interventions for monitoring a dialysis fistula, which the resident did not have. The Pre-Dialysis Assessment and Communication forms, meant to be completed and sent with the resident to dialysis appointments, were inconsistently returned, with only five out of nineteen forms being returned. These forms correctly documented the use of a CVC, yet the facility's care plan and staff documentation continued to reference a fistula. Interviews with the resident and staff revealed a lack of awareness and understanding of the resident's actual dialysis access site. The resident confirmed they had never had a fistula and showed the CVC on their chest. Staff initially stated the resident had a fistula but then corrected themselves to acknowledge the CVC. The Director of Nursing acknowledged that the dialysis orders and care plan interventions should have reflected the use of a CVC but did not. This discrepancy in documentation and communication led to the deficiency in providing appropriate dialysis care for the resident.
Inadequate Staffing Leads to Resident Safety Concerns
Penalty
Summary
The facility failed to ensure adequate staffing to meet the needs of its residents, as evidenced by the experiences of three residents. Resident 90, who had severe cognitive impairment and a history of falls, required constant supervision due to impulsive behavior and frequent attempts to self-transfer. Despite the need for one-on-one supervision, the facility was unable to provide it due to understaffing, leading to multiple falls and the administration of antipsychotic medication. The resident's power of attorney expressed concerns about overmedication and the resident's deteriorating condition. Resident 110, who had a history of psychoactive substance abuse and schizophrenia, was admitted to the facility without a care plan addressing their substance use disorder. The resident eloped from the facility shortly after admission, was found intoxicated, and ended up in the hospital. The facility's failure to complete necessary assessments and implement appropriate interventions contributed to the resident's elopement and subsequent hospitalization. Resident 83, who was dependent on staff for most activities of daily living, reported excessively long call light wait times, sometimes up to one hour and 40 minutes. Interviews with staff and the ombudsman revealed concerns about insufficient staffing, particularly in the evenings and on weekends. The facility's staffing coordinator and director of nursing acknowledged the staffing challenges, with some staff working multiple roles and double shifts, yet maintained that the scheduled staff was adequate to meet resident needs.
Failure to Monitor Adverse Effects of Blood Thinning Medication
Penalty
Summary
The facility failed to consistently monitor potential adverse effects from a blood thinning medication for Resident 22, who was part of a sample of five residents reviewed for unnecessary medications. Resident 22 had diagnoses of heart failure and high blood pressure and was taking Xarelto, a blood thinning medication. The provider orders required licensed staff to monitor for adverse reactions such as bleeding, severe bruising, difficulty breathing, or chest pain. However, the Medication Treatment Record for January 2025 showed multiple instances where the monitoring documentation was left blank across various shifts. Interviews with facility staff confirmed the deficiency. Staff N, a Registered Nurse, acknowledged that the documentation was incomplete and stated that the expectation was for all charting to be completed each shift as ordered. Staff B, the Director of Nursing, also confirmed that the medication monitoring had not been consistently performed, reiterating that the expectation was for documentation to be completed before the end of each shift. This lack of consistent monitoring placed Resident 22 at risk for medical complications and adverse side effects.
Exposed Wiring on Resident Beds
Penalty
Summary
The facility failed to ensure that resident beds were in safe operating condition, as observed in four out of 26 beds on the [NAME] nursing unit. Specifically, the bed controls for these beds had exposed wires and old electrical tape that had peeled off, which was noted during observations on multiple occasions. For instance, a resident in room [ROOM NUMBER]-1 was found seated on a bed with exposed wiring at the bed control, although no frayed wires were present. Similar conditions were observed in other rooms, with exposed wires and peeling electrical tape on the bed controls. During an interview, the Maintenance Director, Staff K, stated that they were unaware of beds in disrepair unless a work order was submitted. Staff K also mentioned that they did not conduct regular preventive inspections or audits of the equipment on the nursing units. This lack of proactive maintenance and reliance solely on work orders contributed to the deficiency, as the unsafe conditions of the beds were not addressed until they were specifically reported.
Deficiency in Call Bell System Functionality
Penalty
Summary
The facility failed to ensure that the call bell systems were in working condition for two residents, placing them at risk of having their urgent needs unanswered. Resident 74's call light was observed to be non-functional, with the cord pulled out of the wall and coiled up, and the button taped over. The resident reported that the call light had not worked for a couple of weeks and had informed a staff member, but the issue was not addressed until the day of the observation. The maintenance director confirmed receiving a work order but had not seen it until the morning of the observation. Similarly, Resident 4's call light was found to be non-functional when they attempted to use it to request food. The resident had experienced previous issues with the call light, which had been replaced several times. A staff member provided a manual call bell as a temporary solution and notified the maintenance director, who repaired the call light. The maintenance director admitted that they did not conduct regular audits of the equipment and relied on work orders to identify non-functioning call bells.
Failure to Maintain Clean and Safe Resident Refrigerators
Penalty
Summary
The facility failed to maintain resident personal refrigerators in a clean manner, free of expired foods, and at appropriate temperatures for two residents. Resident 74 had a small dormitory-style refrigerator with a brown liquid spilled inside, a can of soft drink resting in the liquid, and a supplement drink on the shelf. The resident was unsure who was responsible for monitoring the refrigerator's temperature, and there was no temperature log present in the room. Subsequent observations showed the refrigerator was cleaned, but there were empty coffee mugs and half-full fruit cups on top, still without a temperature log. Resident 51's personal refrigerator contained expired vanilla yogurt and butterscotch pudding, and was observed to be unclean with spilled brown liquid on the bottom shelf. Multiple observations confirmed the presence of expired food and lack of cleanliness over several days. Interviews with staff revealed confusion about who was responsible for monitoring the refrigerators. Staff X, a Nursing Assistant, was unsure of the responsibility, while Staff C, a Resident Care Manager, stated that temperature logs should be kept in resident rooms and expired food should be discarded. Staff B, the Director of Nursing, indicated that nurses were responsible for monitoring the refrigerators, including temperature checks and discarding expired food to prevent illness.
Failure to Investigate Allegations of Abuse and Falls
Penalty
Summary
The facility failed to thoroughly investigate potential allegations of abuse for two residents, Resident 30 and Resident 83. Resident 30, who had a stroke with weakness and/or paralysis affecting one side of the body, alleged that their call light was removed by staff, leading to a fall. The investigation into this incident was inadequate, as it did not include specific staff or witness statements about the removal of the call light, and the conclusion was reached without thoroughly addressing the resident's specific allegation. Resident 83, who had severe cognitive impairments and required assistance with repositioning, had a scabbed area on their arm allegedly caused by staff. The investigation into this incident was also insufficient, as it did not include staff interviews or a thorough examination of the resident's claims, and the initial conclusion ruled out abuse without adequate evidence. The facility also failed to investigate falls for two other residents, Resident 4 and Resident 14. Resident 4, who had a history of falls and was at risk for additional falls, was found lying on their floor mat and sent to the hospital, but no investigation was conducted into the fall. Similarly, Resident 14, who had a history of falls and was at risk for additional falls, was found on the floor mat next to their bed, but no investigation was conducted as the fall was not reported to the administrator. These failures to investigate potential abuse and falls placed residents at risk of further potential abuse and diminished quality of life. The facility's policy required thorough investigations of allegations, but this was not adhered to in these cases, leading to incomplete assessments and conclusions regarding the incidents involving the residents.
Inadequate Discharge Planning and Documentation for Two Residents
Penalty
Summary
The facility failed to prepare comprehensive discharge summaries and plans for two residents, leading to potential risks of unsafe discharges and unmet care needs. Resident 90, who had severe cognitive impairment and required moderate assistance with daily activities, was discharged to the community without proper documentation of their condition at discharge, who they left with, or what information was reviewed with them. The resident's power of attorney expressed concerns about overmedication and a decline in the resident's physical abilities upon discharge. Resident 110, who had a history of psychoactive substance abuse and mental health issues, was admitted to the facility but eloped shortly after. The facility did not document the resident's status or follow-up actions after they were located at a local hospital. The resident's discharge was not properly documented, and there was confusion regarding the requirements of the facility's new bridge bed program, which contributed to the lack of proper discharge documentation. Interviews with facility staff revealed a lack of clarity and consistency in the discharge process, with responsibilities for discharge planning and documentation not clearly defined. Staff acknowledged the absence of necessary documentation and the need for improvements in the discharge process, particularly in relation to the new bridge bed program.
Failure to Provide Assistance and Bathing as Care Planned
Penalty
Summary
The facility failed to ensure that a staff member was available to assist Resident 109 during an appointment with an outside provider. Resident 109, who was severely cognitively impaired and dependent on nursing staff for activities of daily living (ADLs), was left without a caregiver at the appointment. The resident, who required two nursing staff for toileting and a mechanical lift for transfers, was reported to have been dropped off at the appointment without necessary assistance. This led to a situation where the resident needed help to use the bathroom but was unattended. The Director of Nursing confirmed that a staff member or family member should have accompanied Resident 109 due to their need for assistance with ADLs. Additionally, the facility did not provide bathing as care planned for Resident 54. Despite being cognitively intact, Resident 54 required staff assistance for ADLs, including bathing. The care plan specified that the resident should be bathed one to two times per week, with a bed bath offered if the resident refused a shower. However, documentation showed inconsistent bathing, with several instances marked as non-applicable or where the resident refused, and no alternative was documented. The Director of Nursing acknowledged the resident's preference for bed baths in the evening, but this preference was not reflected in the care plan.
Failure to Timely Identify and Treat Pressure Ulcer
Penalty
Summary
The facility failed to timely identify and treat a pressure ulcer for Resident 54, who was at risk for pressure ulcers due to immobility and other health conditions such as diabetes and Multiple Sclerosis. Despite being cognitively intact and able to communicate needs, the resident developed a pressure ulcer on the left heel, which was not promptly addressed by the facility staff. The resident's representative reported the presence of a significant sore on the heel, which had been an ongoing issue for about a year, but no follow-up on a requested wound consultation was conducted. The facility's care plan for Resident 54 had been revised multiple times to address the potential for skin impairment and pressure ulcer development. However, the interventions, such as encouraging nutrition, using an air mattress, and keeping heels floated, were not effectively implemented to prevent the development of a new pressure ulcer. The facility's records showed that the left heel wound was previously healed, but a subsequent skin check documented an unstageable pressure ulcer, which later was identified as a stage four pressure ulcer. Interviews with facility staff revealed a lack of awareness and timely response to the resident's condition. Staff GG, a Nursing Assistant, was unaware of any wounds, and Staff N, a Registered Nurse, was unsure of when the wound developed. The Resident Care Manager only became aware of the pressure ulcer after the resident's representative brought it to their attention, leading to a delayed referral for wound treatment. This lack of timely identification and intervention placed the resident at risk for worsening pressure ulcers and delayed healing.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to ensure that allegations of potential misappropriation were reported immediately to the facility administration and the State Survey Agency as required. This deficiency involved a resident who reported an allegation of rough treatment by a staff member to Staff C, Social Services, on November 14, 2024. However, the facility's Incident Log for November 2024 did not show any entries related to this resident's allegation. Staff C confirmed that the resident reported the allegation to them on the same day, and they stated that they reported it to unidentified staff who were investigating the incident while Staff C was out of the facility. Staff C typically reported abuse allegations to Staff A, the Administrator, but could not recall who they reported the initial allegation to or who directed them to report the incident. Staff A was notified of the allegation during a clinical meeting on November 18, 2024, and immediately reported it to the State Survey Agency. Staff A was unaware of the delay in reporting until reviewing the documentation in the resident's progress note. This delay in reporting placed the resident at risk for abuse.
Failure to Provide Proper Wound Care
Penalty
Summary
The facility failed to provide necessary wound care services for Resident 3, who was admitted with an open surgical wound requiring wound vacuum therapy. The treatment administration record indicated that the wound vacuum dressing was to be changed on specific days, but staff misinterpreted this as the only days the therapy should be applied. Consequently, the wound vacuum dressing was removed prematurely and replaced with a wet-to-dry dressing without proper documentation or notification to the medical provider. This misinterpretation and lack of adherence to the prescribed treatment regimen placed the resident at risk for delayed wound healing and potential infection. Interviews revealed that staff responsible for Resident 3's care were not familiar with the continuous application requirement of wound vacuum therapy. The Director of Nursing was informed of the resident's concerns and discovered the staff's misunderstanding of the treatment protocol. Although some staff received one-on-one education on wound vacuum therapy, documentation did not show that all relevant staff, including those directly involved in the incident, received the necessary training.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 157 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Spokane
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Regency At Northpointe | 0.5 mi | ★★★★★ | 0 | 0 |
| Royal Park Health And Rehabilitation | 1.6 mi | ★★★★★ | 14 | 0 |
| Spokane Falls Care | 2.5 mi | ★★★★★ | 34 | 0 |
| Spokane Health & Rehabilitation | 2.8 mi | ★★★★★ | 1 | 0 |
| Emerson Health & Rehabilitation | 4.1 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.