Average — CMS composite of the measures below.
A standard survey is most likely before around February 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Marianwood Health And Rehabilitation during CMS and state inspections, most recent first.
The facility failed to maintain an effective antibiotic stewardship and IC monitoring program. One resident with an indwelling catheter received antibiotics for possible UTI without documented daily symptom monitoring or reassessment when urine testing was contaminated, and another resident with a sacral wound received an antibiotic without documentation of infection monitoring or adverse-effect surveillance. The monthly IC reviews also lacked required analysis of CAI, prevalent sites or organisms, trends, and comparisons, and the infection rate was calculated incorrectly.
Advanced directive documentation was not ensured for 3 residents. One resident had severe memory impairment, aphasia, and a surrogate decision maker, but staff had no documentation that ADs were discussed and the resident said they had not been. Another resident with cancer, malnutrition, and a feeding tube had no AD, and the social services assessment did not show the resident or representative was informed of the right to formulate ADs. A third resident with cognitive issues, a history of brain bleed, cancer, heart and kidney disease, and speech difficulty had expired guardianship paperwork with no further documentation showing updated paperwork was obtained.
Facility staff failed to maintain a clean, homelike environment in multiple unit pantries and resident rooms. Surveyors observed soiled Bistro tables, broken refrigerator/freezer security, water-damaged cabinets with mold-like growth and odor, damaged laminate and walls, extensive wall damage after curtains were removed, stained carpet, scratched walls and furniture, personal care supplies left on a nightstand, and peeling wallpaper behind residents’ beds.
Failure to Provide Transfer Notices and Hospital Report: Staff did not document calling report to the receiving hospital for multiple residents transferred or discharged for acute care, and 3 residents did not receive written transfer notices. Records showed incomplete transfer documentation, including missing notes on resident condition, notifications, and eInteract assessments, while staff interviews confirmed the lack of documentation for hospital report calls and written notices.
A resident admitted with depression had a PASRR I showing SMI and requiring a PASRR II evaluation, but the record contained no completed PASRR II before admission. Social service and admissions staff stated the PASRR II determination or invalidation was expected prior to admission, and no referral documentation was found.
Care plans were not kept current for two residents, including one with paraplegia who needed waist-high compression stockings and laundering support and another with HF and DM whose plan lacked details for diuretic and insulin management. In addition, care conferences were not held for two newly admitted residents, and both residents reported that the IDT meeting they were told about never occurred; the record confirmed no CC was completed.
Failure to follow and clarify physician orders: two residents had ordered meds not administered as prescribed, including a beta blocker held parameters and a stool softener held for loose stools, with orthostatic BP entries documented as identical across positions. Another resident had a wheelchair seatbelt in use without a physician order, and a resident with constipation had an incomplete PRN bowel order that was not clarified. Staff reported one CNA took only seated BP readings and an LPN documented them without questioning the results.
Failure to provide required ADL assistance affected residents who were dependent on staff for daily care. One resident with paraplegia and other medical conditions did not receive consistent laundering and application of prescribed waist-high compression hose, another resident dependent for personal hygiene had long fingernails with debris underneath, and a third resident dependent for hygiene was repeatedly observed unbrushed, in bed, and wearing a hospital gown. Staff reported expected AM care tasks but also described missed care and lack of reporting when care could not be completed.
Medication storage and labeling were not maintained properly on two med carts, with expired items found on one cart and opened insulin pens, an inhaler, and resident-owned supplements lacking required dates or expiration information on another. The facility also failed to monitor the medication refrigerator temperature consistently, and unsecured wound care medications were found on a resident’s nightstand instead of being stored securely.
A resident in an LTC facility experienced psychological harm due to repeated verbal abuse by their roommate, which was not addressed promptly by staff. Despite the resident's requests for a room change and reports of distress, staff failed to take immediate action to separate the residents or protect the victim from further abuse. The facility's policy on abuse prevention was not followed, leading to the resident's emotional distress and retraumatization.
The facility failed to implement its abuse prevention policies, leading to unaddressed verbal abuse incidents between residents. Despite reports of abuse, staff did not take immediate action or document necessary interventions, resulting in ongoing psychological harm. The facility's inaction and delayed reporting to state agencies highlight significant lapses in their abuse prevention protocols.
A resident experienced a fall, and the facility failed to notify the resident's representative as required by policy. The resident, who was non-verbal and dependent on staff, was found on the floor, and the incident was not communicated to their representative until much later, causing frustration. The DON confirmed the lack of documentation and notification.
The facility failed to maintain safe hot water temperatures, secure hazardous chemicals, and address fall risks for a resident. Hot water temperatures in resident rooms exceeded safe limits, posing a burn risk. Chemicals were left unsecured in two nursing units, increasing the risk of accidental ingestion. A resident with a history of falls lacked proper footwear and had a broken bed, contributing to their fall risk.
The facility failed to provide sufficient nursing staff to meet residents' needs, resulting in delayed assistance with ADLs and call light responses, particularly during shift changes. Residents reported waiting times of up to two hours, and staff acknowledged the need for more nursing assistants and LPNs to address care demands.
The facility failed to maintain sanitary conditions in food storage, preparation, and service. Observations revealed improperly stored food items, staff not adhering to hygiene protocols, and uncovered food being transported through the facility, even during a COVID-19 outbreak. These actions were acknowledged by various staff members, including the Senior Cook, Director of Nursing, and Infection Preventionist.
The facility failed to properly log and resolve grievances for several residents, including missing personal items and environmental concerns. A resident with impaired memory reported missing items that were not documented or resolved, while another resident experienced delays in retrieving laundry. Additionally, a resident with paraplegia had their AC unit removed, causing discomfort, and was not provided with a grievance report. Staff inconsistencies in handling grievances contributed to these deficiencies.
The facility failed to ensure accurate MDS completion dates for three residents, as the RN coordinator backdated the assessments, which is unethical. Staff T, the MDS Coordinator, admitted to the discrepancy and acknowledged the need for further MDS education. Staff A, the Administrator, confirmed that backdating is unacceptable and emphasized the importance of documenting actual completion dates.
The facility failed to maintain accurate and accessible Level 1 PASRR documentation for three residents, leading to unassessed mental health needs. A resident's PASRR did not include a dementia diagnosis, another's PASRR was not accessible to staff, and a third resident's PASRR was outdated and not updated after significant changes in their condition.
The facility failed to update care plans for several residents, leading to discrepancies between documented care needs and actual conditions. A resident's care plan included nebulizer treatments no longer needed, while another's required continuous oxygen therapy that was not provided. An IV antibiotic care plan was outdated, and a resident with a feeding tube had care plans encouraging oral fluids. A fall mat was not documented in a care plan despite its use, and a resident's care plan lacked guidance for care refusal. The Director of Nursing acknowledged these deficiencies.
The facility failed to provide adequate restorative nursing care to residents with limited range of motion (ROM), as required by their care plans. Several residents did not receive the prescribed active ROM exercises and splint training consistently, and there was a lack of documentation to support that these services were offered. Additionally, residents on hospice care were not evaluated for restorative nursing needs, and there were no orders for necessary interventions such as skin checks for those using braces.
The facility failed to properly manage tube feeding for residents, including inadequate documentation of feeding administration, insufficient weight monitoring, and improper labeling of feeding bags. A resident with multiple medical conditions had no recorded tube feeding intake for nearly a month, and their weight was not monitored as ordered. Two other residents had unlabeled or partially labeled feeding bags, which staff confirmed did not meet facility policy requirements.
Two residents in the facility experienced dissatisfaction with meal accommodations due to the facility's failure to honor their food preferences. One resident, who disliked sausage and rice, continued to receive these items despite informing staff. Another resident, with impaired swallowing and severe malnutrition, was unable to request preferred meals due to inconsistent menu distribution. Staff confirmed the lack of menu distribution, impacting the ability to meet residents' nutritional needs.
A facility failed to obtain informed consent for the use of an antidepressant medication for a resident with schizophrenia, impaired memory, and a history of cancer. The resident received the medication without documented consent, despite the facility's policy requiring informed consent for psychotropic medications. The Director of Nursing acknowledged the requirement but did not provide evidence of consent.
A facility failed to notify a Medicaid recipient when their personal fund account balance exceeded the SSI resource limit, as required by policy. The resident's account balance was $696.53 over the limit, risking their Medicaid coverage. Staff interviews revealed a lack of awareness and communication regarding Medicaid SSI resource limitations.
The facility failed to provide timely assistance in formulating Advanced Directives (ADs) for several residents. One resident with intact memory did not have an AD documented until 47 days after admission. Another resident received the AD packet over two weeks after admission. A resident with severe cognitive impairment was given an AD packet almost two months after admission, despite being unable to make decisions. Additionally, a resident with no memory impairment had incomplete AD documentation, and another resident did not have an AD or declination documented until two months after admission.
A resident, dependent on staff for transfers and toileting, experienced an unwitnessed fall, and the facility failed to conduct a thorough investigation as required by policy. The investigation lacked staff interviews, witness statements, and a neurological assessment, with conflicting information about the fall's circumstances. Interviews with staff revealed undocumented conversations instead of formal documentation, and the facility could not provide evidence supporting claims made in the investigation report.
The facility failed to provide written transfer/discharge notices and notify the LTCO for two residents hospitalized. One resident with severe memory impairment was sent to the hospital without a transfer notice, and another resident with a brain injury was discharged with an unsigned and incomplete notice. Staff confirmed the absence of required notifications and documentation.
The facility failed to complete a resident's Quarterly MDS assessment within the regulatory timeframe, as required by the RAI Manual. The resident's assessment was completed three days late, which was confirmed by the MDS Coordinator and acknowledged by the Administrator. This delay in assessment completion posed a risk for delayed care planning and unidentified care needs.
The facility failed to accurately complete MDS assessments for three residents, leading to potential risks of unmet care needs. A resident's Entry Tracking MDS was incorrectly coded, another's Quarterly MDS omitted a psychosis diagnosis despite antipsychotic medication use, and a third resident's activity preferences were inaccurately recorded due to unresponsiveness during the interview.
The facility failed to develop and implement comprehensive care plans for five residents, including those with malnutrition and feeding tube requirements. Despite the facility's policy, care plans lacked specific goals and interventions, as acknowledged by the DON.
The facility failed to follow and clarify physician's orders for two residents, leading to potential medication errors. A resident received a pain gel without proper measurement, and another had conflicting orders for oral medication despite requiring a PEG tube. Staff interviews confirmed the need for accurate dosing and order clarification.
The facility failed to assist two residents with ADLs, leading to poor hygiene and discomfort. One resident with Alzheimer's was not shaved for several days, despite their care plan. Another resident, with visual impairment, lacked adequate clothing and grooming assistance, resulting in long nails and unkempt hair. The DON acknowledged these deficiencies, noting staff should have reported care refusals.
A facility failed to provide individualized activities for a resident with dementia during a COVID outbreak. The resident expressed feelings of isolation and lack of engagement, as their care plan did not include specific activities. Staff interviews revealed that while group activities were halted, individual activities should have continued, but were not documented. The Resident Council also reported a lack of activities, leaving residents with limited recreational options.
A resident with chronic pain due to osteoarthritis did not receive adequate pain management in the facility. Despite having a care plan, the resident's complaints of sharp pain in the left leg were not documented or communicated between shifts. Interviews revealed that staff were unaware of the resident's pain, and the Director of Nursing acknowledged the lack of proper documentation, leading to ineffective pain management.
The facility failed to properly store, label, and dispose of medications, with issues found across multiple units. Medications were improperly labeled, expired, or stored with disinfectants. Unlocked medication carts and unsecured medications at a resident's bedside were also observed, highlighting lapses in safety protocols.
The facility failed to maintain an effective infection prevention and control program, with issues including overfilled sharps containers, uncleanable surfaces, incomplete Water Management Program, improper wound care, and poor catheter management. These deficiencies increased the risk of infection transmission among residents.
A resident's bed in an LTC facility was found to have a significant gap between the mattress and bed frame, posing an entrapment risk. The resident, with multiple medical conditions requiring substantial assistance, had an air mattress that was smaller than the bed frame, creating a gap confirmed by the Facilities Manager. The Director of Rehabilitation acknowledged the oversight, as the Rehabilitation Department failed to identify the risk despite frequent interactions with the resident.
A resident was discharged without the necessary information being provided to the Home Health Agency (HHA), leading to a delay in home health services. Additionally, the facility did not provide or document education on indwelling catheter care to the resident or their collateral contact (CC), resulting in a significant gap in post-discharge care.
Antibiotic Stewardship and Infection Control Monitoring Deficiencies
Penalty
Summary
The facility failed to establish an infection prevention and control program that included an antibiotic stewardship program to promote appropriate antibiotic use and reduce unnecessary antibiotic use. The revised antibiotic stewardship policy, dated 06/11/2025, stated the facility would review new antibiotic orders and prescribing criteria daily, track antibiotic use outcomes for QAPI, consider antibiotic time-out practices, and have the Infection Preventionist collect and review data with physician feedback. However, the survey found that these processes were not consistently carried out for the residents reviewed. For one resident with a spinal cord injury, urinary tract dysfunction, and an indwelling catheter, the record showed antibiotics were started after a low-grade fever and urine testing that showed organisms in the urine, but there was no documentation of ongoing monitoring for UTI signs and symptoms or adverse effects during the antibiotic course. The physician initially noted the resident denied systemic symptoms and planned to wait for culture results before starting antibiotics, yet the record also showed antibiotics were ordered and later restarted, with no documentation that the resident was monitored daily for symptoms or that the antibiotic was reassessed when the urine specimen was contaminated and culture results were not available. Staff stated the resident should have been monitored daily and that antibiotic time-outs should be used to avoid unnecessary antibiotics. For another resident with malnutrition, heart failure, and a sacral pressure ulcer, the record showed an antibiotic was ordered for wound infection after an elevated white blood cell count and a physician note indicating a wound culture would be obtained before antibiotics were started. The wound culture later required recollection, but there was no documentation of signs or symptoms of wound infection, inability to process the culture, or adverse effects from the antibiotic. In addition, the September and October 2025 infection control documents lacked monthly analysis of community-acquired infections, prevalent sites or organisms, comparisons to prior months, trends, and actions or plans to reduce infection rates, and the infection rate calculations were based on an incorrect method rather than total resident days.
Advanced Directive Documentation Not Ensured
Penalty
Summary
The facility failed to implement a system to ensure Advanced Directives (AD) were in place for 3 of 5 residents reviewed for ADs: Residents 18, 5, and 30. The facility policy stated staff would provide the resident/family written information about the right to formulate an AD, document that the information was provided at admission, and obtain a copy of the resident’s AD for the record. However, the record review showed no adequate documentation that these steps were completed for the reviewed residents. Resident 18 had severe memory impairment, Moyamoya disease, and aphasia, and was unable to make decisions for themselves; the care plan identified a family member as the legal next of kin/surrogate decision maker. The record included a progress note that the family member was not prepared to take on legal guardianship and declined applying for guardianship for health care, and the resident stated staff had not discussed ADs with them. Resident 5 had no cognitive impairment and diagnoses including cancer, malnutrition, and a feeding tube, but the social services assessment left blank the checkbox indicating the resident and/or representative had been informed of the right to formulate ADs, and staff stated there was no documentation that AD planning or assistance was offered or declined. Resident 30 had some problems with thinking and memory, diagnoses including a history of brain bleed, cancer, heart and kidney disease, and difficulty expressing speech; the record showed guardianship paperwork had expired, social services requested updated paperwork, and there was no further documentation showing the updated guardianship paperwork was obtained.
Failure to Maintain Homelike Environment and Repair Damaged Resident Areas
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment in multiple areas across Units 100, 200, 300, and 400. In the Bistro area used by residents on Units 100 and 200, surveyors observed tables with dried spill marks and food debris on repeated visits, a refrigerator/freezer labeled for staff access only but stocked with resident food and drinks, a broken combination cable lock on the refrigerator door, no lock on the freezer door, and a cabinet under the sink with water damage, black patches of mold-like growth, and odor. Staff stated the area needed repair to prevent possible mold exposure during food and beverage preparation and to prevent unauthorized access to the refrigerator and freezer, and housekeeping stated the area was assigned for nightly cleaning and needed disinfection. Similar conditions were observed in other areas of the facility. The Unit 300 pantry had water damage under the sink cabinet with black patches of mold-like growth and odor, and Unit 400 had damaged laminate on a cabinet and damaged wall beneath a hand sanitizer dispenser. Surveyors also observed extensive wall damage in resident rooms after window dressings were removed from multiple rooms, with staff stating the wall damage would be repaired later when residents were away or rooms became vacant. Additional observations included plaster missing from a wall corner, deep scratches beneath a television, a stained hallway carpet, multiple deep scratches on walls, a headboard with missing laminate exposing chipboard, personal care and wound supplies left on a resident’s nightstand, and wallpaper peeling and hanging behind the head of the bed in two resident rooms.
Failure to Provide Transfer Notices and Hospital Report
Penalty
Summary
The facility failed to call report to the receiving hospital for 6 residents who were transferred or discharged to the hospital, and failed to provide written transfer notices to 3 of those residents. The report states that these failures involved Residents 38, 11, 8, 74, 9, and 22, and that the written notice issue involved Residents 8, 74, and 9. The facility policy required notification to the receiving facility when a transfer was made and required the resident or resident representative to receive transfer or discharge notice information, including appeal-related contact information. For Resident 38, records showed discharge to the hospital with return anticipated, but progress notes did not document a transfer note, the resident's condition, who was notified, or the reason for transfer. The eInteract Change in Condition Evaluation was incomplete, with only a brief statement that the resident seemed different than usual and blank sections for multiple assessments; it also did not document that the provider or family was notified or that report was called to the hospital. For Resident 11, records showed multiple hospital discharges with return anticipated, but staff did not document that report was called to the receiving facility, and only some eInteract assessments were completed without documentation that hospital staff were given report. For Resident 8, records showed transfer to an acute care hospital, but there was no written transfer notification and no documentation that report was provided to the receiving hospital. For Resident 74, records showed a transfer to an acute care hospital with no written transfer notification and no documentation that report was provided to the receiving hospital. For Resident 9, records showed transfer to the hospital for severe abdominal pain, but there was no written transfer notification and no documentation that report was provided to the receiving hospital. For Resident 22, a transfer notice was present and signed by staff, but the progress notes did not document that the hospital was called to give report of the resident's status. Staff interviews confirmed the lack of documentation for written notices and hospital report calls for these transfers.
PASRR II Not Completed Before Admission
Penalty
Summary
The facility failed to ensure Preadmission Screening and Resident Review (PASRR) level II coordination was completed before admission for one resident reviewed for PASRR. Resident 28 was admitted to the facility with a diagnosis of depression, and the admission MDS dated 10/28/2025 documented the resident’s admission. A review of the resident’s records showed a PASRR I dated 10/20/2025 that identified serious mental illness (SMI) and indicated that a level II evaluation was required. The resident’s records did not contain a completed PASRR II. In an interview, the Social Service staff member stated the admissions department was expected to obtain the PASRR II determination or invalidation before admission and that there was no documentation of a PASRR II referral for Resident 28. The Admission Coordinator stated that when a resident was referred for a level II PASRR, the PASRR II was expected to be completed before admission, and that they had missed the resident’s incomplete level II before admitting the resident.
Care plans not updated and care conferences not held for multiple residents
Penalty
Summary
The facility failed to keep care plans updated and revised as needed for two residents and failed to conduct timely care conferences with the interdisciplinary team for two residents. The facility policy stated care planning conferences would be held with the resident and/or representative and the IDT to create, review, and revise person-centered care needs and preferences when additions were necessary. Surveyors reviewed records, interviewed residents and staff, and observed care-related issues that showed the care planning and conference processes were not completed as expected. Resident 22 had paraplegia, a blood clotting disorder, and anxiety disorder, and was ordered to wear waist-high compression stockings when out of bed. The resident reported frustration that the stockings were soiled and unavailable for use, which affected attendance at recreation activities. Observations over several days showed the compression hose hanging at bedside, and the resident stated they had not been laundered. The comprehensive care plan dated 04/30/2025 included an intervention for compression hose when out of bed, but the 09/02/2025 care plan did not include interventions for the waist-high stockings or laundering. The DON reviewed the record and stated the care plan was not updated accurately and left out the compression hose and laundering care. Resident 75 had heart failure, kidney disease, and diabetes, and was receiving a water pill and injectable diabetes medications. The comprehensive care plan dated 10/14/2025 did not include a focused plan for the water pill or heart failure, including weight monitoring or adverse reactions, and did not include a focused plan for diabetes or diabetic medication management, including usual blood sugar levels, monitoring for high or low blood sugars, or adverse reactions. Resident 75 also stated they did not have a care conference with therapy, nursing, or social services, and the record showed no care conference assessment or progress note documenting that one was offered or arranged. Staff O confirmed the resident did not have a care conference. Resident 28 also stated no care conference had occurred since admission, and the record showed none was offered or attended; Staff O confirmed this resident did not have a care conference.
Failure to Follow and Clarify Physician Orders
Penalty
Summary
The facility failed to administer physician-ordered medications as prescribed for two residents. Resident 9 had heart failure and was ordered a medication to slow heart rate and reduce the force of heart beat, with instructions to hold it if systolic blood pressure was less than 110 mmHg or heart rate was less than 60 beats per minute. Review of the September, October, and November 2025 MARs showed staff did not hold the medication on multiple dates when the order required it. Resident 9 also had an order for monthly orthostatic blood pressures, but the recorded result on 11/19/2025 showed the same blood pressure for lying, sitting, and standing positions. Resident 12 had impaired memory, poor nutrition, elevated blood sugar, and risk for skin injury. The resident had an order for a stool softener with instructions to hold for loose stools and an order for monthly orthostatic blood pressures. Review of the October and November 2025 documentation showed staff recorded loose stools but did not hold the stool softening medication on multiple dates. The orthostatic blood pressure recorded on 11/19/2025 also showed identical readings for lying, sitting, and standing. Staff J stated they performed one blood pressure measurement for Resident 9 and Resident 12 while seated and did not recall how to obtain orthostatic blood pressures, and Staff G stated they documented the results without questioning the identical readings. The facility also failed to obtain a physician order for a seatbelt used on Resident 74's wheelchair and failed to clarify an incomplete bowel medication order for Resident 30. Resident 74, who had paraplegia and PTSD, stated the seatbelt had been in the wheelchair for a long time and staff observed them for safety related to its use, but no physician order was found in the record. Resident 30, who had mild cognitive impairment, had repeated periods without documented bowel movements and an as-needed bowel medication order that did not specify when it should be given. Staff K stated the resident did not have a complete bowel protocol ordered and that the order needed to be clarified.
Failure to Provide Required ADL Assistance
Penalty
Summary
The facility failed to provide assistance with ADLs for 3 of 5 residents reviewed who were dependent on staff for daily cares. Resident 22 had paraplegia, a blood clotting disorder, and anxiety disorder, and required staff to perform all effort needed to dress the lower extremities and apply footwear. The resident reported frustration that waist-high compression hose needed for out-of-bed use had been soiled and unavailable, and stated the garment had last been washed two weeks earlier by a different aide. Observations over several days showed the soiled compression hose hanging at the bedside, and the resident stated it could not be worn because it was unclean and stretched out from prior use. Record review showed a physician order for waist-high compression stockings when out of bed and a care plan noting a risk for autonomic dysflexia requiring the stockings when out of bed. However, the order summary, care plan, and Kardex reviewed later did not show an order, intervention, or laundering task for the stockings. A CNA stated they were aware of the resident's need for daily evening handwashing of the hose and had completed the task on past shifts, while the DON stated CNAs were expected to handwash garments for dependent residents as needed and acknowledged the facility's failure to launder and apply the hose limited the resident's access to essential ADL support. Resident 38 was dependent on staff for personal hygiene, and observations showed fingernails on both hands extending past the fingertips with dark debris underneath. The resident's spouse stated the nails were preferred short and clean. Resident 10 was dependent on staff for all hygiene cares, yet repeated observations showed the resident lying in bed with hair not brushed and wearing a hospital gown. Staff stated they were expected to assist with AM cares including brushing hair, washing the face, brushing teeth, and getting residents dressed and out of bed, but also reported Resident 10 had no personal clothing except one pink gown and that they had not notified management about the missing clothing or the incomplete care tasks.
Medication Storage, Labeling, Refrigeration Monitoring, and Security Deficiencies
Penalty
Summary
The facility failed to ensure medications were stored and labeled in accordance with accepted professional standards of practice. On the Unit 100 medication cart, an RN observed one full bottle of Aspirin expired in 10/2025, one tube of antibiotic skin wound gel expired on 05/30/2025, and one bottle of liquid disinfectant expired on 05/05/2025. The RN confirmed the medications were expired and stated expired medications should be disposed of properly for resident safety. On the Unit 300 medication cart, an LPN observed two opened insulin injection pens, one with mislabeled open and discard dates and one without a discard date, as well as one opened steroid inhaler with no open and discard dates listed. Four bottles of resident-owned nutritional supplements also lacked expiration dates. The DON confirmed the labeling issues and stated medications should be labeled appropriately with open and discard dates, and that the resident-owned supplements should have been clarified with the provider. The facility also failed to monitor the medication refrigerator temperature on multiple days in October and November 2025, including a period when the refrigerator was not working for two days in October. In addition, unsecured medicated wound treatments were observed on a resident's nightstand, including two tubes of medicated honey and four bottles of spray wound cleanser, and the RCM stated these items should not have been left there but contained in the resident's closet.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident from verbal abuse and mistreatment, as evidenced by the experiences of a resident who suffered psychological harm due to repeated verbal abuse by their roommate. The resident, who had a history of depression and PTSD, was subjected to derogatory remarks and foul language, which escalated when staff did not address the situation promptly. Despite the resident's requests for a room change and reports of feeling distressed, the staff did not take immediate action to separate the residents or protect the victim from further abuse. The facility's policy on abuse prevention and prohibition was not followed, as staff failed to take measures to protect the resident from further psychological harm during the investigation. The resident's requests for a room change were not accommodated in a timely manner, and staff did not document any actions taken to prevent further abuse. The resident's emails to the social services assistant highlighted the severity of the situation, expressing feelings of disrespect, emotional crisis, and retraumatization due to the verbal abuse. Interviews with staff revealed a lack of adherence to the facility's abuse policy, as staff did not separate the residents or report the incidents to management and the state hotline as required. The Director of Nursing acknowledged that the staff did not follow the facility's abuse policy, which allowed the abuse to escalate and resulted in the resident experiencing emotional distress and retraumatization. The resident was eventually moved to a different room, but only after enduring significant psychological harm.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its abuse policies and procedures effectively, particularly in identifying verbal abuse, conducting thorough investigations, protecting residents, preventing further abuse, and timely reporting of abuse and neglect incidents. This was evident in the case of four residents who were involved in resident-to-resident incidents. The facility's policy on abuse prohibition and prevention required staff to identify abuse, conduct thorough investigations, document incidents, and implement immediate interventions to protect affected residents. However, these procedures were not followed, as seen in the incidents involving Residents 1 and 2, where verbal abuse was not addressed promptly, and the necessary notifications and interventions were delayed. Resident 1, who had a history of depression and other medical conditions, reported verbal abuse from their roommate, Resident 2, shortly after moving into the shared room. Despite Resident 1's requests to move rooms and reports of verbal abuse, staff failed to take immediate action or document the necessary interventions. The facility investigation revealed that Resident 1 experienced distress and psychological harm due to the ongoing verbal abuse, which was not reported to the state agency until four days after the initial incident. Similarly, Resident 3 experienced verbal abuse from Resident 4 during a dining room incident, which was not reported or investigated promptly, and there was a lack of documentation regarding monitoring for psychological harm. The facility's inaction and failure to adhere to its policies resulted in residents being exposed to ongoing verbal abuse and psychological harm. Staff did not separate the residents involved in the incidents, failed to notify management and state agencies in a timely manner, and did not document or implement protective measures for the affected residents. These deficiencies highlight significant lapses in the facility's abuse prevention and response protocols, putting all residents at risk for unidentified and ongoing abuse.
Failure to Notify Resident's Representative of Fall
Penalty
Summary
The facility failed to ensure that the responsible parties of residents were notified of changes in condition or incidents such as falls. This deficiency was identified in the case of one resident who was unable to make their own decisions and was non-verbal due to a history of a brain bleed, high blood pressure, and diabetes. The resident was dependent on staff for mobility and had impairments on one side of their body. Despite the facility's policy requiring notification of the resident's representative after a fall, there was no documentation to confirm that this notification occurred. The incident involved the resident being found on the floor by their bed, and it was believed that the fall was caused by the resident attempting to reposition themselves. The resident's representative was not informed of the fall until a care conference over a month later, leading to frustration and concern. The Director of Nursing Services confirmed that the notification was not documented and therefore not done, acknowledging the lapse in communication with the resident's representative.
Deficiencies in Water Temperature, Chemical Security, and Fall Prevention
Penalty
Summary
The facility failed to maintain safe hot water temperatures in resident rooms, posing a risk of burns and scalding. Observations revealed that hot water temperatures in multiple rooms exceeded the safe range of 105 to 115 degrees Fahrenheit, with some measurements reaching as high as 134 degrees Fahrenheit. The facility's Domestic Water Policy required monthly checks of hot water temperatures, but the logs showed inconsistencies and did not include measurements from resident rooms. Staff interviews confirmed that the hot water system required repairs, which had not been completed despite being identified months earlier. Additionally, the facility did not secure hazardous chemicals in two of its nursing units, increasing the risk of accidental ingestion or skin impairment. Observations showed that shower room doors were left unlocked, and chemicals were accessible to residents. Staff interviews confirmed that the doors should have been locked to prevent residents, especially those who are confused or wandering, from accessing these chemicals. The facility also failed to identify and mitigate fall risks for a resident with a history of falls. The resident, who required assistance with mobility and had visual impairments, reported having inadequate footwear and a broken bed, which contributed to their risk of falling. Despite previous falls and documented interventions, the facility did not adequately address the resident's needs, as evidenced by the resident's continued falls and the condition of their living environment.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient qualified nursing staff were available to meet the needs of all residents, particularly in providing assistance with Activities of Daily Living (ADL) and timely response to call lights. Observations and interviews revealed that call lights were left unanswered for extended periods, especially during shift changes. For instance, on one occasion, call lights were observed alarming for over ten minutes while nurses were in a shift change report. Residents reported waiting times ranging from 10 to 15 minutes to as long as two hours for assistance, particularly during shift changes between evening and night shifts. Multiple residents expressed concerns about the delayed response times and the impact on their care. Resident 52 recounted an incident where they had to manage a bladder accident on their own due to delayed staff response, which posed a risk of slipping and injury. Staff interviews indicated that while the facility was within required staffing ratios, there was a consensus that staffing should be based on the complexity of residents' care needs rather than just the number of residents. Staff members acknowledged that the facility could benefit from more nursing assistants and licensed practical nurses to adequately meet the care demands.
Sanitation Deficiencies in Food Handling and Storage
Penalty
Summary
The facility failed to ensure that food storage, preparation, and service were conducted in a sanitary manner, as observed in both the main kitchen and a unit pantry. In the dry storage area, a box of thickening powder was left open and exposed, and a container of granulated garlic was not labeled with a use-by date. Staff Z, the Senior Cook, acknowledged these storage issues. Additionally, Staff DD, a Dietary Assistant, was observed preparing a drink without securing their hair with a hairnet, contrary to facility policy as stated by Staff AA, the Food Service Director. In the 400 Unit Pantry, a refrigerator contained improperly stored items, including a half-eaten quesadilla and an opened, unlabeled bottle of lemonade. The pantry's water and ice dispensing machine had a buildup of yellow-green slime. Staff B, the Director of Nursing, confirmed the need for cleaning and proper food storage. During lunch preparation, Staff R, a Cook, was observed handling food with soiled gloves after adjusting their surgical mask without performing hand hygiene, despite the facility being in a COVID-19 outbreak. Meal tray service was also compromised, with desserts left uncovered while being transported past an isolation room. Staff P, a CNA, admitted that some desserts were left uncovered, potentially due to concerns about frosting. Staff Q, the Infection Preventionist, and Staff N, the District Dietary Manager, both emphasized the importance of covering food to prevent contamination, especially during a COVID-19 outbreak. Observations on a later date showed similar issues with uncovered food being transported through the facility.
Deficiencies in Grievance Handling and Resolution
Penalty
Summary
The facility failed to maintain a system to ensure resident grievances were identified, logged, and resolved in a timely manner, affecting four residents. Resident 28, who had impaired memory and was dependent on staff for self-care, reported missing personal items, including an electric razor, nail clippers, and a $350 watch. Despite the facility's policy requiring grievances to be resolved within ten days, there was no record of these grievances in the facility's log. Staff E, the Social Services Director, acknowledged the missing watch but could not provide documentation or evidence of resolution, highlighting a gap in the grievance process. Resident 31, who had no memory impairment, expressed frustration over missing clothes that had been sent to the laundry. Despite repeatedly asking staff for assistance, the clothes were not returned promptly, and no grievance was logged. Staff E admitted that missing items were not tracked in the grievance log but were instead communicated via emails, which were set to delete after two years. This lack of formal documentation and follow-up contributed to the delay in resolving Resident 31's grievance. Resident 6, who had paraplegia and required an air conditioner for medical reasons, reported that their AC unit was removed, causing discomfort. Despite verbalizing the need for the AC to nursing staff, the issue was not addressed promptly, and Resident 6 was not provided with a grievance report. Staff interviews revealed inconsistencies in the grievance process, with some staff unaware of how to file grievances and others failing to log or investigate reported issues. These deficiencies in the grievance handling process placed residents at risk for unresolved concerns and a decreased quality of life.
Inaccurate MDS Completion Dates by RN Coordinator
Penalty
Summary
The facility failed to ensure that the Registered Nurse (RN) responsible for attesting to the accuracy and completeness of resident assessments was knowledgeable of the Minimum Data Set (MDS) process. This deficiency was identified for three residents whose Quarterly MDS assessments were reviewed for accuracy and timeliness. The RN coordinator inaccurately recorded the completion dates of the MDS assessments for Residents 67, 20, and 45, as the dates in the medical records did not match the actual completion dates found in the assessment history report. This discrepancy indicates that the assessments were backdated, which is considered unethical and a violation of the guidelines outlined in the Resident Assessment Instrument (RAI) Manual. During interviews, Staff T, the MDS Coordinator, acknowledged referring to the RAI manual for assessment coding and guidance and confirmed that the MDS assessments should be completed accurately. Staff T admitted that the completion dates for the residents' assessments were backdated and expressed a need for further MDS education. Additionally, Staff A, the Administrator, stated that backdating MDS completion dates was unacceptable and emphasized the expectation for MDS coordinators to document the actual completion dates in the residents' medical records.
Failure to Maintain Accurate and Accessible PASRR Documentation
Penalty
Summary
The facility failed to ensure accurate and updated Level 1 Preadmission Screening and Resident Reviews (PASRR) for three residents, which is required to assess the need for further evaluation for serious mental illness or intellectual disabilities. Resident 28's PASRR did not include their dementia diagnosis, despite the resident having impaired memory and receiving antipsychotic, antidepressant, and antianxiety medications. Staff E acknowledged the importance of having accurate PASRRs but failed to update Resident 28's PASRR with the dementia diagnosis. Resident 45's PASRR was not accessible to staff, even though the resident had been referred for a Level 2 evaluation due to serious mental illness. Staff E found the updated PASRR in their office, indicating it was not readily available to other staff members. Resident 32's PASRR was outdated and did not reflect significant changes in their condition, such as the decision to enroll and later dis-enroll from hospice services. Staff E admitted to not knowing that a Level 1 screening was required after significant changes, resulting in the failure to update Resident 32's PASRR.
Care Plan Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure that care plans were revised and updated to reflect the current care needs of six residents. For Resident 28, the care plan included nebulizer treatments for shortness of breath, but observations showed no nebulizer machine in the room, and the Director of Nursing confirmed that the resident no longer received these treatments, indicating the care plan needed revision. Similarly, Resident 32's care plan indicated the need for continuous oxygen therapy, yet observations showed the resident breathing without supplemental oxygen, and the Director of Nursing acknowledged the care plan was outdated. Resident 66's care plan included instructions for monitoring an IV site for antibiotic administration, but the medication had been discontinued weeks earlier, and the Director of Nursing stated the care plan should have been updated. Resident 189's care plan contained instructions to encourage fluid intake, despite a physician's order for no oral intake, which was not reflected in the care plan. The Director of Nursing confirmed the need for revision. For Resident 239, the care plan did not include the use of a fall mat, despite observations and a physical therapy assessment indicating its necessity after a fall. The Director of Nursing stated the care plan should have been updated to include this intervention. Lastly, Resident 64's care plan lacked specific instructions for staff on handling care refusal, and observations showed the resident feeling neglected and lonely. The Director of Nursing acknowledged the care plan needed to be complete and accurate to guide staff in providing care.
Failure to Provide Adequate Restorative Nursing Care
Penalty
Summary
The facility failed to ensure that residents with limited range of motion (ROM) were evaluated or provided with the necessary care and services, including a Restorative Nursing Program (RNP). This deficiency was observed in four residents who were assessed to require such interventions. The facility's policy mandates the provision of restorative nursing services to promote residents' ability to function at their highest level. However, the facility did not adhere to this policy, as evidenced by the lack of consistent RNP offerings and documentation. Resident 45, who had functional limitations due to heart and kidney failure and a brain injury, was not provided with the prescribed active ROM exercises and splint training as frequently as assessed and planned. The facility's documentation showed inconsistencies in offering these services, and there was no evidence of skin checks being conducted as ordered. Similarly, Resident 20, with a brain injury and resulting weakness, did not receive the planned RNP interventions consistently, and there was no documentation to support that the program was offered as required. Resident 58, who was on hospice care, had functional limitations but was not receiving any exercises for their condition. The facility failed to notify the hospice care team of the need for an RNP evaluation. Resident 239, also on hospice care, had a functional limitation in ROM and was using a wrist brace, but there was no assessment or evaluation for RNP. The facility did not have any orders for the use of the brace or for conducting skin checks. These failures indicate a lack of adherence to the facility's policies and procedures, placing residents at risk for further decline in mobility and function.
Deficiencies in Tube Feeding Management and Documentation
Penalty
Summary
The facility failed to implement necessary care for residents with feeding tubes, as evidenced by the lack of documentation of tube feeding (TF) administration, inadequate weight monitoring, and improper labeling of TF bags. Resident 45, who had medical conditions including heart and kidney failure, uncontrolled blood sugar levels, and difficulty swallowing, was on a tube feeding regimen. However, from July 1 to July 29, 2024, there was no documentation of the TF intake being monitored or recorded by nurses during each administration, despite the facility's policy requiring such documentation. Additionally, Resident 45 was not weighed weekly as ordered, with significant fluctuations in weight observed, indicating a failure to monitor the resident's nutritional status effectively. Resident 75, who required a feeding tube for at least half of their nutritional intake, was found with an unlabeled TF bag in their room. The bag did not have the resident's name, product information, date/time, or rate of administration, contrary to the facility's policy. Similarly, Resident 26, who also required a feeding tube for nutritional intake, had a TF bag that was only partially labeled, missing critical information about the contents and administration rate. These labeling deficiencies were confirmed by staff members during observations and interviews. The facility's Director of Nursing (DON) acknowledged the deficiencies, stating that TF orders must be complete and accurately documented to evaluate residents' nutritional needs effectively. The DON also confirmed that weight monitoring was essential for residents on TF to assess the appropriateness of nutritional interventions. The lack of proper documentation and labeling placed residents at risk of not meeting their nutritional requirements and developing complications from tube feeding.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
The facility failed to provide meals that accommodated the food preferences of two residents, leading to dissatisfaction and potential nutritional risks. Resident 31, who had no memory impairment and was able to communicate effectively, expressed dissatisfaction with the meals provided, specifically noting a dislike for sausage and rice. Despite informing staff multiple times, these items continued to be served. Observations confirmed that Resident 31 was not consuming the sausage provided, and the resident expressed frustration over the inability to request meal changes due to the late distribution of daily menus. The resident's care plan highlighted the importance of encouraging meal consumption to prevent pressure ulcers, yet their preferences were not being honored. Similarly, Resident 20, who had medical conditions including impaired swallowing and severe malnutrition, was unable to have their food preferences accommodated due to the late distribution of menus. The resident's care plan required staff to assess and incorporate their food preferences to address nutritional risks. However, the facility's process for distributing menus was inconsistent, and the dietary manager responsible for this task had left the facility. Staff interviews confirmed the lack of menu distribution, which hindered the ability to honor residents' food preferences.
Failure to Obtain Informed Consent for Antidepressant Use
Penalty
Summary
The facility failed to obtain informed consent for the use of an antidepressant (AD) medication for one resident, identified as Resident 79, who was reviewed for unnecessary medications. This oversight placed the resident at risk of receiving unwanted psychotropic medications. Resident 79 had impaired memory, an acute onset change in mental status, and fluctuating attention and consciousness, with medical diagnoses including uncontrolled muscle movements, schizophrenia, and a history of cancer. The resident received an AD medication during the assessment period, as per the physician's order dated 07/15/2024, to be administered at night for schizophrenia. A review of the resident's records showed no evidence that informed consent was obtained before administering the AD medication. During an interview, the Director of Nursing acknowledged that informed consent was required prior to the use of an AD medication and stated they would verify and provide evidence of informed consent for Resident 79's medication use. However, no further information was provided by the facility.
Failure to Notify Resident of SSI Resource Limit Exceedance
Penalty
Summary
The facility failed to notify a Medicaid recipient, Resident 10, when their personal fund account balance reached $1,800, which is within $200 of the $2,000 resource limit that could impact their Medicaid coverage. According to the facility's Resident Trust policy, revised in May 2017, the facility was required to notify the resident, their guardian or durable power of attorney, the facility social worker, and the local department of social and health services in writing when a resident's account balance approached this limit. However, the facility did not adhere to this policy, resulting in Resident 10's account balance exceeding the SSI resource limit by $696.53 as of July 23, 2024. Interviews with facility staff revealed a lack of awareness and communication regarding the Medicaid SSI resource limitations. Staff W, an Administrative Assistant, confirmed the excess balance but was unaware of the Medicaid SSI resource limitations and did not discuss trust balances with the social worker. Staff E, the Social Services Director, mentioned that it had been years since they were notified about a resident exceeding their SSI resource limits. The facility administrator, Staff A, acknowledged that Resident 10 should have been notified as per the policy but was not. This oversight placed the resident at risk for personal financial liability for their care.
Failure to Timely Assist Residents with Advanced Directives
Penalty
Summary
The facility failed to provide timely assistance in formulating Advanced Directives (ADs) for five out of six residents reviewed. Resident 68, who had intact memory, was admitted to the facility and did not have an AD documented until 47 days after admission. The document lacked details on when the AD toolkit was provided or if the resident needed assistance. Resident 31, with no memory impairment, received the AD packet over two weeks after admission, as confirmed by the resident. Resident 75, with severe cognitive impairment, was provided an AD packet almost two months after admission, despite being unable to make decisions and having family involvement noted in their records. Resident 189, who had no memory impairment, had an incomplete AD status section in their records and no documentation of a Power of Attorney (POA), despite the resident stating they had one. Resident 6, who was understood and had clear comprehension, did not have an AD or declination documented until two months after admission. The facility's social services department noted that an AD toolkit was provided and a copy requested from the resident and family. Staff interviews revealed expectations that ADs should be readily available in residents' records, highlighting the facility's failure to meet these expectations.
Inadequate Investigation of Resident Fall
Penalty
Summary
The facility failed to conduct a thorough investigation of an unwitnessed fall involving a resident, identified as Resident 239, which left the resident at risk for unidentified abuse and/or neglect. Resident 239, who was totally dependent on two staff members for transfers and toileting, had a history of falls and was receiving end-of-life care due to multiple medical conditions, including cancer and pressure ulcers. Despite the facility's policy requiring a comprehensive investigation, the report lacked staff interviews or witness statements, and there was conflicting information regarding whether the fall was witnessed or unwitnessed. Additionally, the investigation did not include a neurological assessment for the resident, and there was no documentation to support that the resident was offered toileting assistance multiple times before the fall, as claimed in the investigation report. Interviews with facility staff revealed further deficiencies in the investigation process. The Director of Nursing acknowledged that the fall was unwitnessed and admitted to having undocumented conversations with staff instead of formal interviews or statements. The Administrator emphasized the importance of thorough investigations to rule out abuse or neglect but noted that the designated staff failed to complete the investigation as required. The facility's inability to provide documentation supporting the claims made in the investigation report further highlighted the inadequacy of the investigation process.
Failure to Provide Transfer/Discharge Notices and Ombudsman Notification
Penalty
Summary
The facility failed to provide written transfer or discharge notices and complete notification to the Office of the State Long-Term Care Ombudsman (LTCO) for two residents reviewed for hospitalization. Resident 32, who had severe memory impairment and was diagnosed with Alzheimer's disease and Diabetes Mellitus, experienced an acute change in condition and was sent to the hospital emergently. However, there was no evidence that a transfer notice was completed and given to Resident 32 or their representative. Staff S, the Health Information Manager, confirmed the absence of a written transfer notification and stated that it could not be sent to the LTCO office as it did not exist. Resident 20, who had a brain injury, malnutrition, and difficulty urinating, was discharged to the hospital due to pressure and pain in the lower abdomen and blood clots in the urine. The medical records showed an unsigned and incomplete transfer notice, lacking an explanation to support the discharge. Staff S confirmed the notice was not signed by the resident or their representative and acknowledged the absence of documentation to support that the Ombudsman was notified. Staff A, the Administrator, emphasized the importance of providing written transfer/discharge notifications to communicate the resident's current location and ensure notification of rights and regulations associated with their transfer/discharge.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to complete the Quarterly Minimum Data Set (MDS) assessments within the regulatory timeframe for one of the three residents reviewed, specifically Resident 67. According to the October 2023 Resident Assessment Instrument (RAI) Manual, a Quarterly MDS is a non-comprehensive assessment that must be completed no later than 14 days after the established Assessment Reference Date (ARD) and no later than 92 days from the ARD of the most recent prior quarterly or comprehensive assessment. Resident 67's comprehensive Admission assessment was completed on March 18, 2024, but the subsequent Quarterly assessment, scheduled for June 3, 2024, was not completed until June 17, 2024, which was three days past the 92-day regulatory completion timeframe. During interviews, Staff T, the MDS Coordinator, acknowledged the importance of timely MDS assessments for appropriate and safe care planning and confirmed that Resident 67's Quarterly MDS was completed late. Staff A, the Administrator, stated that they expected MDS coordinators to complete assessments accurately and timely as required. This deficiency in timely assessment completion placed residents at risk for delayed care planning, unidentified care needs and services, and a decreased quality of life.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for three residents, leading to potential risks of unidentified and unmet care needs. For Resident 189, the Entry Tracking MDS was incorrectly coded as an admission instead of a reentry after a hospital stay of less than 30 days. This error was acknowledged by the MDS Coordinator, who admitted to the mistake and emphasized the importance of accurate coding for continuity and coordination of care. Resident 28's Quarterly MDS did not reflect a diagnosis of psychosis, despite the resident receiving antipsychotic medication for delusions. The Director of Nursing confirmed the oversight, noting that the diagnosis should have been included in the MDS. Resident 68's Admission MDS inaccurately recorded their activity preferences due to the resident being unresponsive during the interview. Although the resident was able to answer questions about mood, pain, and daily preferences, the activity preferences section was marked as nonresponsive, and a staff assessment was used instead. This assessment failed to capture the resident's specific interests, such as spending time outdoors, which the resident later expressed. The staff member conducting the interview acknowledged the discrepancy and the lack of a follow-up attempt to gather more detailed information.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans (CPs) for five residents, which is a requirement within 21 days after admission according to the facility's policy. Resident 68, who had intact memory and diagnoses including a wound infection, malnutrition, and depression, was observed to be very thin and expressed a desire to regain lost weight. However, their CP for severe calorie protein malnutrition lacked any associated goals or interventions. Similarly, Resident 31, who had multiple medically complex diagnoses including cancer, had no CP addressing their nutritional concerns despite being assessed for such needs. Resident 66, with mild memory impairment and an unhealed pressure ulcer, had a CP for severe protein calorie malnutrition initiated but without any resident-specific goals or interventions. Resident 75, who required a feeding tube for nutritional intake, also had an altered nutrition CP initiated without goals or interventions. Lastly, Resident 189, who similarly required a feeding tube, had an altered nutrition CP initiated without any goals or interventions. The Director of Nursing acknowledged the importance of complete CPs to ensure necessary interventions are in place, yet these deficiencies were observed.
Failure to Follow and Clarify Physician's Orders
Penalty
Summary
The facility failed to ensure that physician's orders were followed and clarified as needed for two residents, leading to potential risks of medication errors and adverse outcomes. For Resident 13, during a medication pass, a staff member was observed preparing a pain medication gel without using a dose measuring card, as required by the physician's order. The medication administration record indicated that the resident was prescribed four grams of the gel to be applied to the right knee twice daily. However, the staff member used a medication cup instead, which did not allow for accurate measurement of the prescribed dose. Interviews with facility staff confirmed that the correct procedure involved using a dosing card to measure the medication accurately. For Resident 189, the facility failed to clarify conflicting physician's orders regarding medication administration. The resident, who had multiple complex medical diagnoses and required a feeding tube for nutrition, had an order indicating no food or fluids by mouth. Despite this, the medication administration record showed an order to administer a blood-thinning medication orally, contradicting the previous order. The Director of Nursing acknowledged that the order needed clarification to ensure the medication was administered correctly through the PEG tube, as per the resident's dietary restrictions.
Failure to Assist Residents with ADLs
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADL) for two residents who were dependent on staff for their daily care. Resident 32, diagnosed with Alzheimer's disease, was observed over several days with an unshaven beard, despite their care plan indicating a preference for being clean-shaven. The Director of Nursing acknowledged that Resident 32's appearance was important to them and expected staff to assist with shaving as part of their ADL care. However, the resident was not shaved until several days after the initial observation, indicating a lapse in the provision of grooming assistance. Resident 64, who required assistance with dressing and grooming due to visual impairment and functional cognition issues, reported having inadequate clothing and footwear, leading to discomfort and poor hygiene. Observations revealed that Resident 64's fingernails and toenails were excessively long, and their hair was unkempt. Despite the care plan stating that staff should meet Resident 64's ADL needs daily, the resident expressed that they rarely received help with dressing and grooming. The Director of Nursing noted that staff should have reported the resident's long nails and refusals for care, but this was not done, further highlighting the deficiency in providing adequate ADL support.
Failure to Provide Individualized Activities During COVID Outbreak
Penalty
Summary
The facility failed to ensure that activity programs met the needs of each resident, specifically for Resident 64, who was reviewed for activities. Resident 64, who had unspecified dementia and behavioral disturbances, expressed a preference for books, newspapers, music, and choosing daily activities. Despite this, the resident's care plan indicated a need for encouragement to participate in daily activities and assistance in choosing enjoyable activities. However, the Kardex did not list any activities for Resident 64, and the resident expressed feelings of isolation and lack of engagement, stating they had nothing to do and were not allowed to go outside. Interviews with staff revealed that group activities were halted due to a COVID outbreak, but individual activities were supposed to continue. Staff U, the Activities Supervisor, mentioned that newsletters were distributed, and activities for cognitive stimulation were provided, but no specific activities were documented for Resident 64. The Director of Nursing acknowledged the lack of an activity assessment for Resident 64 and emphasized the importance of individualized care plans for residents with dementia. The Resident Council also reported a lack of activities during the outbreak, with residents feeling limited to phone calls or watching television.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide adequate pain management for Resident 12, who was experiencing chronic pain due to osteoarthritis. Despite having a care plan that included goals for pain relief and instructions for staff to report unrelieved pain to the Medical Director, the facility did not follow through with these measures. Resident 12 reported experiencing daily pain and specifically mentioned sharp pain in the left lower leg, which was not addressed by the nursing staff. The resident expressed frustration that their complaints were not being communicated between shifts or followed up by the medical team. Interviews with staff revealed a lack of awareness and documentation regarding Resident 12's pain. Staff V, an LPN, was unaware of the resident's calf pain and stated that residents needed to inform nurses daily about their pain issues. The Director of Nursing, Staff B, acknowledged that documentation of pain was not completed as expected, which hindered the identification and treatment of the resident's pain. The absence of proper documentation and communication among the nursing staff led to the deficiency in managing Resident 12's pain effectively.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage, labeling, and disposal of medications across multiple units, leading to potential risks for residents. On Unit A, a medication cart was found with an open vial of blood thinning medication lacking a date or resident label, and an insulin vial that was not refrigerated as required. Staff HH acknowledged the expectation for medications to be labeled and dated, and for insulin to be refrigerated. On Unit B, an eye drop medication was found expired, and various creams and ointments were improperly stored together. Staff M admitted to missing the expiration and confirmed the improper storage. On Unit D, medications were stored next to a disinfectant container, which was confirmed by Staff CC. In the medication rooms of Units A and B, expired supplies and medications for discharged residents were found. Staff II and Staff M acknowledged the presence of expired items and the need to return medications to the pharmacy. Staff B confirmed the expectation for medications to be labeled, dated, refrigerated, and returned within 30 days of a resident's discharge. Additionally, an unlocked medication cart was observed on Unit C, with Staff EE acknowledging the expectation for carts to be locked. Resident 240 was found with unsecured medications at their bedside, including an inhaler and a cup of pills. Staff KK and Staff B confirmed the lack of a self-medication assessment for Resident 240, despite an order for an inhaler to be kept at bedside. Staff B emphasized the importance of securing medications and conducting assessments for resident safety.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, resulting in several deficiencies. Observations revealed that sharps containers in three resident rooms were filled beyond the maximum fill line, posing a risk of accidental needle sticks and disease transmission. Additionally, one resident room had floor mats with torn and peeling corners, making them uncleanable and increasing the risk of infection. The facility also lacked a complete Water Management Program, as the Facilities Manager admitted to not having a diagram of the facility with identified areas of risk for Legionella, and the risk assessment was incomplete. Further deficiencies were noted in wound care and catheter management. A resident with a Stage IV pressure ulcer did not receive care in accordance with infection control standards, as a Certified Nursing Assistant failed to perform hand hygiene after removing personal protective equipment and before retrieving a clean garbage bag. Another resident with a long-term indwelling urinary catheter was observed with their catheter drainage bag lying on the floor, which was acknowledged by a Licensed Practical Nurse as an infection control concern.
Entrapment Risk Due to Improper Bed and Mattress Fit
Penalty
Summary
The facility failed to ensure that resident beds did not have gaps that could pose an entrapment risk, specifically for one resident whose bed was observed for accident hazards. The facility's policy required regular inspections and maintenance of medical devices and equipment, including beds and mattresses, to ensure resident safety. However, during an observation, it was found that the resident's air mattress was smaller than the bed frame, creating a gap of six inches at the head of the bed, which increased to ten inches when a pillow was removed. This gap was confirmed by the Facilities Manager as an entrapment risk. The resident involved had multiple medical diagnoses, including elevated blood sugar levels, heart and kidney failure, and generalized weakness, requiring substantial assistance with daily activities, including bed mobility. Despite the care plan's instructions to minimize gaps between the mattress and bed frame, the gap was not addressed. The Director of Rehabilitation acknowledged the oversight, noting that the Rehabilitation Department, which frequently interacted with the resident, failed to identify the risk. This deficiency placed the resident at risk for injury, entrapment, or death.
Failure to Ensure Safe Discharge and Provide Necessary Care Instructions
Penalty
Summary
The facility failed to ensure a safe discharge for a resident who was reviewed for discharges. The resident, who had a left hip fracture, left lower leg fracture, and an indwelling catheter, was discharged without the necessary information being provided to the Home Health Agency (HHA). The discharge summary did not specify the required home health services, and the referral to the HHA was incomplete, leading to a delay in the initiation of home health services for five days after discharge. Additionally, the facility did not provide or document education on indwelling catheter care to the resident or their collateral contact (CC). The resident and their CC were unaware of how to care for the catheter, which was crucial for the resident's post-discharge care. The facility's social services director assumed that the HHA would contact them if more information was needed, but this did not happen promptly, resulting in a lack of necessary care instructions being communicated. The HHA required specific information about the resident's care needs, including details about the catheter, which were not provided in a timely manner. The facility's failure to ensure that the HHA had all the required information and to educate the resident and their CC on catheter care led to a significant gap in the resident's post-discharge care, placing the resident at risk for unmet care needs and potential complications.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,007 citations issued within 25 miles in the last 12 months — including the 3 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Issaquah
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avamere Rehabilitation Of Issaquah | 2.5 mi | ★★★★★ | 0 | 0 |
| Briarwood At Timber Ridge | 3.3 mi | ★★★★★ | 27 | 0 |
| Bellevue Post Acute | 5.8 mi | ★★★★★ | 66 | 0 |
| Covenant Shores Health Center | 7.9 mi | ★★★★★ | 25 | 0 |
| Redmond Care And Rehabilitation Center | 8.3 mi | ★★★★★ | 1 | 0 |
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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 October 2026) and official state health department websites.