Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Heartwood Extended Healthcare during CMS and state inspections, most recent first.
Failure to identify fall trends and update interventions for a resident with repeated falls. A resident with dementia, repeated falls, and a BIMS score of 00 had multiple unwitnessed falls, including injuries such as a facial bruise, eyebrow skin tear, head hematoma, and a distal clavicle fracture. The record showed the resident continued to self-transfer, use the wheelchair unsafely, and not use the call light, while the care plan largely repeated the same interventions without documented evaluation of effectiveness or progressive resident-centered changes.
Menu substitutions were not consistently prepared in advance, followed, or communicated to residents. Posted meals were changed with sticky notes, several items were served in place of the menu, and the DNM stated alternate meals were decided day-of based on available stock and were not posted for residents or offered as a choice. The Administrator stated residents should be informed of substitutions and able to choose between the main and alternate meal.
The facility failed to complete infection control surveillance for a month and did not accurately identify an MDRO for a resident whose EHR showed ESBL E. coli with contact precautions noted. The laundry area was also used for central supply, soiled linens were sorted in the washing area, temperature logs were not kept current, and residents were allowed to go into the laundry room to look for missing clothing.
Failure to obtain assessment and consent for restrictive safety devices. Surveyors found that a resident with hospice care and dementia had half side rails in use without documentation explaining the device, a resident with repeated falls and dementia had an anti-rollback device on the wheelchair that prevented backward movement without an order or consent, and a resident with dementia had a wander guard wrist band without a provider order, assessment, or informed consent. Staff interviews confirmed the missing documentation and that the devices restricted movement.
Missing Transfer and Bed-Hold Notices: The facility failed to provide Nursing Home Transfer/Discharge Notices and bed hold notices for 4 sampled residents transferred to the hospital. The residents had diagnoses including dementia, Alzheimer's disease, AFib, HF, diabetes, and a traumatic subdural hemorrhage, and staff stated transfer packets should include the notice and bed hold, but the records reviewed did not contain the required documentation.
Inaccurate MDS coding affected multiple residents. A resident was coded for anticoagulant use despite MARs showing none, another resident had the same error, and other residents were miscoded for bedrails, hospice status, BIPAP use, broken/missing teeth with chewing pain, and wander/elopement alarm use. Observations, MARs, dental records, and staff interviews showed the MDS did not match the residents’ actual care and conditions.
Failure to provide advance directive information: Two residents who were able to make needs known, including one with diabetes and foot wounds and another with end stage kidney disease receiving dialysis, had no documentation in the EHR showing they were given written information or assistance with completing advance directives. The Social Services Director stated both should have been offered help at admission but were not.
A resident with polyneuropathy, DM, and dysphagia reported missing two pairs of jeans and said they had not been contacted about the missing items. The resident also stated their clothing came from the facility's donation closet. During a Resident Council meeting, members reported ongoing laundry problems and said clothes sometimes were not returned. Grievance logs showed multiple complaints about missing clothing, and the Administrator stated missing clothing should be handled through a grievance for investigation or reimbursement.
A resident with polyneuropathy, DM, and dysphagia reported missing jeans, but the concern was not documented, investigated, or resolved. The RN confirmed the report was made and did not complete a grievance, and the SS Director stated no grievance had been received. The Administrator stated missing clothing concerns should be handled through a grievance so they can be investigated or reimbursed.
Failure to Report Injury of Unknown Source: A resident with Alzheimer's disease, CHF, and depression developed bruising to the forehead and was sent to the hospital after an unwitnessed event. The incident was logged as a fall and treated as reasonably related to the resident's condition, but it was not reported to the State Agency even though the DON later stated it should have been documented as an injury of unknown origin and reported to the State Hotline.
Failure to investigate a neglect allegation for a resident with polyneuropathy, DM, and dysphagia. The resident reported a long delay after pressing the call light, and a collateral contact said the wait for a brief change was neglect. The allegation was reported to the Administrator, but the EHR had no alert charting or documentation, and the DON and Administrator stated the resident was not placed on psychosocial alert even though they said it should have been.
The facility failed to develop comprehensive care plans for two residents with dental concerns. One resident had broken and missing teeth, gum irritation, and pain with a need for extraction noted on a dental visit form, but the care plan did not reflect those issues. Another resident had missing and broken upper teeth, tooth pain affecting eating, and an MDS showing likely cavity or broken natural teeth, yet the care plan had no oral care or dental interventions.
Failure to hold timely care conferences for two residents. One resident with renal dialysis dependence, HTN, and encephalopathy had only one documented care conference, with no record of the required quarterly conference. Another resident with DM, COPD, and PVD had no documentation of an admission care conference. The SSD and Administrator both stated the required conferences were not documented.
Failure to follow provider orders for pain and edema affected two residents. One resident with HF, DM, anxiety, and TBI had severe LE edema and an active TED hose order, but the resident said no one had discussed the TED hose and staff stated the order should have been discontinued. Another resident with repeated falls, DM, and dementia had a lidocaine patch order written for BID, but the MAR showed it was applied once daily for 12 hours; staff said the order was written that way for documentation purposes and the ARNP said it was intended as once-daily use.
Missed showers and incontinent briefs not provided: Two residents did not receive needed ADL support. One resident with polyneuropathy, DM, and dysphagia reported inconsistent showers, and the shower record showed only four showers in 30 days while a CNA said one shower aide covered the building and documentation was sometimes not entered. Another resident with cholecystitis, CKD, and rectal cancer said requested briefs were never received; Central Supply said there was no formal request process or documentation, and the DON said this did not meet expectations.
Delayed Assistance With Breakfast Meal Service: A resident who was dependent on staff for eating and other ADLs was observed in bed with breakfast tray placed nearby while waiting for help to eat. The resident stated they were waiting for staff, and a roommate reported the meal had arrived 10 to 15 minutes earlier. An RN was notified, and the DON later stated the delay in assisting the resident with breakfast did not meet expectation.
Failure to provide prescribed glasses for a resident with blurred vision and impaired visual function. The resident, who had quadriplegia, HTN, and depression, reported staff knew glasses were needed but they were never received. Records showed an eye exam found blurred vision and issued a new glasses Rx, but staff later stated the glasses should have been provided and they were not aware the resident had not received them; the DON also was unaware the Rx had not been fulfilled.
Restorative nursing programs were not accurately provided, evaluated, or documented for a resident with quadriplegia, HTN, and depression. Observations showed PROM was provided, but no splints, braces, or PRAFO boots were applied, and no fine motor tasks were observed. The care plan included AAROM, fine motor tasks, and a splint/brace program, yet restorative documentation showed the splint/brace program as not occurring while the restorative overview incorrectly listed participation in PRAFO boots and fine motor tasks.
Oxygen therapy was not provided as ordered for two residents. One resident had orders for O2 at 3 L/min, weaning to keep sats above 90%, and a sleep study for hypoxia, but the TAR showed missing and inaccurate documentation, O2 sats were sometimes below ordered parameters, and provider notification was inconsistent. Another resident had an order and care plan for O2 at 4 L/min continuously, but observations showed the O2 set at 3 to 3.5 L/min instead of 4 L/min.
Incomplete Pain Assessments and Missing NPI Documentation: A resident with renal dialysis dependence, anxiety, and dorsalgia received PRN oxycodone for pain that was often rated 7/10 or higher, but the care plan did not document NPIs beyond reporting signs of pain. Admission and pain interview assessments were left incomplete, including blank responses about non-medication interventions, and the DON and RN/UM confirmed the assessments did not meet expectations.
Unsecured medications and treatment carts were observed in the facility. A resident had a saline laxative enema, two inhalers, and a nasal spray at bedside, and the DON stated no meds were expected at bedside. Two treatment carts were also left unlocked and unattended at nurses' stations, with staff stating one cart's key was missing and the carts should have been secured.
Failure to Provide Routine Dental Services: Two residents had unmet dental needs, including broken and missing teeth, pain, and difficulty chewing. One resident with quadriplegia had a prior dental exam showing broken teeth, irritated gums, and referrals for x-rays and extractions, but the issue was not care planned. Another resident had missing and broken upper teeth with tooth pain affecting eating, and staff could not locate a dental referral despite monthly dental provider visits and the DON stating the resident should have been referred and care planned.
Daily nurse staffing data was not posted in a prominent location and did not include actual hours worked. Observations showed the posting was only visible near the staffing scheduler's office window and not from all common entry areas, and an LPN staffing posting was not updated the same day to reflect current hours worked. The Staffing Coordinator stated the actual hours were being monitored but were not posted, and the Administrator stated the postings should have been visible to all and updated every shift.
A resident with CHF and morbid obesity was not accurately weighed as required, with staff documenting repeated identical weights and failing to re-attempt weights after refusals. Logistical barriers and possible inaccurate documentation were identified, and a significant weight gain was observed during the survey, indicating a failure to properly assess and manage the resident's CHF.
A facility failed to inform a resident of the risks/benefits and obtain consent for an antidepressant medication. The resident, admitted with a spine fracture, quadriplegia, and depression, was receiving the medication without documented consent. Staff confirmed the oversight, acknowledging the protocol to provide such information and obtain consent was not followed.
A resident with multiple health conditions expressed dissatisfaction when staff disposed of personal condiments without prior notice or agreement. The resident, who could communicate needs, was not informed of the facility's food policy beforehand. Despite the resident's concerns, no grievance was filed, contrary to the facility's protocol.
A facility failed to assess the use of a low bed as a restraint for a resident with hemiplegia and hemiparesis, who was at risk for falls and required staff assistance for mobility. The resident's care plan included a low bed intervention, but the necessary consent, assessment, order, and care plan were not in place, as acknowledged by the DON.
A facility failed to provide a resident with written notification of a hospital transfer. The resident, diagnosed with polyneuropathy and bipolar disorder, was transferred without receiving the required notice. Interviews with the DON and Administrator confirmed the oversight, as the EHR lacked documentation of the notice.
A facility failed to provide a written bed hold notice to a resident with polyneuropathy and bipolar disorder during their hospital transfer. The resident's electronic health record lacked documentation of a bed hold offer, confirmed by the Business Office Manager. The Administrator noted that bed holds should be done at transfer or within 24 hours, but this was not followed, risking the resident's awareness of their bed hold rights.
The facility failed to accurately complete comprehensive assessments for three residents, leading to discrepancies in their medical records. A resident's pressure ulcers were misrecorded, another's dental and respiratory conditions were inaccurately documented, and a third resident's discharge was incorrectly coded. Staff confirmed these inaccuracies, indicating a failure to meet expected standards.
The facility failed to conduct timely care planning meetings for a resident with respiratory failure, paraplegia, and depression. The resident, dependent on staff for daily activities, did not recall a recent care conference, and records showed the last offer was several months prior. Staff interviews confirmed the expectation of quarterly care conferences, but the date of the last meeting could not be located.
A resident was discharged without a complete discharge summary, lacking an overview of their stay, a final status summary, and necessary signatures. The resident, diagnosed with multiple sclerosis, dementia, and receiving hospice care, was discharged home without these critical documents. Staff interviews confirmed the discharge process was not completed as expected.
The facility failed to provide necessary positioning devices for a resident with multiple health issues, and did not follow bowel management protocols for two residents. The resident did not receive a required boot and splint, and staff were unaware of the orders. Additionally, two residents experienced lapses in bowel movement documentation and protocol adherence, leading to unaddressed constipation issues.
A facility failed to ensure a resident received appropriate care to maintain or improve range of motion (ROM), leading to a risk of worsening mobility and contractures. Despite a referral for a resting hand splint and exercises, the resident did not receive the necessary assistance, and the care plan lacked interventions for splint/brace assistance. Interviews with staff revealed a lack of follow-up on the referral, contrary to the expectations of the DON.
The facility failed to secure hazardous items in a shower room and did not implement fall interventions for a high-risk resident. Observations showed unsecured razors and nail clippers in an unlocked shower room, contrary to staff expectations. Additionally, a resident identified as a high fall risk did not have recommended safety measures, such as a fall mat and a low, locked bed, in place.
The facility failed to administer nutritional supplements as recommended for a resident with significant weight loss and did not follow fluid restrictions for two residents with critical health conditions. The Registered Dietician's recommendations for supplements were not fully implemented, and fluid intake documentation was missing for residents on fluid restrictions, as confirmed by staff interviews.
A resident with multiple health conditions was using oxygen without a physician's order or a care plan in place. Staff interviews confirmed that oxygen services should be provided per provider's orders and monitored, which was not done, leading to a deficiency in respiratory care.
A facility failed to conduct consistent pain assessments for a resident receiving oxycodone for chronic pain. Despite frequent changes in medication orders, the last pain assessment was documented in early January, with no further assessments conducted. The resident had multiple health conditions and was dependent on staff for daily activities. The DON noted a shortage of care managers, leading to LNs being responsible for pain assessments.
A facility failed to provide dialysis care consistent with professional standards for a resident with end-stage renal disease. The facility's policy required documentation of dialysis care, but records showed inconsistent documentation of pre- and post-dialysis evaluations. Staff interviews confirmed that the process was not followed as expected, placing the resident at risk for substandard care.
A facility failed to limit a PRN psychotropic medication for a resident to 14 days, as required by policy. The resident, with multiple health conditions including anxiety and depression, had an indefinite order for clonazepam without documented rationale for extension. Staff acknowledged the oversight and stated the expectation for provider documentation.
A resident with respiratory issues and broken teeth did not receive routine dental services, as observed during a survey. The resident's care plan did not address the dental issues, and staff interviews confirmed that a dental appointment should have been made. The DON acknowledged the deficiency in dental care.
The facility failed to maintain effective infection control practices, as staff did not consistently use PPE according to Enhanced Barrier Precautions for a resident with a PEG and catheter. Additionally, respiratory care equipment for another resident was improperly stored on the floor. These actions increased the risk of infection transmission.
A resident reported rough care by a CNA, leading to the CNA's dismissal. Later, the resident felt retaliated against by other CNAs, but this was not reported or investigated as required. Staff interviews confirmed the incident should have been reported and investigated due to potential psychosocial harm.
The facility did not post actual nursing staffing hours daily for 30 days, preventing residents and visitors from knowing the available nursing staff. The policy required daily posting of staffing data, but reviews showed missing facility names and adjustments for absences. Interviews revealed a lack of awareness and expectation about posting actual hours worked.
A resident was discharged from a facility with a zero balance, yet over-payments were made post-discharge, resulting in a credit of $4,363.44 that was not refunded nearly a year later. Automatic withdrawals were made from the resident's bank account without a located authorization form, and staff confirmed the refund should have been issued within 30 days.
A facility failed to provide appropriate care for a resident with a urinary catheter and bowel incontinence. The resident did not have physician orders for catheter use, nor a care plan for catheter care and monitoring. The facility also failed to continue the resident's established bowel program from the hospital. Improper catheter care was observed, and the Director of Nursing confirmed the absence of necessary orders and care plans, placing the resident at risk for infections and diminished quality of care.
The facility did not accurately assess and develop/implement a care plan for a resident with chronic heart failure and lung disease, leading to unmonitored weight gain and fluid volume overload, resulting in respiratory failure and emergency hospitalization. Additionally, the facility failed to consistently monitor and document bowel movements for two residents, leading to delayed interventions for constipation despite having bowel management protocols in place.
The facility failed to accurately assess 7 residents, leading to deficiencies in their care plans. Errors included incorrect coding of falls, dental status, weight changes, mental health history, and medical conditions. These inaccuracies impacted the development of comprehensive care plans, potentially risking unmet needs and diminished quality of care.
The facility failed to develop, implement, and update person-centered comprehensive care plans for six residents, leading to unmet care needs and potential risks. Issues included missing care plans for depression, catheter care, and bowel management, as well as outdated and conflicting information in care plans for various medical conditions.
The facility failed to meet professional standards of practice in medication administration, vital sign monitoring, physician orders, insulin administration, weight monitoring, and heart failure care, placing residents at risk of medical complications.
Failure to identify fall trends and update interventions for a resident with repeated falls
Penalty
Summary
The facility failed to identify fall trends, evaluate the effectiveness of prior fall prevention interventions, and implement progressive resident-centered interventions for a resident who had repeated falls. The resident was admitted with diagnoses including repeated falls, diabetes, and dementia, and the MDS dated 01/19/2026 showed a BIMS score of 00 with partial/moderate assistance needed for chair and toilet transfers. The resident was able to make needs known, but the record showed six falls over a 10-week period, including two unwitnessed non-injury falls and four unwitnessed falls with injury. The care plan included interventions such as encouraging call light use, not placing the bed in the lowest position, assisting with toilet hygiene, frequent checks, and offering toileting every two hours. After the 01/02/2026 fall, the resident was found trying to pick up the remote, was transferred to the hospital, and treated for a bruise on the face; no new interventions or corrective measures were documented. After the 01/18/2026 fall, the resident was described as impulsive and continuing to ambulate and self-transfer without using the call light, and sustained a skin tear to the left eyebrow where a previous fall bump was located; again, no new interventions or corrective measures were documented. Subsequent falls continued despite the existing plan. After the 01/26/2026 fall, the resident attempted to self-transfer to the wheelchair and fell because the wheelchair brakes were not locked; therapy was to assess the wheelchair for anti-lock brakes, and a fall screening later recommended an anti-rollback device. After the 02/11/2026 fall, the resident slid from the wheelchair while going to the bathroom, and the planned interventions repeated prior care plan measures. After the 03/03/2026 fall, the resident attempted to transfer from the wheelchair to the bed, was transferred to the hospital, and treated for a head hematoma. After the 03/14/2026 fall, the resident was found on the bathroom floor, could not state what happened, and was treated for a distal clavicle fracture.
Menu substitutions were not consistently posted or offered as choices
Penalty
Summary
The facility failed to ensure menus were prepared in advance, followed, and reflected input from residents and the resident group for 3 sampled days. On 03/26/2026, the posted weekly menu in the cafeteria showed beef tip au jus, rice, seasoned peas, wheat roll, margarine, and frosted marble cake for lunch, but sticky notes had been placed over menu items to indicate changes. Similar sticky notes were observed on 03/25/2026 showing changes to lunch and dinner items, including no apples and a change to pineapple and peaches, and diced potatoes not mashed. At 12:52 PM on 03/26/2026, residents were served beef tip au jus, rice, carrots, bread, and yellow cake instead of the posted peas, wheat roll, and marble cake. The lunch menu for 03/27/2026 listed chicken fried rice, broccoli, egg roll, and tropical fruit, but at 12:06 PM apricot was served in place of tropical fruit. The Dietary Manager stated substitutions were supposed to be reviewed by the registered dietician and recorded on a substitution log, but also stated the alternative meal was not posted for residents, was based on what extra food was available in the kitchen, and was decided on the day it would be served. The Dietary Manager stated residents were not informed of substitutions except by sticky note, and there was no system for residents to choose between the main or alternate meal. The Administrator stated residents should be informed of substitutions and should be able to choose between the main course and the alternative menu item, and stated the facility's menu system did not meet expectations.
Infection Control Surveillance and Laundry Handling Deficiencies
Penalty
Summary
The facility failed to implement its infection control program by not completing surveillance of possible communicable diseases for January 2026. The infection control log for that month did not identify any infectious organisms, yet the record for Resident 110 showed an entry dated 01/30/2026 stating the organism was not an MDRO and did not require special infection control precautions. Review of Resident 110’s EHR showed a laboratory test dated 01/20/2026 that identified Escherichia coli ESBL positive organism, an MDRO, and noted that contact precautions should be observed. During interview, the IP/RN stated the January log did not include the identified organisms and should have, and stated they did not have access to hospital records and did not know which organisms were present for Resident 110. The facility also failed to ensure proper handling and processing of soiled linens in the laundry area. A resident stated that when clothing was missing, the facility let residents go into the laundry room to look for items. Observation showed boxes of supplies stored in the soiled linen sorting room, including an open box of gauze bandages, with one soiled linen barrel present. Laundry staff stated the soiled laundry room was being used for central supply and that soiled linens were sorted in the laundry room. The temperature log for March 2026 was not current, with the last entry on 03/24/2026, and staff stated it should be monitored every shift. Additional interviews confirmed residents had gone into the laundry room to look through non-labeled clothes, and the DON, IP/RN, and Administrator stated soiled linens should be sorted separately from clean linens, temperatures should be monitored daily, and residents should not have been going through the laundry themselves.
Failure to obtain assessment and consent for restrictive safety devices
Penalty
Summary
The facility failed to ensure that safety devices did not restrict residents’ ability to move and failed to have resident or representative consent for restrictive safety devices for 3 of 4 sampled residents reviewed for physical restraints. The deficiency involved Resident 51, Resident 66, and Resident 105, and surveyors identified the issue through observation, interview, and record review. Resident 51 was admitted with hospice care, depression, anxiety, and vascular dementia, was dependent on staff for ADLs, and was not able to communicate needs. The resident had a very low body weight and was observed multiple times in bed with half side rails raised on both sides while lying in a fetal or curled position, including during meals and while watching TV. The record showed a Device and Bed Rail/Bed Enabler Evaluation and consent for bilateral grab/assist/mobility bars, and the care plan listed bilateral grab bars for bed mobility, but staff could not find documentation to explain the use of half side rails. The RN/UM stated the process required therapy evaluation, consent, and assessment, and the DON stated any device that could be a potential restraint should have assessment, consent, and periodic reassessment. Resident 66 was admitted with repeated falls, diabetes, and dementia and was able to make needs known. The MDS showed the resident could independently wheel 150 feet in a wheelchair, but observation showed an anti-rollback device attached to both wheelchair wheels, preventing backward movement and causing the resident frustration. The EHR contained no order or consent for the device. Staff stated the device had been installed after a fall, that the resident could not self-propel backward, and that the resident would attempt to stand instead; the OT and DOR confirmed the resident was restrained from propelling backward and had not been assessed after the device was installed. Staff also stated the device was installed incorrectly. Resident 105 was admitted with dementia, unsteadiness on feet, and cognitive communication deficit. Observation showed a wander guard wrist band securely fastened to the left wrist. The EHR had no provider order, no wander guard assessment, no informed consent, and the quarterly MDS indicated a wander/elopement alarm was not used. The RN/UM stated the resident had an elopement risk evaluation for exit seeking, but it did not include an assessment for a wander guard, and staff could not locate the required order, assessment, consent, or documentation showing function and placement monitoring. The DON stated they were not aware those documents were missing and that they should have been in place.
Missing Transfer and Bed-Hold Notices
Penalty
Summary
The facility failed to provide Nursing Home Transfer/Discharge Notices and bed hold notices at the time of hospital transfer for 4 of 4 sampled residents reviewed for hospitalization. Resident 5 was admitted with diagnoses including Alzheimer's disease, depression, and atrial fibrillation and was transferred to the hospital for head injuries; the EHR did not contain a Nursing Home Transfer and Discharge Notice or bed hold notice for that transfer. Resident 6 was admitted with diagnoses including dementia, diabetes, and high blood pressure and was transferred to the hospital for vomiting; the EHR did not contain a Nursing Home Transfer and Discharge Notice or bed hold notice for that transfer. Resident 66 was admitted with diagnoses including atrial fibrillation, heart failure, and dementia and was transferred to the hospital for hip pain; the EHR did not contain a Nursing Home Transfer and Discharge Notice or bed hold notice for that transfer. Resident 110 was admitted with diagnoses including diabetes, traumatic subdural hemorrhage, and high blood pressure and was transferred to the hospital for critical blood test results; the EHR did not contain a Nursing Home Transfer and Discharge Notice or bed hold notice for that transfer. Staff D stated that when a resident was transferred to the hospital, nurses sent a copy of the transfer notice and bed hold and the next day the business office manager would follow up. Staff S stated that a transfer packet should include medical record information plus the Nursing Home Transfer or Discharge Notice and bed hold, but only transfer/discharge notice forms were available in the folder of copies. Staff A stated the nurses were to present the Nursing Home Transfer or Discharge Notice with a bed hold and then the business office manager was to follow up on completing them, and acknowledged the lack of documentation and bed hold for the four residents did not meet expectations.
Inaccurate MDS Coding for Medications, Devices, Dental Status, and Safety Alarm Use
Penalty
Summary
The facility failed to accurately code multiple resident assessments for 6 of 20 sampled residents reviewed for assessment accuracy. The inaccurate coding involved Resident 11 and Resident 32 being coded as using anticoagulant medication when medication administration records showed no anticoagulant was administered, Resident 51 being coded as not using bedrails and not having six months or less to live despite observations showing half side rails in use and the resident being on hospice, Resident 33 being coded as not using a BIPAP machine despite the resident having an order to wear it while sleeping and the device being present at bedside, Resident 10 being coded as not having broken or missing teeth and not having mouth or facial pain or difficulty chewing despite dental documentation showing broken teeth, missing teeth, and pain, and Resident 105 being coded as not using a wander/elopement alarm despite observation of a wander guard wrist band in place. Resident 11 was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, dementia, high blood pressure, and depression, and was unable to communicate needs. The quarterly MDS coded anticoagulant use, but the December 2025 and January 2026 MARs showed no anticoagulant medication. Resident 32 was admitted with end stage renal disease, anemia, heart failure, and substance abuse disorder, and could communicate needs. The admission MDS also coded anticoagulant use, but the February 2026 MAR showed no anticoagulant administered. During interview, the RN/MDS staff stated these were coding errors, and the DNS stated the expectation was for MDS coding to be accurate. Resident 51 had hospice, depression, anxiety, and vascular dementia and was dependent on staff for ADLs. Observations showed the resident lying in bed with half side rails up on multiple occasions, yet the quarterly MDS did not mark bedrails in section P and did not mark six months or less to live in section J. Resident 33 had COPD and CHF, was observed with a BIPAP machine at bedside, stated it was worn when sleeping, and had a provider order for BIPAP while sleeping, but the quarterly MDS did not indicate use of the device. Resident 10 had quadriplegia with incomplete damage to the neck and reported broken upper teeth and difficulty chewing; a dental form documented broken teeth or root tips, missing teeth, irritated gums, and pain, but the significant change and quarterly MDS did not code broken teeth or mouth/facial pain or chewing difficulty. Resident 105 had dementia, unsteadiness on feet, and cognitive communication deficit; observation showed a wander guard wrist band securely fastened, the care plan included a wander guard intervention, but the quarterly MDS was coded as not using a wander/elopement alarm.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to inform and provide written information on the formulation of advance directives for 2 of 3 sampled residents, Residents 99 and 15. Resident 99 was admitted with diagnoses of diabetes and foot wounds and was able to make needs known, but the EHR contained no documentation that the resident was provided written information on or assistance with completing advance directives. Resident 15 was admitted with diagnoses of end stage kidney disease and was receiving dialysis, was able to make needs known, and the EHR also contained no documentation that the resident was provided written information on or assistance with completing advance directives. The Social Services Director stated both residents should have been offered assistance with formulating advance directives when admitted but had not.
Missing Resident Clothing and Ongoing Laundry Grievances
Penalty
Summary
The facility failed to ensure personal property was protected for one sampled resident who was admitted with diagnoses including polyneuropathy, diabetes, and dysphagia and who was able to make needs known. The resident reported missing two pairs of jeans that had only been worn once, and later reported the missing jeans to a registered nurse. The resident stated they had not been contacted about the missing jeans and that the clothes they were wearing came from the facility's donation closet. During a Resident Council meeting, members stated that when they sent clothes to the laundry, they sometimes did not get them back and that the laundry issues had been ongoing. Review of grievance logs from October 2025 through March 2026 showed 27 grievances related to missing clothing, and the Administrator stated that when residents had missing clothing, a grievance should be completed so it could be investigated or the resident could receive reimbursement.
Failure to Process Resident Grievance for Missing Clothing
Penalty
Summary
The facility failed to initiate, investigate, and resolve a grievance for one sampled resident who was reviewed for personal property and grievances. Resident 9 was admitted with diagnoses including polyneuropathy, diabetes, and dysphagia, and was able to make needs known. During an interview, the resident stated that two pairs of jeans were missing and that the clothing had only been worn once, but the resident had not reported the missing clothing to staff at that time. Later, the resident reported the missing jeans to an RN, but the EHR contained no documentation related to the concern. The Social Services Director stated no grievance had been received regarding the missing clothing, and the resident stated they had not been contacted about the issue. The RN confirmed the resident reported missing clothing and stated a grievance was not completed. The Administrator stated that when residents have missing clothing, a grievance should be completed by the staff member who received the report so it can be investigated or the resident can receive reimbursement.
Failure to Report Injury of Unknown Source
Penalty
Summary
The facility failed to ensure an injury of unknown source was reported to the State Hotline for Resident 5. Resident 5 was admitted with diagnoses including Alzheimer's disease, congestive heart failure, and depression, and was unable to make needs known. The January 2026 accident and incident log documented an unwitnessed fall on 01/18/2026 with small bruises in places generally vulnerable to trauma, and the event was recorded as reasonably related to the resident's condition. The log also indicated the action taken was medical treatment and that the incident was not reported to the State Agency. The facility investigation dated 01/18/2026 stated the floor nurse reported bruising to the right side of the forehead, and that Resident 5 had an unwitnessed fall and may have hit the head on the bottom of the overbed table. A progress note in the investigation documented that Resident 5 was sent to the hospital due to a black and blue bruise on the right side of the forehead. A post-fall huddle documented that Resident 5 was found with bruising to the forehead while sitting in a wheelchair in the room and could not recall what happened. During interview, the DNS stated that after speaking with staff who worked that day, it was confirmed Resident 5 did not have a fall, and the incident should have been documented as an injury of unknown origin and reported to the State Hotline.
Failure to Investigate Neglect Allegation
Penalty
Summary
The facility failed to thoroughly investigate a potential abuse and/or neglect allegation for Resident 9. Resident 9 was admitted with diagnoses including polyneuropathy, diabetes, and dysphagia, and was able to make needs known. During an interview, Resident 9 stated they pressed their call light and, after 15 minutes, a collateral contact went to the nurse's station to request assistance, which took an additional 30 minutes. The collateral contact stated they were unhappy with the care Resident 9 was receiving and, based on their experience working in LTC, believed the long wait time for a brief change was neglect. The allegation was reported to the Administrator, but review of the EHR on multiple dates showed no alert charting or documentation related to the neglect allegation. During a joint interview, the DNS and Administrator stated Resident 9 was not placed on alert for psychosocial well-being to monitor for psychosocial harm, but should have been, and the Administrator stated this did not meet expectations.
Failure to Care Plan Dental Needs for Two Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for 2 of 20 sampled residents reviewed for care plans, specifically Residents 10 and 1, whose dental needs were not reflected in their care plans. Resident 10 was admitted with diagnoses including quadriplegia with incomplete damage to the neck, high blood pressure, and depression, and was able to make needs known. The resident stated during interview that a dental exam had identified broken upper teeth that needed to be pulled and that chewing took longer because of the broken teeth. The dental visit form showed broken teeth or root tips, missing upper and lower teeth, red/irritated gum tissue, and a handwritten note that tooth #4 caused pain and the resident wanted extraction. The current provider order showed a regular diet with regular texture and thin liquids, but the care plan initiated on 11/14/2024 did not identify or reflect the resident's current dental status or interventions related to broken and missing teeth. Resident 1 was admitted with diagnoses including cholecystitis, chronic kidney disease, and rectal cancer, and was able to make needs known. Observation and interview showed missing and broken upper teeth, and the resident stated they had tooth pain and it was starting to affect their ability to eat. The admission MDS identified obvious likely cavity or broken natural teeth, but the care plan initiated on 01/08/2026 contained no interventions related to oral care or dental concerns. During interview, the DNS stated the expectation was that upon assessment, the resident's oral needs should have been care planned with clear goals and interventions.
Failure to Hold Timely Care Conferences
Penalty
Summary
The facility failed to provide and/or conduct quarterly care conferences in a timely manner and did not include the residents and/or their representatives for 2 of 3 sampled residents, Residents 87 and 99. Resident 87 was readmitted to the facility with diagnoses including dependence on renal dialysis, high blood pressure, and encephalopathy, and was able to make needs known. During an interview, Resident 87 stated they did not remember going to a care conference. The EHR contained a care conference document dated 11/17/2025 showing Resident 87 attended and participated, but no other care conference documentation was found. Staff D, SSD, stated Resident 87 should have had a quarterly care conference in February 2026, but documentation could not be located. Resident 99 was admitted with diagnoses including diabetes, COPD, and peripheral vascular disease, and was also able to make needs known. During an interview, Resident 99 stated they did not remember going to a care conference. Staff D, SSD, stated Resident 99 should have had a care conference upon admission, but no documentation was found showing that one occurred, and stated a care conference needed to be scheduled and conducted. Staff A, Administrator, stated care conferences were to be held upon admission, quarterly, as needed with a significant change in condition, and per resident and/or responsible party request, and stated they were not aware Resident 87 did not have a quarterly care conference and Resident 99 did not have an admission care conference.
Failure to Follow Provider Orders for TED Hose and Lidocaine Patch
Penalty
Summary
The facility failed to ensure provider orders were followed for 2 of 2 sampled residents reviewed for pain and edema. Resident 71 was admitted with diagnoses including heart failure, diabetes, anxiety, and traumatic brain injury, and was able to communicate needs. On observation, the resident was lying in bed with severely swollen feet and stated the legs were swollen and there may be a wound on the back of the leg. The electronic health record showed an order dated 11/28/2025 for TED hose to both lower legs for 12 hours, but the resident stated nobody had talked to them about TED hose. The RN/UM stated the process was to have an order and care plan with documentation in the administration record, and also stated the resident had severe edema and the TED hose order should have been discontinued. The DNS stated the order should have been discontinued and did not meet expectations. Resident 66 was admitted with diagnoses including repeated falls, diabetes, and dementia, and was able to make needs known. The record showed a provider order dated 01/09/2026 for a lidocaine external patch to the right hip topically two times a day for pain related to moisture associated skin damage/fungal infection right thigh abscess. The March 2026 MAR showed the patch was being applied at 8 AM and removed at 8 PM, with no documentation that it was being applied two times per day as ordered. The RN/UM stated staff were applying the patch once daily and that the order was written as two times a day to allow an apply time and removal time on the MAR. The ARNP stated the patch was to be applied once daily and removed after 12 hours, and that the facility requested the order be written two times a day for documentation purposes. The DNS stated the lack of communication to obtain the correct administration did not meet expectations.
Missed Showers and Incontinent Briefs Not Provided
Penalty
Summary
The facility failed to provide the necessary care and services to ensure that two residents received showers as scheduled and incontinent briefs. One resident, admitted with diagnoses including polyneuropathy, diabetes, and dysphagia, was able to make needs known and stated in interview that showers were not being provided consistently because there was only one shower aide. Review of the shower record showed the resident received four showers in the past 30 days. A CNA stated they were responsible for all showers in the building, did not always get to every resident, and did not always turn in shower sheets or enter showers in the EHR because of internet issues. Another resident, admitted with diagnoses including cholecystitis, chronic kidney disease, and rectal cancer, was able to make needs known and pointed to a package of drugstore-brand briefs while stating they had requested incontinent briefs but never received any. Staff in Central Supply stated the facility did not have a formal process for residents to request briefs, that staff would only verbally inform them if a resident needed briefs, and that they did not keep documentation showing whether the resident received briefs. The DON stated the resident not receiving incontinent briefs did not meet expectations and that briefs were always available for residents who needed them.
Delayed Assistance With Breakfast Meal Service
Penalty
Summary
The facility failed to provide assistance with meal service for Resident 8, who was dependent on staff for eating, oral care, hygiene, toileting, dressing, and moving in and out of bed or chair according to the quarterly MDS dated 01/01/2026. Resident 8 was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, parkinsonism, asthma, and epilepsy, and was able to communicate their needs. On 03/23/2026, Resident 8 was observed in bed with the fan on, with a contracture to the right hand and the left hand under the blanket; the resident stated they were unable to move their extremities. On 03/27/2026 at 9:24 AM, Resident 8 was observed lying in bed with the breakfast tray placed on the table next to them. At 9:25 AM, the resident stated they were waiting for staff to come and help them eat, and the roommate stated breakfast had arrived about 10 to 15 minutes earlier. At 9:43 AM, Staff U, RN, was called to the room and stated they would find out what was going on. The facility mealtime schedule showed Resident 8's breakfast tray was scheduled for delivery at 8:45 AM. Later that day, the DON stated residents dependent on staff for assistance with meals should be assisted timely, and Resident 8's delay of breakfast did not meet expectation.
Failure to Provide Prescribed Glasses
Penalty
Summary
Assist a resident in gaining access to vision and hearing services was deficient when the facility failed to provide prompt vision services for Resident 10. Resident 10 was admitted with quadriplegia with incomplete damage to the neck, high blood pressure, and depression, and was able to make needs known. The resident told the surveyor that their vision had become blurry quite a while ago, that they had last seen an eye doctor about six months earlier, and that they were told they needed glasses. The resident also stated staff were aware they needed glasses, but they never received any. Record review showed a care plan for moderate impaired visual function related to age-related decline with an intervention to arrange consultation with an eye care practitioner as required. An eye exam form dated 05/15/2025 documented blurred vision and a new prescription for glasses, with a note that the glasses were to be delivered two weeks after payment was received. The form was later noted on 05/29/25, but during interviews staff stated the resident should have received the glasses by now, they were not aware the glasses had not been provided, and the issue did not meet their expectations. The DON also stated they were not aware the resident had a prescription for glasses and that the glasses had not been provided.
Restorative nursing programs were not accurately provided or documented
Penalty
Summary
The facility failed to ensure restorative nursing programs were provided, evaluated for effectiveness, carried out, and accurately documented for one resident with quadriplegia with incomplete damage to the neck, high blood pressure, and depression. The resident was able to make needs known. Observations on multiple days showed the resident did not have any braces, splints, or PRAFO boots applied to any body part, and the resident stated they used to wear boots on their feet but had developed sores on both heels and now used a pillow to float the heels. Observation and interview showed a restorative aide providing PROM to the resident's bilateral upper and lower extremities and stating they provided ROM from head to toe. The resident stated the PROM was provided at the same time every day. No other restorative programs were observed or mentioned as being provided. Review of therapy communication forms showed recommendations over time for PROM to all joints, PROM plus AAROM to the BLE, continued ROM to the BUE with emphasis on AAROM of the shoulders and elbows, and fine motor tasks such as peg board, ring stacking, and dominoes as tolerated. The resident's care plan included restorative programs for AAROM to the bilateral shoulders and elbows, fine motor tasks, and a splint/brace program with PRAFO boots for 4 hours. However, restorative documentation for the month reviewed showed the splint/brace program was documented every day as 'Activity did not occur,' while PROM to the BLE/BUE was documented as completed and no other programs were noted. The current provider orders showed no order for a splint/brace or PRAFO boots. The restorative overview progress note stated participation in PROM BUE/BLE, bilateral PRAFO boots, and fine motor tasks, but this was inaccurate because the resident had not had PRAFO boots applied and no fine motor tasks were documented as provided. Staff Q stated the splint/brace program should have been discontinued because the resident refused it, and the DON stated the resident did not have an order for splints/braces or PRAFOs, though it was care planned, and that the restorative programs should have been documented and reviewed appropriately.
Oxygen therapy orders and monitoring were not followed for two residents
Penalty
Summary
Respiratory care and services were not provided according to provider orders for two residents. Resident 106 was admitted with diagnoses including dependence on renal dialysis, anxiety disorder, and dorsalgia, and was able to make needs known. The record showed active orders for oxygen at 3 L/min every shift, weaning oxygen as tolerated to greater than 90% O2 sats, and a sleep study for hypoxia during the night requiring new oxygen requirements. Observation on 03/23/2026 did not show the resident receiving oxygen therapy. The March 2026 TAR documented the 3 L/min oxygen order as 0 L/min every shift, with seven blanks in 69 opportunities for documentation, and the sleep study and weaning orders were marked with Xs every day. O2 saturation documentation was inconsistent, with nine readings below ordered parameters ranging from 85% to 90%, and the provider was notified only once out of nine times. Staff stated the oxygen order lacked an indication, the sleep study order needed clarification, the TAR documentation did not match the orders, O2 sats were not consistently documented every shift, and the oxygen care was not care planned. Resident 12 was admitted with diagnoses including sleep apnea, chronic respiratory failure, and diabetes, and the admission MDS showed the resident received oxygen therapy. Observations on multiple dates showed oxygen set at 3.5 L/min and then 3 L/min via nasal cannula, while the provider order dated 08/25/2025 specified oxygen at 4 L/min via nasal cannula. The care plan also included oxygen settings at 4 L continuously. During observation, an LPN stated the oxygen was set at 3 L but should have been 4 L, and staff were expected to check the oxygen setting every shift. The DON stated staff were expected to follow the provider's order and check oxygen settings every shift.
Incomplete Pain Assessments and Missing NPI Documentation
Penalty
Summary
Provide safe, appropriate pain management for a resident who required such services. Resident 106 was admitted with diagnoses including dependence on renal dialysis, anxiety disorder, and dorsalgia, and was able to make needs known. A provider order dated 12/31/2025 prescribed oxycodone HCI 5 mg by mouth every four hours as needed for pain. Review of the March 2026 MAR showed oxycodone was administered one to four times daily, with documented pain levels ranging from 4 to 10, usually 7 or higher. The resident’s focused care plan for pain, initiated on 11/05/2025, included only an intervention to report verbal or physical signs of pain and did not document any non-pharmacological interventions for pain management. The admission nursing evaluation was incomplete, including a blank response to whether any non-medication interventions improved pain. The pain interview evaluations dated 11/05/2025 and 02/09/2026 were also incompletely filled out, with the later assessment documenting a pain rating of 9 out of 10 and increased pain frequency in four areas. Staff interviews confirmed that pain and NPIs were expected to be assessed and care planned, and that the resident’s assessments were incomplete and did not meet expectations.
Unsecured medications and treatment carts
Penalty
Summary
Medication and treatment items were found unsecured in the facility. During observation, Resident 96 was sitting in bed with a saline laxative enema, two medicated inhalers, and a nasal spray placed on the table next to them. Resident 96 stated they were feeling constipated and would be using the enema provided by the facility, and later stated they had not used it yet but had it on standby. The DNS stated that no medications were expected at bedside and that the resident having medications in the room did not meet expectations. Two treatment carts were also observed left unlocked and unattended. One treatment cart on the [NAME] Wing was left unsecured at the nurses' station while a resident walked past it, and staff stated the key was missing and the cart should not have been unlocked while unattended. The DNS later directed staff to place the treatments and supplies from that cart into the secured medication storage room. The Emerald Wing treatment cart was also observed left unlocked and unattended at the nurses' station, and the DNS immediately locked it and stated it contained similar treatment and supplies to the other cart.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to provide routine dental services for 2 of 2 sampled residents reviewed for dental services. Resident 10 was admitted with quadriplegia, high blood pressure, and depression, and was able to make needs known. The resident stated during interview that a dental exam had occurred two or more months earlier and that broken upper teeth needed to be pulled, and that chewing took longer because of the broken teeth. The dental visit form showed broken teeth or root tips, missing upper and lower teeth, and red/irritated gum tissue, with referral for x-rays, evaluation, and extraction of teeth #4 and #12; the form also noted tooth #4 caused pain and the resident wanted the tooth extracted. Resident 10's care plan did not reflect the current dental status or interventions related to broken and missing teeth. Resident 1 was admitted with diagnoses including cholecystitis, chronic kidney disease, and rectal cancer, and was able to make needs known. During observation and interview, Resident 1 had missing and broken upper teeth and stated they had tooth pain that was starting to affect their ability to eat. The admission MDS identified obvious likely cavity or broken natural teeth. Staff stated residents were referred for dental appointments by nursing, that the dental provider had been at the facility monthly for the past three months, and that no referral could be located for Resident 1. The DON stated Resident 1 should have been referred for dental services upon assessment and that oral needs should have been care planned.
Daily nurse staffing data not posted prominently or with actual hours worked
Penalty
Summary
The facility failed to post the daily nurse staffing data in a prominent place and failed to include the actual hours worked for 6 of 6 observed days during the survey period. On 03/23/2026 at 10:00 AM, observations of the front entrance, receptionist desk, and lobby showed no daily nurse staffing data posted. On 03/24/2026, 03/25/2026, 03/26/2026, 03/27/2026, and 03/30/2026, the daily nurse staff data postings were observed on a window to the right of the staffing scheduler's office door after entering the front entrance and turning right toward the [NAME] Wing nurses' station, but the postings did not document actual nursing staff hours. The report states that if a person turned left toward the Emerald Wing nurses' station, they would not have been able to view the daily nurse staff data. During interview, the Staffing Coordinator stated they were responsible for posting the daily nurse staff data but did not post the actual hours even though they were being monitored and tracked, and the postings were not updated the day they were posted but could be revised the next day. The Administrator stated the postings would not be visible unless someone went to the east side of the facility, that the daily nursing staff postings should have been posted in a location for all to see, and that the daily nurse data should have been updated every shift to reflect actual hours worked and any needed changes.
Failure to Accurately Monitor and Document CHF Management
Penalty
Summary
The facility failed to accurately assess and manage the diagnosis of congestive heart failure (CHF) for one resident with a history of morbid obesity and recent hospitalization for acute CHF exacerbation. Upon admission, the resident was alert, oriented, and able to communicate needs. Hospital discharge instructions and provider progress notes indicated the need for daily or at least weekly weight monitoring to assess for fluid retention, a critical aspect of CHF management. However, the facility order only specified weekly weights, and documentation showed repeated identical weights over several weeks, with no evidence that actual weights were obtained. When the resident refused a weight, there were no documented re-attempts to obtain it, and staff interviews revealed logistical barriers to weighing the resident, such as equipment incompatibility and resident discomfort with the Hoyer lift. The resident reported not being weighed for an extended period and expressed understanding of the importance of weight monitoring for CHF. Further review and interviews indicated that staff may have been copying and pasting previous weights rather than obtaining accurate measurements, as the documented weights remained unchanged week after week. The Director of Nursing confirmed that staff should continue to attempt to obtain weights after refusals and that weight monitoring protocols should be adjusted based on stability. The Administrator acknowledged the likelihood of inaccurate documentation. An observed weight obtained during the survey showed a significant increase from the resident's hospital discharge weight, and a previously obtained weight referenced by the resident was not documented in the medical record.
Failure to Obtain Consent for Antidepressant Use
Penalty
Summary
The facility failed to provide necessary information and obtain consent for the use of a psychotropic medication for one resident, identified as Resident 72, who was part of a sample of five residents reviewed for unnecessary medications. Resident 72 was admitted with diagnoses including a spine fracture, quadriplegia, and depression, and was capable of communicating their needs. The electronic health record indicated that Resident 72 was receiving an antidepressant medication as of February 2025. However, there was no documentation showing that the resident had been informed of the risks and benefits of the medication or had given consent for its use. Interviews with Staff K, a Staff Development/LPN, and Staff B, the Director of Nursing Services, confirmed that the facility's protocol required providing risks/benefits information and obtaining consent for antidepressant use upon admission, but this had not been done for Resident 72.
Failure to Address Resident Grievance on Personal Property
Penalty
Summary
The facility failed to properly handle a grievance for a resident concerning personal property, specifically condiments purchased by a family member. Resident 67, who has a medical history including contracture of the right hand, muscle weakness, congestive heart failure, and chronic kidney disease, expressed dissatisfaction when staff disposed of these items without prior notice or agreement. The resident was able to communicate their needs and stated they were not informed of the facility's food policy before the disposal. Despite the resident's expressed concerns, no grievance was filed in the facility's grievance log for the month in question. The facility's administrator acknowledged that staff are expected to initiate grievances for resident concerns, indicating a lapse in following this protocol.
Failure to Assess Use of Low Bed as Restraint
Penalty
Summary
The facility failed to conduct an assessment for the use of a low bed for a resident, identified as Resident 39, who was reviewed for the use of physical restraints. Resident 39 was admitted with diagnoses including hemiplegia and hemiparesis, and was assessed to be at risk for falls, requiring staff assistance for mobility. Observations on two separate occasions showed the resident lying on a bed that was lowered to the floor. The resident's care plan included an intervention to place the bed in a low position, initiated in August 2022. However, during an interview, the Director of Nursing Services acknowledged that a low bed could be considered a restraint and should have had consent, assessment, order, and care plan, which were lacking for this resident, not meeting the facility's expectations.
Failure to Provide Written Notification of Hospital Transfer
Penalty
Summary
The facility failed to provide written notification of the reason for hospital transfer to Resident 291 or their responsible party. This deficiency was identified during a review of the electronic health record (EHR) and interviews with facility staff. Resident 291, who was admitted to the facility with diagnoses including polyneuropathy and bipolar disorder, was transferred to the hospital on 02/08/2025. However, the EHR lacked documentation that a notice of transfer was provided to the resident or their representative. During interviews, both the Director of Nursing Services and the Administrator acknowledged that the resident or their representative did not receive the required written notice of transfer, which was expected to be provided at the time of transfer.
Failure to Provide Bed Hold Notice
Penalty
Summary
The facility failed to provide a written bed hold notice to Resident 291 at the time of their transfer to the hospital, which is a requirement under WAC 388-97-0120 (4). Resident 291, who was admitted to the facility with diagnoses including polyneuropathy and bipolar disorder, was hospitalized, but there was no documentation in the electronic health record indicating that a bed hold was offered. During interviews, the Business Office Manager confirmed that neither the resident nor their representative was offered a bed hold, and the Administrator stated that the expectation was for bed holds to be done at the time of transfer or within 24 hours. This oversight placed the resident at risk of not being informed about their right to hold their bed during hospitalization, potentially affecting their quality of life.
Inaccurate Resident Assessments in MDS Documentation
Penalty
Summary
The facility failed to accurately complete the comprehensive assessments for three residents, leading to discrepancies in their medical records. Resident 79 was admitted with two pressure ulcers, but the admission Minimum Data Set (MDS) inaccurately recorded these ulcers as acquired in the facility. Staff interviews confirmed the inaccuracy, with both the Staff Development/Licensed Practical Nurse and the Director of Nursing Services acknowledging the error. This misrepresentation in the MDS could potentially affect the care planning and treatment provided to the resident. Resident 18's admission MDS inaccurately documented the resident's dental and respiratory conditions. Despite having broken natural teeth and using oxygen, the MDS indicated no broken teeth and no use of oxygen. Similarly, Resident 88's significant change/discharge MDS inaccurately coded the discharge as unplanned, contrary to the electronic health record. The MDS Nurse and the Director of Nursing Services confirmed these inaccuracies, indicating a failure to meet the expected standards for accurate resident assessments.
Failure to Conduct Timely Care Planning Meetings
Penalty
Summary
The facility failed to conduct timely care planning meetings with residents or their responsible parties, specifically for Resident 31, who was one of the two sampled residents reviewed for care planning. Resident 31, who was readmitted to the facility with diagnoses including respiratory failure, paraplegia, and depression, was dependent on staff for activities of daily living and able to communicate needs. Despite this, Resident 31 did not recall having a recent care conference, and the electronic health record indicated that the last care conference offered was on 06/08/2024. Interviews with the Social Service Director and the Administrator confirmed that care conferences were expected to be held quarterly, but they could not locate the date of the last care conference for Resident 31, indicating a failure to meet these expectations.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to ensure a complete discharge summary for Resident 88, who was discharged home without the necessary documentation. The discharge summary was supposed to include a recapitulation of the resident's stay, a final summary of the resident's status, and the resident and/or their representative's signature. Resident 88, who had been readmitted to the facility with diagnoses including multiple sclerosis, dementia, and hospice services, was discharged without these critical components. Interviews with staff revealed that the discharge process was not completed as expected, with the Director of Nursing Services acknowledging the oversight.
Deficiencies in Positioning and Bowel Management
Penalty
Summary
The facility failed to ensure proper positioning and mobility interventions for Resident 17, who had multiple diagnoses including heart and lung disease, diabetes, anxiety, depression, and muscle weakness. The resident was dependent on staff for activities of daily living and required a Prevalon boot for their left foot while in bed, as well as an elbow splint for a contracture. Despite these requirements, the resident reported never receiving the necessary devices, and staff interviews revealed a lack of awareness or follow-through on the orders for these interventions. The medical records staff had received an order for an orthotics referral but were unsure if it had been refused due to expense or lack of insurance, and there was no documentation of refusal in the resident's electronic health record. The facility also failed to consistently monitor and document bowel movements and implement the bowel program for Residents 4 and 82. Resident 4, who had Alzheimer's disease and was unable to communicate needs, had no bowel movements documented over a four-day period, and no medication was administered per the bowel protocol. Similarly, Resident 82, who had cirrhosis of the liver and was able to communicate needs, had extended periods without documented bowel movements, and no laxative medications were administered according to the protocol. Staff interviews confirmed that the facility did not meet expectations for bowel management documentation for these residents.
Failure to Provide ROM Care for Resident
Penalty
Summary
The facility failed to provide appropriate care and services to maintain or improve the range of motion (ROM) for a resident, identified as Resident 67, who was at risk for worsening mobility and developing contractures. Resident 67 was admitted with diagnoses including contracture of the right hand, muscle weakness, congestive heart failure, and chronic kidney disease. Despite a provider note dated 11/22/2025 recommending a referral for a resting hand splint and hand/finger exercises, the resident reported not receiving the splint and was observed with slightly bent fingers. The resident's care plan lacked interventions for a restorative nursing program for splint/brace assistance. Interviews with facility staff revealed a lack of follow-up on the referral for the splint. Staff W, a Restorative Nursing Aide, confirmed that Resident 67 was not receiving splint assistance services. Staff D, an LPN/Care Coordinator, acknowledged that the nursing staff should have followed up on the referral but did not. The Director of Nursing Services, Staff B, stated that the expectation was for the referral to be followed up on in a timely manner, which did not occur.
Failure to Secure Hazardous Items and Implement Fall Interventions
Penalty
Summary
The facility failed to ensure that the resident environments were free from accident hazards, specifically in the 200 Hall shower room. Observations on multiple dates revealed that the shower room was unlocked, and items such as an electric razor, disposable razors, and nail clippers were unsecured inside. Interviews with staff confirmed that these items should have been locked away, either in the medication cart or a cupboard within the shower room, but were not. This oversight placed residents at risk of accessing dangerous items. Additionally, the facility did not implement fall interventions for Resident 67, who was identified as a high fall risk due to factors such as poor safety awareness, generalized weakness, and impaired mobility. Despite a provider's note recommending the use of a fall mat and ensuring the bed was in a low and locked position, observations showed that these interventions were not in place. Interviews with staff indicated that the provider's recommendations were not followed, which did not meet the facility's expectations.
Failure to Administer Nutritional Supplements and Follow Fluid Restrictions
Penalty
Summary
The facility failed to administer the Registered Dietician's (RD) recommendations for Resident 31, who was readmitted with diagnoses including respiratory failure, paraplegia, and depression. The RD recommended Arginaid and Medpass 2.0 supplements due to a significant weight loss of 10%. However, the electronic health record (EHR) showed that while there was a provider's order for Arginaid, it was not administered until February 11, 2025, and there was no order for Medpass 2.0. The Director of Nursing Services acknowledged that the Arginaid should have been administered as ordered and documented on the medication administration records (MARs). Additionally, the facility failed to follow fluid restrictions for Residents 18 and 82. Resident 18, with conditions including end-stage renal disease and heart failure, was on a fluid restriction of 1500 ml per day, but the MARs did not document the amount of fluid consumed. Similarly, Resident 82, with diagnoses including cirrhosis and heart failure, had a fluid restriction order of 1500 ml per day, but the documentation was missing. Staff interviews revealed that the process required documentation of fluid intake, which was not met, as confirmed by the Director of Nursing Services.
Failure to Provide Ordered Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as Resident 18, by not having a physician's order or a care plan for the use of oxygen. Resident 18, who was admitted with diagnoses including end-stage renal disease, acute respiratory failure, chronic obstructive pulmonary disease, and cirrhosis of the liver, was observed using oxygen without a provider's order. The resident stated that the oxygen made it easier to breathe. However, a review of the electronic health record showed no provider's orders for oxygen use, and there was no care plan directing staff on its use. Interviews with staff confirmed that oxygen services should be provided per provider's orders, monitored each shift, and care planned, which was not done in this case.
Failure in Conducting Pain Assessments for Resident
Penalty
Summary
The facility failed to ensure proper pain management for a resident, identified as Resident 9, who was receiving as-needed pain medication, specifically oxycodone. The deficiency was identified through interviews and record reviews, which revealed that the facility staff did not conduct consistent pain assessments for the resident. Despite having a care plan that required pain assessments, the last documented pain assessment was conducted on January 9, 2025, and no further assessments were performed even though the resident's medication orders were frequently changed throughout January and February 2025. Resident 9 was admitted with multiple health conditions, including chronic pain, spinal stenosis, bipolar disorder, muscle weakness, anxiety, and depression. The resident was dependent on staff for daily living activities and could communicate their needs. The Director of Nursing Services acknowledged the expectation for care managers to conduct pain assessments but noted a shortage of care managers, leading to licensed nurses being tasked with this responsibility. However, the lack of ongoing pain assessments after the initial evaluation contributed to the deficiency in pain management for Resident 9.
Inadequate Dialysis Care Documentation for a Resident
Penalty
Summary
The facility failed to provide dialysis care consistent with professional standards for Resident 18, who was diagnosed with end-stage renal disease, among other conditions. The facility's policy required documentation of dialysis care, including the location of the catheter, condition of the dressing, and observations post-dialysis. However, the electronic health record showed only one post-dialysis evaluation and three pre-dialysis evaluations were completed, indicating a lack of consistent documentation. Interviews with staff revealed that the process for completing pre- and post-dialysis evaluations was not followed as expected. Staff D, a Licensed Practical Nurse/Care Coordinator, acknowledged that the dialysis flow sheet was incomplete, and the Director of Nursing Services confirmed that Resident 18's dialysis care did not meet expectations. This deficiency placed the resident at risk for substandard dialysis care, injury, infection, and diminished quality of life.
Failure to Limit PRN Psychotropic Medication to 14 Days
Penalty
Summary
The facility failed to ensure that a PRN psychotropic medication for a resident was limited to 14 days, as required by policy. The policy, dated July 2022, specified that psychotropic medications should not be prescribed or given on a PRN basis unless necessary for a diagnosed condition documented in the clinical record, and PRN orders should be limited to 14 days unless a rationale for extension is documented. However, Resident 9's electronic health record showed an order for clonazepam, a psychotropic medication used to treat anxiety, to be administered every 8 hours as needed with no end date, ordered as indefinite. No additional rationale was documented by the provider to extend the medication beyond 14 days. Resident 9 was admitted with multiple health conditions, including chronic pain, spinal stenosis, bipolar disorder, anxiety, and depression, and was dependent on staff for assistance with activities of daily living. The resident's care plan indicated a decline in mood due to anxiety, with interventions for staff to monitor and encourage the use of PRN medication. During interviews, staff members, including the Staff Development/Licensed Practical Nurse and the Director of Nursing Services, acknowledged the oversight and stated that the expectation would be for the provider to document a rationale for extending the psychotropic medication beyond 14 days.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to provide routine dental services for a resident, identified as Resident 18, who was admitted with acute respiratory failure and chronic obstructive pulmonary disease. Despite being able to communicate needs, Resident 18 had multiple broken teeth, which were observed during a visit. The resident expressed that the staff had not addressed the issue. The care plan, dated several months prior, did not include the resident's dental issues, and the clinical admission note confirmed the presence of broken teeth. A nutrition evaluation also noted obvious cavities and broken teeth. Interviews with staff revealed that a dental appointment should have been made and the oral status should have been included in the care plan. The Director of Nursing Services acknowledged that the dental care provided did not meet expectations.
Infection Control Deficiencies in PPE Use and Equipment Storage
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by staff not consistently applying Personal Protective Equipment (PPE) in accordance with Enhanced Barrier Precautions (EBP) for Resident 47. Despite clear signage indicating the need for gowns and gloves during high-contact care activities, staff members were observed entering the resident's room and performing tasks such as urine collection and catheter flushing without wearing the required gowns. Interviews with staff confirmed that they were aware of the requirements but failed to adhere to them, citing forgetfulness. Additionally, the facility did not ensure that respiratory care equipment for Resident 18 was stored in a clean and sanitary manner. Observations revealed that the nebulizer machine, mouthpiece, and oxygen tubing were placed on the floor, which is against the facility's expectations for maintaining sanitary conditions. Staff interviews confirmed that this practice did not meet the facility's standards, acknowledging that the equipment should not have been on the floor. These deficiencies in infection control practices placed residents and staff at risk for contracting and spreading infections. The failure to follow established protocols for PPE use and equipment storage compromised the safety and sanitary environment necessary to prevent the transmission of communicable diseases within the facility.
Failure to Investigate Allegations of Abuse and Retaliation
Penalty
Summary
The facility failed to identify and investigate allegations of abuse and neglect for one resident, referred to as Resident 56, which placed the resident at risk of continued abuse and a diminished quality of life. According to the facility's policy on abuse investigation and reporting, all reports of abuse, neglect, and related issues should be promptly reported to the appropriate authorities and thoroughly investigated. However, this protocol was not followed in the case of Resident 56. The resident, who was admitted with diagnoses including muscle weakness, anxiety, and depression, reported experiencing rough care from a CNA during a night shift. Although the CNA was no longer working at the facility following the incident, the resident later felt retaliated against by other CNAs, which was not properly reported or investigated. During interviews, it was revealed that Resident 56 had expressed concerns about potential retaliation to another CNA, Staff C, who did not report the incident as required. Staff D, a Licensed Practical Nurse and Care Coordinator, confirmed that the comment about potential retaliation was a reportable event that should have been investigated. Similarly, the Director of Nursing Services acknowledged that the incident should have been reported and investigated due to the potential for psychosocial harm. The failure to report and investigate these allegations was a clear deficiency in the facility's adherence to its own policies and regulatory requirements.
Failure to Post Actual Nursing Staffing Hours
Penalty
Summary
The facility failed to post the actual nursing staffing hours daily for a period of 30 days, which prevented residents, family members, and visitors from knowing the actual number of available nursing staff. The facility's policy, dated August 2022, required daily posting of nurse staffing data for each shift, including the number of nursing personnel providing direct care and the actual hours worked. However, an observation and record review on February 13, 2025, revealed that the staffing posting did not include the facility's name or adjustments for staff absences due to call-offs or illness, nor did it reconcile to show actual hours worked. Interviews with the Staffing Coordinator and the Administrator indicated a lack of awareness and expectation regarding the requirement to post actual hours worked daily.
Failure to Timely Refund Overpayments to Resident
Penalty
Summary
The facility failed to timely refund charges paid by a resident, identified as Resident 2, who was reviewed for misappropriation and personal funds. Resident 2 was admitted to the facility and later discharged to an Adult Family Home. Despite being discharged with a zero balance, over-payments were made after the discharge, resulting in a credit of $4,363.44 that was due to Resident 2. This credit was identified on a statement dated nearly a year after the discharge, yet the refund had not been issued. Interviews with facility staff revealed that the payments were consistent with the Department of Social and Health Services Award Letter of Participation, which determined Resident 2's share of the cost for room and board. These funds were collected through automatic withdrawals from Resident 2's bank account. However, the facility was unable to locate the authorization form signed by Resident 2 to access these finances. Staff confirmed that the over-payment should have been reimbursed within 30 days of discharge or identification of the overpayment, but this did not occur.
Deficient Care for Resident with Catheter and Bowel Incontinence
Penalty
Summary
The facility failed to provide appropriate care for a resident with a urinary catheter and bowel incontinence, as observed through a survey. The resident, who had a traumatic spinal cord problem affecting their arms, legs, bowel, and bladder, was admitted with a chronic indwelling Foley catheter and was dependent on staff for all activities of daily living. The facility did not obtain physician orders for the use of the catheter, nor did they develop or implement a care plan for catheter care and monitoring. Additionally, the facility did not continue the resident's established bowel program from the hospital, which included a high fiber-bulk forming laxative and a bowel stimulant suppository at night, instead administering the suppository in the morning contrary to the established program. The facility's failure to adhere to professional standards of care was further highlighted by the lack of a personalized bowel program in the resident's care plan. The resident's collateral contact reported improper catheter care, noting an overfilled urine leg bag and urine not draining properly. The Director of Nursing confirmed the absence of necessary physician orders and care plans for the catheter and acknowledged the failure to continue the resident's established bowel program. These deficiencies placed the resident at risk for infections, skin breakdown, constipation, and diminished quality of care.
Deficiencies in Chronic Heart and Bowel Management
Penalty
Summary
The facility failed to accurately assess and develop/implement a care plan for the management of chronic heart problems for Resident 51, who had a history of heart failure and chronic lung disease. Despite experiencing daily difficulty breathing and requiring non-invasive mechanical ventilation, Resident 51 was not routinely weighed or monitored for fluid volume overload. The resident's weight had significantly increased over a few months, indicating a potential fluid imbalance that went unnoticed. Additionally, the facility did not have a consistent plan in place for monitoring and managing Resident 51's edema and fluid status, leading to a delay in identifying and addressing the fluid volume overload that ultimately resulted in respiratory failure and emergency hospitalization. Furthermore, the facility failed to consistently monitor and document bowel movements for Residents 16 and 66, who experienced constipation during their stay. Despite having bowel management protocols in place, the staff did not effectively implement the orders for laxatives and enemas as needed for residents with prolonged constipation. This lack of adherence to the bowel management protocols resulted in delayed interventions for relieving constipation and addressing gastrointestinal issues for both residents. The inadequate monitoring and management of bowel movements for Residents 16 and 66 indicate a systemic issue in ensuring proper care and treatment for residents with gastrointestinal problems within the facility.
Inaccurate Resident Assessments
Penalty
Summary
The facility failed to accurately assess 7 of 20 sampled residents, leading to deficiencies in their care plans. Resident 27 had documented falls that were not correctly coded in their quarterly MDS, which was acknowledged by both the MDS Coordinator and the Director of Nursing Services. Resident 88's admission MDS inaccurately reflected their dental status, despite observations and dental visit documentation indicating broken and missing teeth. This discrepancy was also confirmed by the MDS Coordinator and the Director of Nursing Services. Resident 6's weight records showed significant weight gains that were not coded in their MDS, and their use of antidepressants was not properly documented. Additionally, Resident 6 reported dental issues that were not reflected in their assessments. Resident 9's MDS did not accurately reflect their mental health history, including developmental delay and bipolar disorder, which was confirmed as incorrect coding by the MDS Coordinator. Resident 51's MDS contained multiple coding errors related to their medical conditions, medications, and weight, which were not accurately documented. Resident 69's MDS inaccurately coded their physical impairments and medical conditions, which was acknowledged as an error by the MDS Coordinator. Lastly, Resident 72's admission MDS lacked information on their ADL abilities, despite the resident's report of not being assisted into a wheelchair when requested. These inaccuracies in the MDS assessments directly impacted the development of comprehensive care plans for the residents, leading to potential risks for unmet needs and diminished quality of care.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop, implement, and update person-centered comprehensive care plans (CP) for six residents, leading to unmet care needs and potential risks. For Resident 55, the facility did not create a care plan for depression despite a physician's order for anti-depressant medication. The Director of Nursing Services acknowledged this oversight during an interview. Resident 70, who required an indwelling supra-pubic urinary catheter, did not have a care plan for catheter care, and there were no orders for routine catheter care in the Treatment Administration Record. The resident reported not receiving catheter care, and staff interviews confirmed the absence of necessary care directives in the CP and Kardex. Resident 13's care plan for tobacco use was not updated to reflect multiple unsafe smoking incidents, and the Kardex lacked specific instructions for monitoring and managing these behaviors. Additionally, the Kardex did not provide clear directives for weight monitoring, diet, or meal locations. Resident 52's care plans contained outdated and conflicting information, with no updates for current medical conditions such as diabetes, seizures, and dental concerns. The leisure and trauma care plans were generic and not person-centered, and there were discrepancies between the care plans and the medications listed in the Medication Administration Record. Similar deficiencies were found for Residents 69 and 6. Resident 69's care plans for psychotropic and behavior management were not personalized, and there was no bowel management care plan despite the resident's incontinence and use of medications for constipation. Resident 6's care plans lacked person-centered information addressing dental concerns, nutrition, weight monitoring, preferences, activities, mood, and other medical needs. These failures in care planning placed the residents at risk for poor clinical outcomes and diminished quality of life.
Failure to Meet Professional Standards of Practice
Penalty
Summary
The facility failed to ensure services provided met professional standards of practice for several critical areas, including anti-hypertensive medication administration, orthostatic vital signs, physician orders, insulin administration, injection site rotation, weight monitoring, edema monitoring, and care of patients with heart failure. For instance, Resident 16's blood pressure medication was administered multiple times despite their systolic blood pressure being below the hold parameter of 110, and the provider was not notified of consistently low blood pressures. Similarly, Resident 69's blood pressure medication was administered without documented hold parameters, and orthostatic vital signs were not properly recorded for multiple residents, including Resident 47 and Resident 69, who had identical blood pressure readings for different positions, indicating a failure in proper assessment and documentation. Resident 69 also did not receive a prescribed continuous glucose monitoring device, and their insulin administration records showed a lack of documentation for injection site rotation and failure to follow orders for blood sugar checks after meals. Additionally, there were instances where high blood sugar levels were not addressed according to the physician's orders, and the provider was not notified of critical blood sugar readings. This lack of adherence to prescribed care plans and monitoring protocols placed residents at risk of medical complications. The facility also failed to maintain accurate and updated physician orders for several residents. For example, Resident 70's wound care orders were not updated to reflect the current treatment recommendations from the wound care specialist. Furthermore, weight monitoring protocols were not followed for multiple residents, including Resident 52, who had no documented weights for several months despite being at risk for nutritional problems. Resident 51, who had a history of heart failure, was not weighed routinely, and their care plan did not include necessary monitoring for heart failure symptoms, leading to a significant weight gain and subsequent hospitalization for fluid volume overload.
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 978 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 Tacoma
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avalon Healthcare - Tacoma | 0.9 mi | ★★★★★ | 1 | 0 |
| Tacoma Nursing And Rehabilitation Center | 2.1 mi | ★★★★★ | 10 | 0 |
| Alaska Gardens Health And Rehabilitation | 2.4 mi | ★★★★★ | 20 | 1 |
| Avamere At Pacific Ridge | 2.5 mi | ★★★★★ | 36 | 0 |
| Birch Creek Post Acute & Rehabilitation | 4.3 mi | ★★★★★ | 35 | 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.