Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Canterbury House during CMS and state inspections, most recent first.
Kitchen Sanitation Deficiencies: The facility failed to keep the range vent hood and walk-in freezer clean and sanitary. The vent hood had visible dust, dirt, and spider webs near the food prep area, and the freezer bulkhead had grayish-black dirt buildup in areas of condensation. The Dietary Supervisor confirmed both areas needed cleaning, and the daily cleaning schedule showed a dietary aide was responsible for cleaning the kitchen refrigerators.
Dishwasher Failed Chemical Sanitization Testing: The facility failed to keep a kitchen dishwasher operating within manufacturer specifications. Although the dishwasher was documented as within safe temperatures on the log, staff observed that the chlorine sanitizing rinse did not reach the required 50 PPM after repeated wash/rinse cycles, even after the chemical solution bucket was changed. Staff noted the equipment needed to function properly so residents would not eat from dirty or unsanitized dishes and utensils.
The facility failed to provide written bed hold notices or document them for multiple residents transferred to the hospital. One resident had severe cognitive impairment and relied on a representative, while another was alert and oriented; both records lacked evidence that a bed hold was offered. For another resident, the chart also lacked documentation that a medical report was sent to the receiving hospital, and staff confirmed the required documentation was missing.
The facility failed to follow physician orders for several residents. A resident receiving IV nutrition had a PICC dressing and tubing left in place beyond ordered times, an LPN gave a steroid inhaler and then another inhaler without the ordered mouth rinse or wait, a resident with a catheter-related infection received an incorrect antibiotic dose and the order listed the wrong indication, and a resident with COPD was found on oxygen at a lower flow rate than ordered with documented sats outside the prescribed range.
Restorative nursing services were not consistently provided as assessed for three residents with limited ROM and mobility needs. One resident did not receive a prescribed hand splint/palm guard schedule, another resident’s PROM program was discontinued after a hospital transfer and not re-started on readmission, and a third resident’s grooming/dressing restorative program was only provided intermittently. Staff acknowledged the restorative aide workload made it difficult to meet the ordered frequencies.
Two residents receiving hospice services had care plans that did not identify what hospice services were provided or how often they occurred. For one resident with traumatic brain dysfunction, hospice visit notes were missing from the record and staff could not locate recent documentation. For another resident with heart, respiratory, wound, and pain issues, the hospice nurse reported frequent visits and services such as wound monitoring and medication management, but the record lacked consistent hospice documentation and staff could not locate the hospice binder or related emails.
PPE and respiratory equipment infection control failures were observed for three residents. A resident on EBP was given insulin by an LPN without the required gown, and a resident on Contact Precautions was repositioned by a CNA without a gown despite posted instructions for gown and gloves. In addition, a resident receiving nebulizer treatments had a visibly dirty nebulizer machine with debris, stained parts, and personal items stored in the equipment compartment.
CNA annual in-service training was not tracked or completed for 2 of 5 CNAs reviewed. One CNA completed only 15 minutes during the prior year, and another CNA had 38 assigned in-services with none completed. The LPN/MDS staff member said CNAs should complete 12 hours each year, the Infection Preventionist/Staff Development staff member confirmed there was no tracking system, and the DON stated CNAs were expected to complete 12 hours annually.
Resident Council grievances were not reviewed or documented. Residents raised concerns about shower schedules, ice water, linens, call light delays, staff name tags, trash removal, and bathroom cleanliness, but meeting minutes did not show review of resident rights or the grievance policy, and no grievance forms or written responses were completed. RC members said they were unaware of their right to a written response, while the Activities Director stated concerns were only discussed with the Administrator after meetings.
Late completion of admission and Quarterly MDS assessments affected two residents. An RN Coordinator completed one admission MDS and one Quarterly MDS past the required timeframe, and an LPN/MDS staff member stated timely MDS completion is important because it drives the care plan and helps avoid delays in care planning.
MDS assessments were inaccurate for three residents. One resident with anxiety and bipolar disorder had a Level II PASRR evaluation and care plan, but the MDS did not reflect current PASRR serious mental illness status. Another resident’s MDS did not show hospice services despite a physician order and hospice nurse visits, and a third resident’s MDS did not reflect denture and tooth status documented in records and observed by staff.
A resident with diabetes, depression, anxiety, and a chronic heart condition had repeated refusals of oral, injectable, and cardiac medications. The care plan identified medication refusal as a target behavior but gave no directions for staff, and the record did not show the provider was notified every time the refusals occurred. Staff stated the refusals should have been documented, reported, and addressed in the care plan, but they were not.
Failure to provide required ADL assistance left one resident without needed toenail care and another resident without bathing, grooming, and oral hygiene support. One resident with diabetes had long toenails that were not scheduled or trimmed despite care plan directions, while another resident who was dependent for showers and hygiene was observed unbathed, unshaven, with matted hair, odor, and unopened toiletries. Staff confirmed the bathing schedule was missed and that the toenails should have been cut.
Unsafe water temperatures were found in 2 resident room sinks, with hot water reaching above the facility’s safe range and residents reporting the water was hot but adjustable with cold water. A clean utility room across from the nursing station also was not secured as intended, allowing easy entry despite a keypad lock and exposing a bin of disposable razors that staff identified as hazardous.
The facility failed to implement its abuse and neglect policies, leading to inadequate investigations and reporting of incidents involving several residents. A resident's allegation of sexual abuse was not promptly reported to the police, and incidents of crawling out of bed were not properly assessed or logged. Additionally, staff failed to follow care plans, and investigations into verbal abuse and inappropriate care were incomplete, placing residents at risk for further harm.
The facility failed to ensure residents were free from unnecessary psychotropic medications due to inadequate documentation and monitoring of behaviors, and lack of non-pharmacological interventions. Residents were prescribed psychotropic medications without proper documentation of behaviors or effectiveness of interventions, and medications were extended without documented rationale. Staff interviews revealed a lack of adherence to facility policies regarding behavior monitoring and medication administration.
The facility failed to obtain informed consent for psychotropic medications and devices for three residents. A resident with severe decision-making impairments received an antipsychotic and increased antidepressant dosage without consent from their collateral contact (CC). Additionally, several devices were used without consent. Another resident under hospice care and a resident who could communicate also received medications without documented consent. The Director of Nursing confirmed that consent should have been obtained and documented.
A resident with severe cognitive impairment and multiple diagnoses, including pressure ulcers, experienced a significant injury of unknown origin when a large hematoma on their right calf was not promptly assessed or treated by the facility. Despite an order for an immediate ultrasound, the facility delayed action, leading to the resident requiring surgical intervention and a blood transfusion. The facility failed to follow its policies for skin assessment and notification, and did not report the injury to the state agency or investigate potential abuse or neglect in a timely manner.
A facility failed to complete and incorporate a PASRR Level II evaluation into the care plan for a resident with complex medical diagnoses, including a psychotic disorder. Despite a notification indicating a significant change in behavioral health, no Level II referral or recommendations were documented. The Divisional Director of Social Services confirmed the oversight.
The facility failed to ensure accurate PASRR assessments for several residents, leading to missed mental health indicators and necessary evaluations. A resident's PASRR did not reflect PTSD and bipolar disorder diagnoses, while another's did not require a Level II Evaluation despite severe conditions. Incomplete PASRRs for other residents also missed significant mental health diagnoses, preventing necessary assessments.
The facility failed to develop and implement comprehensive care plans for several residents, leading to potential risks for unmet care needs. A resident's care plan lacked specific goals, another's did not address mobility needs, and others were outdated or missing crucial interventions. Observations showed care plans were not consistently followed, with staff unaware of directives, resulting in inadequate care.
The facility failed to update care plans for several residents, including one whose PICC line was discontinued and another requiring oxygen therapy without specified details. Additionally, care conferences lacked participation from the Interdisciplinary Team (IDT), with residents not receiving prior notice or having overdue conferences. Staff interviews confirmed these deficiencies.
The facility failed to provide adequate ADL assistance, affecting residents' personal hygiene and daily routines. A resident requiring substantial help was left in bed without assistance, while another was not offered the use of a new wheelchair. Inconsistent documentation and failure to honor bathing preferences were noted for several residents, leading to extended periods without proper hygiene care.
The facility failed to provide Restorative Nursing Programs (RNP) as ordered for several residents, leading to deficiencies in maintaining or improving their range of motion (ROM) and mobility. A resident with complex diagnoses received RNP inconsistently, another with severe cognitive impairment did not have their RNP initiated, and two others did not receive their scheduled RNPs due to staff workload issues. These failures were noted in staff interviews and documentation reviews.
The facility failed to provide adequate nursing staff, resulting in delayed call light responses and unmet resident needs. A CNA was found asleep on duty, and residents reported waiting up to three hours for assistance, particularly during night shifts. Grievances highlighted prolonged wait times, and the DON confirmed that call lights should be answered within 15 to 30 minutes.
The facility failed to ensure timely documentation and follow-up on pharmacists' monthly Medication Regimen Reviews (MRRs) for several residents with complex medical conditions. Recommendations for medication adjustments were not acknowledged or acted upon, leading to potential risks for adverse effects. Interviews revealed that the facility's process for handling MRRs was not consistently followed.
Two residents were not free from unnecessary psychotropic medications, with one resident not undergoing a Gradual Dose Reduction (GDR) for over a year and another receiving increased antipsychotic dosages without documented rationale. Despite monthly reviews and care plans, there was insufficient documentation of behaviors or non-pharmacological interventions, leading to a deficiency in medication management.
A facility experienced a 26.92% medication error rate during a medication pass. An LPN doubled a beta-blocker dose and crushed uncrushable medications for a resident, while an RN failed to observe another resident during administration, leading to omitted doses of vitamin D and B. The DON confirmed expectations for proper medication administration and observation.
The facility failed to secure and properly manage medications, with unlocked carts, expired medications, and improper storage noted. Medications were left unsecured at a resident's bedside and in a shower room. Staff interviews confirmed these practices were against policy, posing risks to residents.
The facility failed to adequately explain arbitration agreements to residents and their representatives, leading to confusion and lack of understanding. Four residents, all alert and oriented, did not recall signing or being informed about the agreements. Staff interviews revealed a need for improved communication to ensure residents understood the legal implications of the agreements.
The facility failed to maintain an effective infection control program during a COVID-19 outbreak, with staff not adhering to PPE protocols, neglecting hand hygiene, and failing to maintain a sanitary environment. Observations included improper mask usage, lack of face shields, and inadequate handwashing during resident care, increasing infection risks.
The facility failed to ensure two residents had Advance Directives (AD) in place, as required by policy. One resident, severely cognitively impaired, did not have an AD discussed or offered upon admission, nor reviewed during care conferences. Another resident, with clear comprehension and complex conditions, also lacked an AD, with no review conducted during care conferences. Staff interviews confirmed the oversight in providing and reviewing ADs, risking residents' treatment preferences not being honored.
The facility failed to implement its grievance policy for three residents, leading to unresolved grievances. A resident reported a distressing incident with another resident, but it was not documented or addressed. Two other residents experienced missing clothing items, which were not logged as grievances, resulting in unresolved issues and dissatisfaction.
The facility failed to provide written transfer notices to three residents and did not notify the LTCO for two residents during hospital transfers. A resident with no memory impairment and another who was severely cognitively impaired were transferred without written notifications. Staff interviews revealed confusion about responsibility for these notifications, and the Social Service Director did not report one resident's transfer to the LTCO.
The facility failed to provide written notice of its bed-hold policy to residents and their representatives during hospital transfers, affecting three residents. One resident was transferred without receiving the required information, and staff confirmed the oversight. Another resident, severely cognitively impaired, was not informed about the bed-hold policy, and their representative was not given the option to return to the same room. A third resident was also transferred without the necessary documentation, as confirmed by staff.
The facility failed to clarify and follow physician's orders for three residents, leading to potential risks. A resident received a fiber supplement without a specified dosage, another was given opioid medication without checking respiratory rate, and a third received blood pressure medication despite a low heart rate. Additionally, the administration of a calorie-dense supplement was inconsistent with prescribed dosages.
A facility failed to meet the activity needs of a resident with depression and moderate memory impairment. Despite a care plan indicating a preference for activities like painting and puzzles, the resident did not consistently receive these activities or the daily activity sheet. Staff interviews revealed inconsistencies in activity delivery, with the resident not being on the schedule for activities on certain days.
The facility failed to ensure resident safety by improperly using and monitoring air mattresses, placing a blanket under a resident's mattress, and leaving sharps and chemicals unsecured. A resident with memory impairment had a blanket under their mattress, potentially acting as a restraint. Three residents were on air mattresses without proper assessments or monitoring, and unsecured sharps and chemicals were found in accessible areas.
The facility failed to provide proper oxygen administration and equipment maintenance for several residents, leading to discrepancies in oxygen levels and unclean equipment. A resident with respiratory failure had oxygen set higher than ordered without physician approval, and another with COPD received more oxygen than prescribed, risking carbon dioxide retention. Observations revealed dusty filters and undated tubing, with staff interviews confirming non-compliance with facility policies.
A resident with chronic pain syndrome and pressure wounds did not receive timely pain management, as staff failed to administer PRN pain medication promptly and did not implement nonpharmacological interventions. The resident's representative had to request medication based on physical signs of pain, and there was no care plan for managing the resident's chronic pain.
Two residents in an LTC facility experienced significant medication errors. One resident received both immediate and extended release antipsychotic medications due to a failure to discontinue the former. Another resident was nearly given double the dose of a beta-blocker and missed a calcium channel blocker due to an LPN's error. These incidents were identified through staff review and interviews, highlighting a failure to follow medication administration guidelines.
A resident with complex medical conditions did not receive timely lab services as ordered. Despite orders being marked as completed, no test results were found. Staff interviews revealed a lack of documentation and a system to audit lab results, highlighting a deficiency in the facility's process for obtaining necessary lab tests.
The facility failed to ensure sanitary conditions in food storage and distribution, with dented cans found in storage, uncovered food served during a respiratory outbreak, and mold in the ice machine. Staff acknowledged these issues, highlighting lapses in adherence to sanitary protocols.
The facility failed to maintain complete and accurate Task Care Records for three residents over several months, as required by professional standards. Interviews revealed that the DON and Resident Care Manager were aware of the documentation gaps, yet the records remained incomplete, risking unmet care needs.
A resident with severe cognitive impairment and multiple diagnoses was found with a large hematoma on the right calf, which was not reported to the state agency as required by the facility's policy. The hematoma was discovered by the resident's representative and reported to the nurse and later to the DON, but the injury of unknown origin was not reported to the state agency, leading to a deficiency in reporting and potential risk to residents.
The facility failed to thoroughly investigate alleged abuse/neglect incidents for two residents. One resident, who was severely cognitively impaired, developed a large hematoma, but the investigation was incomplete and delayed. Another resident, requiring maximum assistance with transfers, sustained a leg injury during a transfer, but the investigation lacked caregiver interviews and equipment evaluation. Both incidents were not properly assessed, leading to deficiencies in care.
The facility failed to follow physician orders and care plans, leading to deficiencies in care for several residents. A resident did not receive a prescribed high protein diet, while another experienced delays in receiving anxiety and depression medications. Pain management documentation was inadequate for a third resident, and insulin administration was inconsistent for another. Additionally, the facility did not adhere to its weight monitoring policy, resulting in unaddressed significant weight changes.
The facility failed to provide adequate care for three residents with pressure ulcers, leading to a lack of proper care plans, delayed implementation of wound care recommendations, and missed dressing changes. These deficiencies resulted in the worsening of pressure ulcers and inadequate documentation and care planning, placing residents at risk for further skin deterioration and pain.
A resident with severe impairments and medically complex conditions experienced significant weight loss due to the facility's failure to consistently monitor weights, identify significant changes, and implement RD recommendations. The resident's nutritional needs were not adequately addressed, leading to continued weight loss and decreased quality of life.
Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food was stored and prepared in accordance with professional standards of safety in 1 of 1 kitchen reviewed. Observation of the kitchen range vent hood showed a visible buildup of dust and dirt, with spider webs floating along the stainless vent hood baffle filter. The vent hood was located next to the food preparation area where steam tables were placed and resident trays were prepared for meal service. Staff S, the Dietary Supervisor, confirmed the accumulation of dust and dirt and stated it needed to be cleaned so food prepared and served to residents would remain free from contamination. Observation of the walk-in freezer showed it was dimly lit, with several boxes and packages stored up to the ceiling and almost touching the sprinkler head. The freezer bulkhead had a notable buildup of grayish-black dirt in round patches, mostly in areas of condensation. Review of the November 2025 and December 2025 Daily Cleaning Schedule showed a dietary aide was responsible for cleaning the two refrigerators in the kitchen. Staff S confirmed the freezer bulkhead had accumulated moist dirt buildup and stated they were unsure whether cleaning the freezer bulkhead was part of the daily cleaning schedule.
Dishwasher Failed Chemical Sanitization Testing
Penalty
Summary
The facility failed to ensure a dishwasher was kept in safe operating condition for 1 of 1 kitchen areas reviewed. The facility policy required dishwashing machines to be operated according to manufacturer specifications, and the manufacturer’s instructions for the Ecolab dishwasher specified a minimum wash and rinse temperature of 120 degrees Fahrenheit and a sanitizing rinse solution of 50 PPM chlorine. Review of the kitchen dishwashing temperature log showed the morning monitoring was completed and the dishwasher was documented as within safe operating temperatures and chemical sanitation. During observation and interview, the dishwasher’s chemical sanitation did not meet the required 50 PPM chlorine level when tested after a complete wash/rinse cycle. Staff repeated the cycle, and the test strip showed the same result. After Staff T changed the chemical solution bucket connected to the dishwasher, the wash/rinse cycle was run again, but the chemical testing still did not meet the manufacturer’s criteria. Staff S stated they would call the service maintenance provider to check the dishwasher immediately and use the three-compartment sink for dishwashing in the meantime. In interview, Staff S stated it was important to ensure the dishwasher functioned according to manufacturer specifications so residents would not get sick from eating off dirty and unsanitized dishes and utensils.
Failure to Notify Residents of Bed Hold Policy and Document Hospital Transfer Communication
Penalty
Summary
The facility failed to provide written notice of its bed hold policy to residents and/or their representatives at the time of transfer/discharge or within 24 hours, and failed to document that notification in the resident records for three residents reviewed. The facility policy titled, Bed Hold, updated 05/2025, stated the resident and/or representative should be informed in writing upon admission, transfer, or leave of absence, and if the policy could not be provided at the time of transfer, it must be provided within 24 hours. The policy also stated the Social Services Director or designee would contact the resident and/or representative, notify them of the bed hold policy, obtain a decision about securing a bed hold, and document the notification and decision in the Bed Hold Agreement form. Resident 9 had severely impaired cognitive ability due to a neurological developmental disability, could not communicate words, and depended on a representative for decision-making. The resident was discharged to the hospital, but review of progress notes and medical records showed no documentation that the transfer/discharge was coordinated with the receiving institution or provider for safety, no documentation that a bed hold was offered to the representative, and no documentation that the hospital received the necessary personal and health information for a safe and effective transition of care. The facility did not provide any documentation when asked, and the DON confirmed there was no record that a bed hold was offered or that staff documented coordination with the receiving hospital. Resident 82 was alert, oriented, and their own decision-maker, and was discharged to the hospital. Review of the medical record showed no documentation that a bed hold was offered during or within 24 hours after transfer/discharge. Resident 27 transferred to an acute care hospital with return anticipated, but the record showed no documentation that a medical report was provided to the hospital and no documentation that a bed hold was offered. Staff gave conflicting descriptions of the transfer process, but the record still lacked documentation that the bed hold was offered or that a medical report was called to the hospital for the transfer.
Physician Orders Not Followed for Medications, Oxygen, and IV Therapy
Penalty
Summary
The facility failed to ensure physician orders were followed for multiple residents. One resident receiving intravenous nutrition had a physician order to remove the nutrition bag and tubing from the infusion pump at 12:00 PM each day and discard it, and also had an order for PICC dressing changes every seven days and as needed. Nursing documentation showed a dressing change was not administered on 01/10/2026, and on 01/12/2026 the nutrition bag and tubing were still connected more than two hours after the ordered disconnect time. The PICC dressing was not dated and the edges were detaching from the skin. An RN stated the dressing should have been dated and changed based on appearance, and the tubing should have been disconnected and discarded at the ordered time. Another resident with diabetes, respiratory failure, and memory impairment had an order for a steroid inhaler with instructions to rinse the mouth after use, followed by a long-acting inhaler. During observation, an LPN administered the steroid inhaler and then immediately gave the other inhaler without first rinsing the resident’s mouth and without waiting between the two inhalers. The LPN stated the mouth should have been rinsed after the steroid inhaler and that there should have been a wait between inhalers. A unit manager stated staff should follow inhaler orders as written. A resident with a suprapubic catheter returned from the hospital with discharge orders for two oral antibiotics for a systemic urinary infection, including one double-strength antibiotic. The MAR showed the resident received a single-strength dose on 01/08/2026, and the order was later changed to the double-strength dose but listed pneumonitis as the indication instead of urinary infection. Staff later confirmed both antibiotics were for the urinary infection and acknowledged the dose was incorrect. In addition, a resident with COPD had an oxygen order for 2 L/min to keep oxygen saturation between 88% and 92%, but observations showed the concentrator set at 0.5 L/min and the resident’s documented oxygen saturations repeatedly ranged from 93% to 100%, with no readings within the ordered range. Staff confirmed the concentrator had been changed and that the ordered parameters were not being followed.
Restorative nursing services not consistently provided as care planned
Penalty
Summary
The facility failed to ensure that restorative nursing services were provided as assessed and care planned for three residents with limited range of motion and mobility needs. The facility policy stated that nursing staff were to screen, assess, and track changes in joint mobility and that restorative nursing aides were expected to provide ROM programs and follow splinting schedules when ordered. For one resident with limited ROM to both arms and legs and total dependence for personal care, the care plan required a left-hand splint, hand washing and drying, and a palm guard for 6 to 8 hours per day, seven days a week. Observation showed the resident did not have the palm guard in place, and review of the TARs showed restorative services were not documented as provided on Sundays in December 2025 and January 2026. A licensed practical nurse reviewing the records stated the missing initials meant the restorative services were not completed and should have been provided seven days per week. A second resident with severe cognitive and functional impairment, inability to communicate with words, and limited ROM to both arms/hands and legs had a restorative PROM program recommended by therapy for all tolerated ROM and positional changes. After the resident was discharged to the hospital and later readmitted, the PROM program was automatically discontinued in the software and was not re-initiated. Observation showed the resident’s wrists curled inward with stiff, rigid hands and fingers, and the January 2026 TAR showed PROM was not provided for nearly two weeks. A third resident with a progressive neurologic disorder, tremors, rigidity, limited ROM, and dependence for dressing and personal hygiene had a grooming/dressing restorative program ordered two to four times per week, but the TARs showed it was not consistently provided. The resident stated the program was only provided occasionally, and staff confirmed the restorative aides had difficulty meeting the required frequency because one aide could not cover all residents’ restorative needs.
Hospice Coordination and Care Plan Deficiencies
Penalty
Summary
The facility failed to ensure effective coordination of care between facility staff and hospice staff and failed to implement and develop a coordinated care plan for two residents receiving hospice services. The facility policy stated it would collaborate with outside providers to coordinate hospice care, that the hospice and facility would agree upon a coordinated care plan identifying each party’s responsibilities, and that the unit manager would coordinate care services with the hospice team. The policy also stated hospice staff would notify the facility of the care to be rendered. One resident had traumatic brain dysfunction, was unable to be understood, and was receiving hospice services. The resident’s terminal condition care plan directed staff to work collaboratively with the external hospice team to meet spiritual, emotional, intellectual, physical, and social needs, but it did not identify what hospice services were provided or how often they were provided. The resident’s January Kardex directed staff to provide a shower or bed bath twice weekly, but it did not show what care services were provided by hospice. The medical record documented hospice visits on two dates in the fall, but no hospice visits were documented for January. Staff stated hospice visit notes should be sent to the DON and scanned into the medical record, but recent hospice notes could not be located. A second resident had multiple diagnoses including heart conditions, respiratory conditions, wounds, and pain issues and was receiving hospice care. The revised hospice services care plan again stated staff would work cooperatively with the hospice team to meet the resident’s needs, but it did not show what services hospice provided or how often. The resident stated they had pain and that a hospice nurse visited them. The hospice nurse stated they visited about once every three days, monitored the resident’s wound, provided medication management, and addressed other health and comfort issues. However, the medical record contained only a limited number of hospice visit notes, with no documented visits for several months, and staff were unable to locate the resident’s hospice binder or any emails from hospice regarding the resident. Staff stated they frequently coordinated verbally with hospice staff, but such communication should be documented in the medical record.
PPE and Respiratory Equipment Infection Control Failures
Penalty
Summary
The facility failed to ensure appropriate PPE was used for a resident on Enhanced Barrier Precautions. Resident 55’s record showed the resident had received nutrition intravenously and was identified as being at risk for infection related to the IV site. On observation, an EBP sign was posted outside the resident’s room directing staff to wear an isolation gown and gloves during high-contact patient care activities. Staff E was observed leaning over the resident to administer an insulin injection without wearing a gown, and Staff E stated they did not consider insulin injections to be a high-contact activity requiring a gown. The DON later stated insulin administration was a high-contact patient care activity and that staff were expected to follow the infection control policy, but did not. The facility also failed to follow Contact Precautions for another resident. Resident 88’s room had a Contact Precaution sign posted instructing all staff and visitors to put on a gown and gloves before entering the room. Staff G, a CNA, was observed repositioning Resident 88 in bed without wearing an isolation gown, while the Infection Preventionist observed the care being provided. The Infection Preventionist stated staff were expected to follow the instructions on the sign and put on a gown and gloves before entering the room. The DON stated staff were expected to follow posted precaution signs and the facility’s infection control policy. The facility further failed to keep respiratory equipment free from visible debris for Resident 27. The resident had chronic respiratory conditions, received oxygen therapy, and was receiving nebulizer medication four times daily. A nebulizer machine on the resident’s overbed table had yellowish debris on the upper surface near the oxygen tubing port and a brown-stained air filter port. The tubing and mouthpiece were stored on top of the machine, and the storage compartment contained a bottle of saline nasal spray and numerous sugar packets. Similar observations were made on multiple later checks. The resident stated staff cleaned the tubing and mouthpiece but not the nebulizer machine itself, and staff members stated the machine should be clean and the storage compartment should be emptied of personal items.
CNA Annual In-Service Training Not Completed
Penalty
Summary
The facility failed to implement a system to ensure that 2 of 5 CNAs reviewed received the required annual in-service training of no less than 12 hours per year. Staff H was hired on 11/07/2019, and the training record for the most recent completed year of employment, 11/07/2024 through 11/07/2025, showed only 15 minutes of in-service training completed. Staff I was hired on 10/16/2024, and the records reviewed showed 38 in-service trainings assigned since hire, with none completed. During interviews, the LPN/MDS staff member stated CNAs should complete 12 hours of in-service training each year by their hire anniversary date, the Infection Preventionist/Staff Development staff member confirmed there was no system in place to track annual CNA in-service hours and later confirmed both CNAs did not complete the required 12 hours, and the DON stated CNAs were expected to complete 12 hours annually.
Resident Council grievances were not reviewed or documented
Penalty
Summary
The facility failed to review resident rights and the grievance policy in accordance with its process and failed to initiate, investigate, and document resolutions for grievances raised during 3 of 3 Resident Council meetings reviewed. The facility’s Resident Council policy required staff support for monthly meetings, review of old and new business, and updates on resident concerns through the grievance policy, while the grievance procedures required grievances to be resolved immediately if possible or documented on a Grievance Form and routed to the Grievance Official within 24 hours. Review of the Resident Council minutes showed that residents raised concerns about shower schedules, fresh ice water at the beginning of each shift, removal of soiled linens after care, long call light wait times, nursing staff not wearing name tags, trash not being removed after resident care, and housekeeping issues with bathroom cleanliness. The minutes did not document staff review of resident rights or the grievance policy, and no additional information was documented about resolution of the concerns. During interview, Resident Council members stated they were unaware they had the right to receive a written response regarding grievances and had not received responses for the issues raised. Staff D stated Grievance Forms were not completed during the meetings, and Staff A stated the grievance process should have been initiated for the concerns raised but was not.
Late Completion of Admission and Quarterly MDS Assessments
Penalty
Summary
The facility failed to complete resident assessments within the required regulatory timeframes for 2 of 12 sampled residents reviewed for assessment completion and timing. The deficiency involved an admission MDS for Resident 2 and a Quarterly MDS for Resident 5. The October 2023 RAI Manual stated that the admission MDS must be completed by the end of day 14 of the resident’s stay, with day 1 as the admission date, and that the Quarterly MDS must be completed no later than 14 days after the ARD. Resident 2’s admission MDS, dated 12/08/2023, was completed by the RN Coordinator on 12/23/2025, eight days past the required timeframe. Resident 5’s 11/30/2025 Quarterly MDS was completed by the RN Coordinator on 12/15/2025, one day past the required timeframe. During an interview on 01/14/2026, Staff U, an LPN/MDS staff member, stated that timely completion of MDS assessments was important because it drove the care plan and prevented delays in care planning, and Staff U reviewed both assessments and stated they were completed late.
MDS Assessments Did Not Match Resident Status
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) accurately reflected the status of 3 of 16 sampled residents reviewed for assessment accuracy. The facility’s RAI policy stated that MDS assessments would be completed per the RAI Manual, but the assessments for Resident 67, Resident 3, and Resident 10 did not match the residents’ documented conditions and services. Resident 67’s annual MDS identified anxiety and bipolar disorder and showed use of antipsychotic, antianxiety, and antidepressant medications, but it did not indicate that the resident was currently considered by the state PASRR process to have serious mental illness, even though the resident had been referred for a Level II PASRR evaluation and later had a psychiatric evaluation with mental health care recommendations and a Level II PASRR care plan. Resident 3’s quarterly MDS did not show hospice services despite a physician order documenting hospice admission and a hospice nurse reporting ongoing visits for medication management and wound monitoring. Resident 10’s admission MDS showed no dental issues, although a hospital swallow assessment documented upper and lower dentures and later observation showed only an upper denture in place with no lower teeth present; staff later stated the resident should have been coded as having no natural teeth or tooth fragments.
Incomplete Care Plan for Repeated Medication Refusals
Penalty
Summary
The facility failed to ensure Resident 22’s care plan was comprehensive and implemented for medication refusal. Resident 22’s 12/18/2025 MDS showed multiple complex conditions including diabetes, depression, anxiety, and a chronic heart condition. The revised 10/16/2025 impaired psychosocial well-being care plan identified medication refusal as a target behavior, but it did not include directions for staff on what to do when the resident refused medications, and no other care plan was developed to address the refusal issue. The January 2026 MAR showed repeated refusals of oral diabetes medication from 01/01/2026 through 01/13/2026, anxiety/depression medication from 01/01/2026 through 01/07/2026, a water pill for the chronic heart condition from 01/01/2026 through 01/09/2026, and injectable diabetes medication on multiple dates in January 2026. The medical record did not show the provider was notified every time the resident refused medications. Staff interviews confirmed the refusals were ongoing, that refusals should have been documented and reported to the provider, and that the care plan should have included interventions for staff to follow when the resident refused medications, but it did not.
Failure to Provide Required ADL Assistance
Penalty
Summary
The facility failed to provide ADL assistance to residents who were assessed as dependent on staff for bathing, grooming, and nail care. The facility policy stated that bath or shower assistance was to be provided according to the resident’s care plan and need for assistance. Surveyors found that two sampled residents did not receive the assistance they were assessed to require. One resident had diabetes, respiratory failure, and muscle weakness and required substantial assistance with bathing and lower body dressing. The resident’s diabetes care plan directed staff to notify nurses when toenails were long and for nurses to trim the nails or refer the resident to podiatry. Review of January 2026 task sheets and the TAR did not show toenail care scheduled. Observations on 01/12/2026 and 01/14/2026 showed toenails about half an inch past the nail bed, and the resident stated the nails caused discomfort. An LPN later observed the nails and stated they should have been trimmed for comfort and to prevent curling, but were not. Another resident was admitted with heart and kidney failure, unstable blood sugar, severe obesity, muscle weakness, and difficulty walking, and was assessed as dependent on two staff for showering and toileting hygiene. The revised care plan called for substantial to maximal assistance with showers, grooming, and hygiene, with bathing scheduled twice weekly. Surveyors observed the resident with facial hair/stubble, long matted hair, white flakes on the gown, and a noticeable odor from the breath and lower body. The resident stated they had not had a bath in almost two weeks, had not brushed their teeth since admission, and had unopened toiletries in the room. Staff later confirmed the resident should have received a shower on the scheduled day but did not.
Unsafe Water Temperatures and Unsecured Hazardous Items
Penalty
Summary
The facility failed to maintain safe water temperatures for 2 of 14 resident room sinks reviewed. In one resident bathroom, observation showed the hot water temperature reached 123 F, and later testing with the Maintenance Director showed the sink temperature rose to 125.1 F before settling at 120 F. A resident was observed independently using that sink and stated the water was hot but could be adjusted with cold water. In another resident room, observation showed the sink water temperature was 121.5 F, and later testing showed it reached 122.7 F before settling at 116 F. The occupants of that room stated they used the sink and adjusted the water when it was too hot with cold water. The facility also failed to secure potentially hazardous items in the clean utility room across from the nursing station. Observation showed the room had a keypad lock on the door, but the door opened easily without entering a code on multiple occasions. Inside the room, supplies included a bin of disposable razors. Staff stated the door should have been locked because hazardous items were stored there, and the Administrator stated the door was supposed to be locked but did not latch correctly and needed to be fixed. Staff also stated the razors in the room were hazardous and should be secured for resident safety.
Failure to Implement Abuse and Neglect Policies
Penalty
Summary
The facility failed to implement its abuse and neglect policies and procedures, resulting in multiple deficiencies related to the identification, investigation, protection, and reporting of abuse and neglect incidents. The facility did not thoroughly investigate incidents and allegations of abuse, sexual abuse, and neglect for several residents. For instance, Resident 2 reported an allegation of sexual abuse, but the facility delayed notifying the police and did not conduct a thorough investigation, failing to rule out abuse or neglect. Additionally, the facility did not ensure that staff followed care plans requiring two staff members for certain care tasks, which was not documented or investigated properly. Resident 1, who had a history of crawling on the floor, was found crawling out of bed on multiple occasions without proper assessment for injury or notification to the provider and responsible party. The facility did not log these incidents as falls or investigate them as potential neglect. Furthermore, the facility failed to use bed and chair alarms as ordered, which were intended to prevent such incidents. This lack of adherence to care plans and failure to investigate and report incidents placed residents at risk for further harm. Other residents, such as Resident 4 and Resident 5, reported verbal abuse and inappropriate behavior by staff, but the facility's investigations were incomplete, lacking documentation and follow-up. Staff D, who was involved in these incidents, returned to the residents' rooms despite being instructed not to, and the facility did not adequately monitor or document the psychological impact on the residents. Additionally, Resident 6 reported inappropriate care involving the use of multiple briefs, but the investigation did not rule out abuse or neglect, and other residents expressed concerns about care quality, which were not thoroughly addressed.
Failure to Monitor and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary psychotropic medications, as evidenced by the lack of documentation and monitoring of target behaviors, and the absence of non-pharmacological interventions before administering medications. The facility's policy required the interdisciplinary team to evaluate and implement interventions for residents on psychotropic medications, including environmental and behavioral interventions prior to initiating such medications. However, the facility did not adhere to these guidelines, resulting in residents being at risk for unnecessary medications and adverse side effects. Resident 1, who had severe impairments in decision-making and medically complex conditions, was prescribed multiple psychotropic medications without proper documentation of behaviors or non-medicinal interventions. The facility staff administered as-needed antianxiety medication without documenting the behaviors or the effectiveness of interventions before medicating. Similarly, Resident 3, who had no documented behaviors, was prescribed an antianxiety medication without a stop date, and there was no consent obtained or behavior monitoring conducted. Resident 12, who was unable to make needs known, was also administered antianxiety medication without a stop date or behavior monitoring. The facility's failure extended to Resident 14, who was prescribed an antianxiety medication repeatedly without documented rationale for extended use, despite having no documented behaviors. Resident 15, who was discharged from the facility, was prescribed an antianxiety medication without a stop date or behavior monitoring. Interviews with staff revealed that they were not monitoring behaviors or implementing interventions as expected, and there was a lack of documentation to support the continued use of psychotropic medications.
Failure to Obtain Informed Consent for Psychotropic Medications and Devices
Penalty
Summary
The facility failed to ensure that residents or their representatives were fully informed and provided consent for the use of psychotropic medications and devices. Specifically, three residents were not informed orally or in writing about the potential risks associated with psychotropic medications, and informed consent was not obtained. This deficiency was identified through interviews and record reviews, which revealed that the facility did not adhere to its policy requiring informed consent before administering such medications. Resident 1, who had severe impairments in decision-making and was rarely understood, was administered a one-time dose of an antipsychotic medication and had the frequency of an antidepressant increased without obtaining informed consent from their collateral contact (CC). The facility's records showed no documentation of consent, and the CC confirmed that no discussion about the medications occurred. Additionally, Resident 1 had several devices implemented without consent from the CC, including a fall mat, bed against the wall, and perimeter mattress. Resident 12, who was under hospice care and unable to make decisions, received an antipsychotic medication multiple times without consent from their CC. Similarly, Resident 3, who could make decisions and communicate, was administered an antianxiety medication without documented consent. Interviews with the Director of Nursing confirmed that informed consent should have been obtained and documented before administering these medications.
Failure to Timely Assess and Treat Resident's Hematoma
Penalty
Summary
The facility failed to consistently assess and monitor a change in condition and implement provider orders timely for a resident who experienced a significant injury of unknown origin. The resident, who was severely cognitively impaired and had diagnoses including pressure ulcers and paraplegia, was admitted to the facility with no new skin impairments noted. However, a large hematoma on the resident's right calf was reported by the resident's representative, but the facility delayed in assessing and treating the condition. Despite an order for an immediate ultrasound of the resident's right leg, the facility did not obtain the ultrasound, and the resident was eventually sent to the hospital for surgical intervention due to the expanding hematoma and a critically low blood count. The facility's policies required immediate assessment and documentation of skin impairments, as well as notification to the physician and resident representative, but these were not followed. Additionally, the facility did not conduct necessary pain assessments or monitor the hematoma as required. Interviews revealed that the Director of Nursing was informed of the hematoma but failed to act promptly, resulting in a delay in obtaining the ultrasound and a lack of documentation and assessment. The facility also did not report the significant injury to the state agency within the required timeframe, nor did they initiate an investigation to rule out abuse or neglect. These failures placed the resident at risk for harm and indicated a lack of adherence to facility policies and procedures.
Failure to Complete PASRR Level II Evaluation
Penalty
Summary
The facility failed to ensure that the Pre-admission Screening and Resident Review (PASRR) Level II comprehensive evaluations were obtained, implemented, and incorporated into the Care Plan for a resident reviewed for PASRR Level II. This deficiency was identified for one resident who had medically complex diagnoses, including a history of stroke, alcohol dependence, and a psychotic disorder. The resident was taking antipsychotic medication as per a physician's order. The record review revealed that the resident had a PASRR Notification of Determination form indicating a significant change in their behavioral health, meeting the requirements for Level II services. However, no Level II referral was completed, and no recommendations were documented. During an interview, the Divisional Director of Social Services confirmed the absence of a PASRR Level II evaluation for the resident, acknowledging that a referral and evaluation should have been completed following the Notification of Determination.
Inaccurate PASRR Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate Pre-Admission Screening and Resident Review (PASRR) assessments for several residents, which is crucial for identifying mental health or intellectual disability needs. Resident 22's PASRR was outdated and did not reflect their diagnoses of PTSD and bipolar disorder, despite being on medications for these conditions. The PASRR only listed depression, and a new Level I PASRR was not completed until much later, missing the opportunity to update the resident's mental health indicators. Resident 57's PASRR was also inaccurate, as it did not require a Level II Evaluation despite the resident having severe memory impairment and complex diagnoses, including anxiety, bipolar disorder, and schizophrenia. The PASRR failed to reflect the significant changes in the resident's condition, which included receiving hospice services and multiple medications for mental health conditions. Similarly, Resident 13's PASRR was incomplete, failing to indicate the presence of schizophrenia, mood, or anxiety disorders, despite the resident being on multiple medications for these conditions. This oversight meant that a necessary Level II assessment was not conducted. Additionally, Residents 185 and 53 had inaccuracies in their PASRR Level 1 forms, with Resident 185's form not listing depression and Resident 53's form incorrectly marked, preventing a Level II evaluation referral.
Deficiencies in Care Plan Development and Implementation
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for six of the twenty sampled residents, leading to potential risks for unmet care needs and decreased quality of life. For Resident 53, the care plan was not individualized or measurable, lacking specific goals even 30 days post-admission. Similarly, Resident 70's care plan did not address the resident's ambulation status or required mobility device, despite being assessed with a functional limitation. Staff interviews confirmed the importance of comprehensive care plans, yet these were not adequately developed. Resident 32's care plan was outdated and did not reflect the resident's current needs, such as assistance with bed mobility and pressure wound care. The care plan for Resident 43 lacked interventions for a diagnosed skin condition, and Resident 45's care plan only referred to a baseline plan without specific interventions. Resident 16, diagnosed with paraplegia and chronic pain syndrome, did not have a pain management care plan, and the care plan for contractures was missing, despite a referral for a Restorative Nursing Program. The implementation of care plans was also deficient. Resident 16's care plan directed staff to keep the resident's heels elevated to prevent pressure ulcers, but observations showed this was not consistently done. Staff interviews revealed a lack of awareness and adherence to care plan directives, as seen with Resident 32, who reported not being repositioned as required. Staff claimed the resident refused assistance, but there was no documentation of such refusals, indicating a failure in implementing and documenting care as per the care plans.
Deficiencies in Care Plan Updates and Care Conferences
Penalty
Summary
The facility failed to ensure that care plans were updated and revised to reflect person-centered care for several residents. Resident 70's care plan was not updated to reflect the discontinuation of a PICC line, which was initially listed as an intervention. Resident 53's care plan lacked specific details regarding the use of oxygen therapy, including the reason for the therapy and whether a humidifier was required. Similarly, Resident 185's care plan did not specify a toileting schedule or the primary language for communication, despite the resident's need for substantial assistance with these activities. Staff interviews confirmed that these care plans needed to be updated to reflect the residents' current conditions. The facility also failed to ensure that residents participated in care conferences that included the Interdisciplinary Team (IDT). Resident 21, who had no memory impairment, reported being unfamiliar with care conferences and did not recall attending one. Documentation showed that care conferences for Resident 21 were conducted without the presence of the IDT, and the resident was invited on the same day the conferences occurred. Staff interviews confirmed that care conferences should include the IDT and that residents should receive prior notice of these meetings. Resident 43, who had no memory impairment and was working towards returning home, reported having a care conference upon admission but not subsequently. Staff interviews revealed that Resident 43 was overdue for a quarterly care conference due to a lack of staff to arrange these meetings. The Executive Director confirmed that care conferences should be conducted upon admission, quarterly, and as needed, and that care plans should be updated to reflect current conditions.
Deficiencies in ADL Assistance and Hygiene Care
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADL) for several residents, leading to deficiencies in personal hygiene and daily routines. Resident 70, who required substantial assistance due to a functional limitation, was observed lying in bed without being assisted to get up, despite expressing frustration over the lack of help. The care plan for Resident 70 lacked specific directions for daily ambulation, and staff interviews revealed a misunderstanding of responsibilities, with some staff assuming physical therapy would handle getting residents out of bed. Resident 21, who was totally dependent on staff for transfers, was not regularly assisted out of bed as per their care plan. Despite having a new wheelchair, Resident 21 reported not being offered the opportunity to use it. The facility's documentation showed inconsistencies in offering and recording bathing assistance, with several instances of blank or 'not applicable' entries, indicating a failure to adhere to the resident's preferences for showers or bed baths. Other residents, such as Resident 20, 13, 22, 43, 16, and 45, also experienced similar issues with inadequate ADL support. Resident 20 had long, unkempt nails that led to skin injuries, contrary to their care plan's goal of maintaining short nails. Residents 13, 22, 43, 16, and 45 were not consistently offered showers or bed baths according to their preferences and schedules, with some residents going extended periods without bathing assistance. Staff interviews confirmed that residents' preferences were not always honored, and documentation of refusals was lacking, contributing to the overall deficiency in care.
Failure to Implement Restorative Nursing Programs
Penalty
Summary
The facility failed to provide appropriate Restorative Nursing Programs (RNP) for several residents, leading to a deficiency in maintaining or improving their range of motion (ROM) and mobility. Resident 70, who had multiple complex diagnoses and a recent surgical procedure, was supposed to receive an RNP three times a week to maintain muscle strength and ROM. However, the program was only provided twice in six occurrences, despite the resident's expressed desire to work on mobility for discharge goals. The delay in implementing the RNP and the lack of consistent delivery were noted. Resident 16, who was severely cognitively impaired with conditions such as Alzheimer's dementia and paraplegia, was referred for an RNP that included hand splints and stretching exercises. Despite the referral, the program was not initiated, and observations showed the splints were not used. Staff interviews revealed a lack of awareness and initiation of the RNP, which was crucial to prevent further deformity of the resident's contracted hands and limbs. Resident 43, with chronic pain syndrome and nerve damage, was referred for elastic band exercises to improve ROM in their arms. However, the resident reported not receiving the RNP, and staff confirmed the program was not offered due to workload issues. Similarly, Resident 46, diagnosed with paraplegia, was scheduled for an RNP to maintain leg muscle strength but did not receive the program as documented. The lack of RNP provision and documentation of refusals were highlighted as deficiencies.
Inadequate Staffing and Delayed Call Light Response
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple observations and interviews. On one occasion, a Certified Nursing Assistant (CNA) was found asleep at the nurse's station with call lights going unanswered, indicating a lack of staff to cover the needs of residents during the night shift. The CNA admitted to being asleep and expressed that there were not enough staff at night, which prevented them from taking all their breaks. The night shift supervisor confirmed that staff should not be sleeping on duty. Several residents reported excessive wait times for assistance, particularly during the night shift. One resident stated they waited three hours to be changed after an aide failed to return promptly. Another resident reported having to wait hours for their call light to be answered, resulting in them soiling themselves. Additional residents described waiting times ranging from 30 minutes to three hours for their call lights to be answered, with one resident expressing concern over their health condition due to prolonged wait times in a soiled brief. Grievance forms filed by residents further highlighted the issue of long call light response times. Residents and their families reported waiting over 30 minutes for assistance, and staff were reportedly educated on the importance of timely responses. The Director of Nursing stated that call lights should be answered within 15 to 30 minutes and confirmed that staff should not be sleeping while on duty. The facility's failure to provide adequate staffing and timely responses to call lights placed residents at risk for unmet care needs and decreased quality of life.
Failure to Document and Act on Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that licensed pharmacists' monthly Medication Regimen Reviews (MRRs) were properly documented in resident records and that recommendations were reviewed and acted upon in a timely manner. This deficiency was observed in the cases of five residents, including those with complex medical conditions such as dementia, depression, bipolar disorder, and psychotic disorders. For Resident 3, there was no documentation of MRRs being completed monthly since March 2024, and multiple recommendations for medication review and dose reduction were not acknowledged or acted upon by the physician. Similarly, Resident 13's records showed a lack of follow-up on recommendations regarding medications for side effects of antipsychotic drugs and thyroid medication adjustments. Resident 23's records indicated a delay in the physician's acknowledgment of a recommendation to discontinue an iron supplement, which was not addressed until nearly a month later. Resident 16, who was severely cognitively impaired, had no MRRs documented, and a recommendation to adjust the timing of blood pressure medication was not implemented or recorded. Resident 46, who had diabetes and was on insulin, had a recommendation regarding the use of sliding scale insulin without a longer-acting insulin acknowledged by the physician only after a significant delay. Interviews with the Director of Nursing (Staff B) revealed that the facility's process for handling MRRs was not being followed as expected. Staff B stated that MRRs should be reviewed and addressed by the end of the month in which they were completed, but this was not happening consistently. The lack of timely follow-up on pharmacy recommendations placed residents at risk for delays in necessary medication changes, adverse side effects, and negative outcomes.
Failure to Ensure Residents are Free from Unnecessary Psychotropic Medications
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary psychotropic medications, which left them at risk for adverse side effects and other negative health outcomes. Resident 3, with complex medical diagnoses including dementia and bipolar disorder, had not undergone a Gradual Dose Reduction (GDR) for over a year, and there was no documentation from a physician indicating that a GDR was clinically contraindicated. Despite monthly reviews showing that Resident 3's mood and behaviors were managed by medications, there was no significant documentation of target behaviors or monitoring related to the antidepressant. The pharmacist had recommended a review of the psychotropic medications, but there was no documented clinical rationale or acknowledgment from the physician. Resident 23, diagnosed with conditions such as stroke and dementia, was administered routine antipsychotic medication without a GDR attempt or physician documentation of contraindication. The resident's care plan included interventions for behavior management, but behavior monitoring showed no documented behaviors except for one instance. Despite this, the antipsychotic medication dosage was increased twice within a short period, with no documented rationale for the increases. The practitioner had previously declined a GDR recommendation, citing past failures and the benefits outweighing the risks, but there was no documentation of attempted GDRs. Interviews with staff revealed expectations for documenting resident behaviors, identifying triggers, and using non-pharmacological interventions before increasing medications. However, there was a lack of documentation supporting these practices for both residents. The facility's interdisciplinary team was expected to review medication dosages and recommendations, but the records did not reflect adherence to these processes, contributing to the deficiency.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 26.92% error rate during a medication pass observation. For Resident 72, a Licensed Practical Nurse (LPN) mistakenly prepared and almost administered a double dose of an extended-release beta-blocker blood pressure medication while omitting a calcium channel blocker. Additionally, the LPN crushed medications that should not have been crushed, including an enteric-coated iron tablet, an extended-release beta-blocker, and a delayed-release anticonvulsant. The LPN was unaware of a list of medications that should not be crushed, which was later provided by the Director of Nursing (DON). For Resident 4, a Registered Nurse (RN) failed to properly observe the resident during medication administration, resulting in two pills falling, one on the floor and one on the resident's shirt. The RN mistakenly believed all medications were administered, leading to the omission of a vitamin D tablet and a vitamin B tablet. The RN acknowledged the error, attributing it to the similarity in the names and doses of the medications on the computer system. The DON confirmed the expectation that staff should administer medications as ordered and observe residents during administration.
Medication Security and Management Deficiencies
Penalty
Summary
The facility failed to ensure the security and proper management of medications and biologicals, leading to several deficiencies. Observations revealed that medication carts were left unlocked and unattended, containing both over-the-counter and prescription medications with resident information. Staff interviews confirmed that the carts should have been locked, and medications should not have been left unsecured. Additionally, a medication room contained an opened vial of tuberculin testing solution without an open or discard date, which was acknowledged by staff as a failure to adhere to expected standards. Further deficiencies were noted with the improper storage of medications. A medication cart contained a prescription medication for a discharged resident and a bottle of topical antifungal powder stored alongside oral medications, which staff confirmed was incorrect. Another cart had expired lubricating jelly and medicated patches, with one patch opened and returned to its box. The cart was also found to be dirty, and documentation for narcotic counts was incomplete, as noted during a shift change observation. Additional issues included unsecured medications at a resident's bedside and in a shower room. A resident had two pills left unsecured in their room, which they had not taken. In the shower room, an unlocked cabinet contained prescription medicated shampoos, which staff admitted should have been secured. These findings indicate a failure to comply with professional standards for medication security and management, placing residents at risk of accessing expired or unsecured medications.
Failure to Explain Arbitration Agreements
Penalty
Summary
The facility failed to ensure that the arbitration agreement was explained in a manner that residents and their representatives could understand. This deficiency was identified for four out of five residents reviewed for arbitration agreements. The facility's policy required the admissions coordinator to review the arbitration agreement with residents upon admission, but this was not effectively implemented. Resident 37, who was alert and oriented, did not recall signing the arbitration agreement or being informed about its contents. When presented with the agreement, the resident expressed surprise at waiving their right to a court hearing and stated that they would not have agreed to it if they had understood. Similarly, Resident 48, also alert and oriented, found the admission paperwork overwhelming and did not remember signing the arbitration agreement or being informed about it. Resident 35, who was alert and oriented, did not recall any discussion about the arbitration agreement and suggested that the facility staff might have spoken to their family member instead. However, the family member also stated they were not informed about the agreement. Resident 59's representative, who signed the agreement, did not remember doing so and stated they would not have signed if they understood what it entailed. Staff interviews revealed a lack of clarity in the process, with the Admission Director acknowledging the need for better communication to ensure residents understood the agreement.
Infection Control Deficiencies During COVID-19 Outbreak
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple observations of staff not adhering to proper PPE protocols during a COVID-19 outbreak. Staff members, including medical directors, nurses, and aides, were observed not wearing masks properly, neglecting to wear required face shields, and failing to change or disinfect PPE as directed by the facility's policies. These lapses in protocol were noted despite clear signage and instructions posted outside resident rooms indicating the necessary precautions for aerosol and contact precautions. Additionally, staff did not consistently follow hand hygiene protocols, particularly during wound care and personal care activities. Instances were observed where staff did not wash their hands between glove changes or after handling soiled materials, which is critical to preventing the spread of infections. This was particularly concerning during the care of residents with COVID-19, where strict adherence to hygiene protocols is essential to prevent cross-contamination and further spread of the virus. The facility also exhibited deficiencies in maintaining a sanitary environment, as evidenced by cracked and uncleanable surfaces on linen cart covers and improper disposal of soiled linens and garbage. These issues, combined with the failure to follow PPE and hand hygiene protocols, placed residents and staff at increased risk of infection during an active COVID-19 outbreak. The facility's infection preventionist acknowledged these expectations and the importance of following established protocols to mitigate infection risks.
Failure to Ensure Advance Directives for Residents
Penalty
Summary
The facility failed to ensure that residents had the appropriate Advance Directives (AD) in place, as required by their policy. This deficiency was identified for two residents during a review of their records and interviews. Resident 16, who was severely cognitively impaired and had diagnoses of non-Alzheimer's dementia, anxiety disorder, and depression, did not have an AD on file. The facility did not offer or discuss the formulation of an AD with Resident 16's representative upon admission, nor was it reviewed during care conferences. The representative confirmed that the facility had not discussed or offered assistance in formulating an AD. Similarly, Resident 32, who had clear comprehension and multiple medically complex conditions, also lacked an AD. The facility's records showed that the review of ADs was not completed during care conferences, as indicated by unchecked boxes on the forms. Staff interviews revealed that ADs should be provided upon admission and reviewed quarterly, but this process was not followed for Resident 32. The failure to provide and review ADs placed residents at risk of not having their medical treatment preferences honored.
Failure to Implement Grievance Policy
Penalty
Summary
The facility failed to implement its grievance policy for three residents, leading to unresolved grievances and potential impacts on their quality of life. Resident 54 reported a distressing incident where another resident entered their room in a disoriented state, but the staff did not document or address the grievance. The facility's grievance log did not reflect this incident, and staff interviews revealed a lack of awareness and action regarding the grievance. Resident 70 experienced frustration over missing clothing items, which they reported to staff without resolution. Despite the resident's repeated inquiries, the grievance was not logged, and the missing items were only partially found after a significant delay. Staff interviews indicated a lack of adherence to the grievance procedure, with staff failing to report the issue promptly. Resident 53 also reported missing clothing items, which were not resolved or logged as grievances. The resident expressed dissatisfaction with the situation, and staff interviews confirmed that the grievance process was not followed. The facility's policy required grievances to be logged and addressed within a specific timeframe, but this was not adhered to, resulting in unresolved issues for the residents.
Failure to Provide Written Transfer Notices and Notify LTCO
Penalty
Summary
The facility failed to provide required written notices to residents and their representatives at the time of transfer or discharge, as well as notify the Office of the State Long-Term Care Ombudsman (LTCO) for certain residents. Specifically, three residents did not receive written transfer notifications, and two residents were not reported to the LTCO. Resident 65, who had no memory impairment, was discharged to an acute care hospital without any record of a written transfer notification. Resident 16, who was severely cognitively impaired, was also transferred to a hospital without a written notification being provided to their representative, who confirmed not receiving such notice. Additionally, Resident 53 was sent to the hospital without documentation of a written notice before transfer. Staff interviews revealed confusion and lack of clarity regarding the responsibility for providing written transfer notifications. The Social Service Director and Director of Nursing both indicated that their departments were not responsible for these notifications, and the Executive Director did not provide further information on who was responsible. The Social Service Director also failed to notify the LTCO about Resident 53's transfer, as confirmed by their review of the notification log.
Failure to Provide Bed-Hold Policy Notification
Penalty
Summary
The facility failed to provide written notice of its bed-hold policy to residents and their representatives at the time of transfer to a hospital or within 24 hours, as required by regulations. This deficiency was identified for three residents who were reviewed for hospitalization. Resident 67 was transferred to an acute care hospital with an anticipated return, but there was no documentation indicating that the facility provided the required bed-hold information. Staff L, responsible for providing this information, confirmed that Resident 67 did not receive the bed-hold policy upon transfer. Similarly, Resident 16, who was severely cognitively impaired, was transferred to a hospital without receiving the necessary bed-hold information. The resident's representative reported that they were not informed about the bed-hold policy and did not have the option to return to the same room. Staff K and Staff L acknowledged that they failed to discuss the bed-hold policy with Resident 16 and their representative. Additionally, Resident 53 was sent to the hospital, and there was no documentation of a bed-hold form being provided. Staff D confirmed that the admissions department was responsible for this task but could not locate the necessary documentation for Resident 53.
Failure to Clarify and Follow Physician's Orders
Penalty
Summary
The facility failed to ensure physician's orders were clarified and followed for three residents, leading to potential risks for unneeded care and unmet care needs. For Resident 29, a physician's order dated 08/15/2024 for a fiber supplement lacked a specified dosage, which was acknowledged by the Director of Nursing as needing clarification. This oversight could lead to improper administration of the supplement. For Resident 4, a physician's order from 12/06/2023 required that opioid pain medication be withheld if the resident's respiratory rate was below 14 breaths per minute. However, during a medication pass on 10/03/2024, a registered nurse failed to measure the resident's respirations before administering the medication. Additionally, Resident 3, who had heart failure and difficulty swallowing, was given blood pressure medication despite orders to hold it if the heart rate was below 60 BPM. The medication was administered on two occasions when the resident's heart rate was below the specified threshold. Furthermore, the administration of a calorie-dense supplement for Resident 3 was inconsistent with the prescribed dosage, with varying amounts given over several months.
Failure to Provide Adequate Activities for Resident
Penalty
Summary
The facility failed to ensure that the activity programs met the needs of Resident 32, who was part of a sample reviewed for activities. Resident 32 had a diagnosis of depression and moderate memory impairment but could communicate their needs and be understood by others. The resident's care plan indicated a preference for activities such as painting, arts and crafts, and coloring, with a goal to participate in one-on-one activities two to three times weekly. Despite this, observations and interviews revealed that the resident did not consistently receive the activities they preferred, such as puzzles and music, and often did not receive the daily activity sheet. Interviews with staff, including Staff Y and the Activities Director, Staff X, highlighted inconsistencies in the delivery of activities to Resident 32. Staff Y, who was new to assisting with activities, admitted to not stopping at Resident 32's room with the activity cart because the resident was not on the schedule for that day. Staff X acknowledged that Resident 32 should have received one-on-one activities and that the activities schedule should be delivered daily to bed-bound residents. However, observations showed that the activity sheet was not present in Resident 32's room, and the resident expressed dissatisfaction with the lack of activities provided.
Deficiencies in Resident Safety and Equipment Monitoring
Penalty
Summary
The facility failed to ensure residents were free from accident hazards, as evidenced by several deficiencies observed during the survey. Resident 41, who had moderate memory impairment and required substantial assistance, was found with a folded blanket placed under the right side of their mattress, raising it by one to two inches. This practice was not in line with facility protocols, as confirmed by the Director of Nursing, who stated that such placement could act as a restraint. For Residents 57, 43, and 16, the facility did not properly assess or monitor the use of air mattresses. Resident 57, who was on hospice care and at risk of falls, was observed on an air mattress with a pump set incorrectly and a flashing red light indicating low air pressure. There were no physician orders or assessments for the air mattress, and similar issues were found for Residents 43 and 16, with no monitoring or documentation of air mattress settings and safety checks. Additionally, the facility failed to secure sharps and chemicals, posing potential risks to residents. Unsecured sharps were found in a hallway, and chemicals, including a hazardous spray can, were left in an unlocked shower room. Staff interviews confirmed that these items should have been secured to prevent resident access, highlighting a lapse in safety protocols.
Deficiencies in Oxygen Administration and Equipment Maintenance
Penalty
Summary
The facility failed to provide oxygen administration consistent with professional standards of practice for five residents, leading to deficiencies in care. Resident 32, who had respiratory failure and required oxygen therapy, was observed with oxygen levels set higher than the physician's order of two LPM, reaching up to 4.25 LPM without documented physician approval. Additionally, the oxygen equipment was not maintained properly, with dusty filters and tubing found on the floor or incorrectly placed on the resident's head. Resident 45, diagnosed with COPD and respiratory failure, was also administered oxygen at 3.5 LPM instead of the ordered two LPM, risking carbon dioxide retention. The oxygen concentrator for this resident was observed with a thick layer of dust and an unclean filter, indicating a lack of regular maintenance. Staff interviews confirmed the discrepancies in oxygen administration and equipment maintenance, highlighting a failure to adhere to physician orders and facility policies. Other residents, including Residents 53, 185, and 22, were found with undated oxygen tubing and unclean oxygen concentrator filters. These observations were corroborated by staff interviews, which revealed a lack of awareness and adherence to the facility's policy on cleaning and maintaining oxygen equipment. The deficiencies in oxygen administration and equipment maintenance posed risks to the residents' respiratory health and safety.
Inadequate Pain Management for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide adequate pain management for Resident 16, who was severely cognitively impaired and had diagnoses of chronic pain syndrome and pressure wounds. The resident's records indicated that they received pain medications both routinely and as needed (PRN), but there were no documented nonpharmacological interventions for pain management. Additionally, there was no care plan in place for managing the resident's chronic pain. The resident's representative reported having to request PRN pain medication for the resident, as staff did not administer it based on the resident's physical signs of pain, such as heavy breathing, restlessness, or excessive sweating. On one occasion, the resident appeared sweaty and had labored breathing, prompting the representative to request PRN pain medication from a Licensed Practical Nurse (LPN). However, the LPN delayed administering the medication, prioritizing wound care instead, and only returned with the medication 40 minutes later. Interviews with staff revealed that there was an expectation for nonpharmacological interventions to be ordered and for pain medications to be administered promptly, ideally within 15 minutes of a request or observation of pain. The Director of Nursing acknowledged the need for a pain care plan for residents with chronic pain, which was not in place for Resident 16.
Medication Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors, which placed them at risk for adverse health outcomes. Resident 23, who had a history of stroke, dementia, and other conditions, was administered both an immediate release and a 24-hour extended release antipsychotic medication simultaneously. This error occurred because the immediate release medication was not discontinued when the extended release medication was prescribed. The error was identified when a registered nurse reviewed the medication cards and confirmed the discrepancy with the physician's order. The facility pharmacist also confirmed that the 24-hour extended release medication should not have been administered twice daily, indicating a need for clarification of the order. Resident 72, who had complex medical diagnoses including high blood pressure and end-stage kidney failure, experienced a medication error during a medication pass. A licensed practical nurse mistakenly prepared and almost administered double the ordered dose of a beta-blocker while omitting the calcium channel blocker. This error was caught before administration, and the nurse acknowledged the potential negative impact of incorrect blood pressure medication administration on the resident's condition. The Director of Nursing stated that it was expected for staff to administer medications as ordered. These incidents highlight the facility's failure to adhere to its medication administration guidelines, which require verification of medications three times before administration. The errors in medication administration for both residents were due to a lack of proper verification and clarification of medication orders, leading to significant medication errors that could have adversely affected the residents' health.
Failure to Obtain Timely Lab Services for Resident
Penalty
Summary
The facility failed to provide timely laboratory services for a resident with multiple complex medical diagnoses, including heart failure, high blood pressure, diabetes, lung disease, and a thyroid disorder. The resident had a STAT order for a Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), and Thyroid-Stimulating Hormone (TSH) level on one occasion, and a subsequent order for the same tests plus a vitamin D level on another occasion. Both orders were marked as completed in the Medication Administration Records, but no test results were found in the resident's records. Interviews with facility staff revealed that there was an expectation for lab tests to be obtained as ordered, with STAT orders typically completed the same day and routine orders on the next scheduled lab day. However, the lab confirmed that no tests were performed for the resident's orders, and there was no documentation or lab requisition slips to explain the oversight. The Director of Nursing acknowledged the lack of a system to audit the receipt of lab test results and emphasized the importance of lab tests in monitoring residents' conditions and determining necessary interventions.
Sanitation Deficiencies in Food Storage and Distribution
Penalty
Summary
The facility failed to maintain sanitary conditions in the storage and distribution of food and drinks, as observed in the kitchen and during meal service. During an inspection of the dry food storage area, several large cans of apricots, sliced apples, and diced pears were found to be significantly dented, contrary to the facility's policy that requires such cans to be discarded. Staff CC, a Food and Nutrition Service Aide, acknowledged that dented cans should not be present in storage. Additionally, during meal service, staff were observed distributing lunch trays with uncovered desserts and fruit cups, carrying them through hallways past multiple rooms, including a unit experiencing a contagious respiratory outbreak, which violated sanitary protocols. Further observations revealed unsanitary conditions in the facility's ice machine, which had mold and black, sticky debris along its opening. Staff T, the Dietary Manager, confirmed the presence of mold and stated that the ice machine should be cleaned monthly. However, the last cleaning was reported to have occurred in August 2024, indicating a lapse in the maintenance schedule. These deficiencies in food storage, distribution, and equipment cleanliness posed a risk of foodborne illness to residents.
Incomplete and Inaccurate Documentation of Resident Care
Penalty
Summary
The facility failed to ensure that the medical records for three residents were complete and accurate, as required by professional standards. Specifically, the Task Care Records for Residents 16, 43, and 45 were found to be incomplete and inaccurately documented over several months. For Resident 16, the Task Care Records for August, September, and October 2024 showed multiple instances where staff did not document the care provided. Similar issues were found for Resident 43 in July, August, September, and October 2024, and for Resident 45 in June, July, August, September, and October 2024. Interviews with staff revealed that the Director of Nursing and the Resident Care Manager were aware of the missing documentation. Staff BB confirmed that the Director of Nursing had reviewed the Task Care Records and informed staff about the documentation gaps. Staff B emphasized the importance of accurate and complete documentation to ensure that residents receive the care they need. Despite these expectations, the records remained incomplete, placing residents at risk for unmet care needs and inaccurate assessments.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report a significant injury of unknown origin for a resident, identified as Resident 16, which placed the resident and all other residents at risk for repeated incidents and unidentified abuse and/or neglect. The facility's policy required immediate reporting of such injuries to the state agency, but this was not adhered to. Resident 16, who was severely cognitively impaired and diagnosed with paraplegia, non-Alzheimer's dementia, and chronic pain syndrome, was found to have a large hematoma on the right calf. The hematoma was discovered by the resident's representative on August 10, 2024, and reported to the nurse on duty the same day, and later to the Director of Nursing on August 13, 2024. Despite the report of the hematoma, the Director of Nursing acknowledged that the significant injury of unknown origin was not reported to the state agency as required. The Executive Director also admitted that the injury should have been reported within two hours but was not. The facility's policies on abuse reporting and response, as well as abuse identification, were not followed, leading to a deficiency in reporting and potentially compromising the safety and well-being of the residents.
Inadequate Investigation of Alleged Abuse/Neglect Incidents
Penalty
Summary
The facility failed to conduct thorough investigations into alleged abuse or neglect for two residents, leading to deficiencies in their care. For Resident 16, who was severely cognitively impaired and on blood thinners, an incident involving a large hematoma on the right calf was not properly investigated. The incident report was incomplete and submitted eight days past the regulatory requirement. Key assessments, such as pain, skin, and mental status, were not conducted, and potential environmental or situational factors were not explored. The investigation was prematurely concluded without determining the root cause of the hematoma, despite the resident's representative raising concerns about a possible injury during a transfer. For Resident 4, who required maximum assistance with transfers and used a wheelchair, the facility did not adequately investigate an incident where the resident's right shin was injured during a transfer. The investigation was completed 18 days after the incident, and crucial steps were missed, such as interviewing caregivers, evaluating the sit-to-stand lift's function, and assessing caregivers' ability to safely transfer the resident. The investigation failed to consider whether the lift remained a safe method for transferring the resident, and the conclusion was reached without a comprehensive assessment of the incident.
Deficiencies in Care and Medication Management
Penalty
Summary
The facility failed to ensure that residents received necessary care and services in accordance with professional standards of practice. For Resident 2, the facility did not follow physician orders for a high protein diet, as indicated in hospital transfer orders. The Registered Dietician acknowledged the oversight, and the Director of Nursing confirmed that Resident 2 was not discussed in nutrition/hydration skin committee meetings. Additionally, Resident 2's nutritional status was not assessed within the required timeframe, and care plans were not developed promptly. Resident 4 experienced a delay in the implementation of psychiatric provider recommendations for anxiety and depression medications. The recommendations were made on September 4, 2024, but the physician orders for the medications were not written until six days later. This delay affected Resident 4's eating, sleeping, and therapy progress, as reported by the resident's Collateral Contact. The Director of Nursing was unable to explain the delay in implementing the provider's recommendations. Resident 3's pain management was inadequately documented, with staff failing to record observed side effects of opioid use and actions taken to address them. Despite documentation indicating side effects for 12 days, there were no progress notes detailing the side effects or staff responses. Additionally, Resident 5 did not receive insulin as ordered, with missed doses and a lack of timely clarification of insulin orders. The facility's emergency medication kit was not utilized effectively, and staff failed to communicate medication shortages to the resident or physician. Furthermore, the facility did not adhere to its weight monitoring policy for several residents, including Residents 1, 2, and 3, leading to unaddressed significant weight changes.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary care and services for three residents with pressure ulcers, consistent with professional standards of practice. Resident 3 was admitted with multiple skin impairments, including a stage 4 pressure ulcer, but did not have a care plan developed to manage these conditions. The facility delayed implementing wound care provider recommendations for seven days, and staff frequently documented 'not applicable' for assisting Resident 3 with bed mobility, indicating a lack of repositioning. Resident 3's collateral contact reported concerns about inadequate care, including the resident being left in soiled conditions and not being repositioned, which contributed to the worsening of the pressure ulcer. Resident 4 was admitted with a risk for skin impairments but did not have a care plan to address this risk. Despite a physician's order for a foam dressing to be applied to the tailbone, the dressing change was missed when Resident 4 was out of the facility for an appointment. A new stage 2 pressure ulcer was discovered at a subsequent medical appointment, and the facility did not have a care plan with interventions to manage this new wound. Staff B acknowledged the lack of appropriate documentation and care planning for Resident 4's condition. Resident 1 was admitted with a stage 2 pressure ulcer but did not have a care plan that identified the type and location of the wound. Weekly wound assessments were not documented after the initial assessment, and Resident 1 was not referred to a wound provider as expected. Staff B confirmed that the facility failed to conduct weekly assessments and did not have a proper care plan in place for Resident 1's pressure ulcer. These deficiencies in care and documentation placed all residents at risk for deterioration in skin condition, pain, and diminished quality of life.
Failure to Maintain Resident's Nutritional Status
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable parameters of nutritional status, leading to significant weight loss and decreased quality of life. The facility did not consistently obtain timely weights and re-weights, identify significant weight changes promptly, notify interested parties, or implement the Registered Dietician's (RD) recommendations. This failure placed the resident at risk for delayed identification of interventions to prevent continued weight loss and decreased quality of life. The resident, who had severe impairments in decision-making, highly impaired vision, and behaviors of rejecting care, was admitted with medically complex conditions including fracture, dementia, and muscle weakness. The resident experienced a weight loss of five percent or more in the last month and had an unhealed stage 3 pressure ulcer (PU). Despite the facility's policy requiring weekly weights for residents with PUs, the resident's weight was not consistently monitored, and significant weight changes were not promptly addressed. The resident's weight record showed multiple instances where weights were not obtained or re-weighed within the required 24-hour period, and significant weight loss was not documented or communicated to the physician or resident representative in a timely manner. The facility's Nutrition Hydration Skin Committee (NHSC) failed to identify the resident's significant weight loss during their review meetings, and the RD's recommendations for an appetite stimulant were not implemented. The resident's collateral contact reported that staff did not provide adequate supervision and encouragement during meals, and there was confusion and lack of communication regarding the need for a feeding tube. The resident continued to lose weight, and the facility did not take appropriate actions to address the resident's nutritional needs, leading to the resident being moved to another care facility.
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 1,200 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Auburn
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Auburn Post Acute | 0.7 mi | ★★★★★ | 12 | 2 |
| Lea Hill Rehabilitation And Care Center | 2.4 mi | ★★★★★ | 61 | 0 |
| North Auburn Care | 3.4 mi | ★★★★★ | 4 | 0 |
| Garden Terrace Healthcare Center Of Federal Way | 5.3 mi | ★★★★★ | 1 | 0 |
| Avalon Care Center Federal Way, L.l.c. | 5.3 mi | ★★★★★ | 26 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.