Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Burlington Health And Rehabilitation Center during CMS and state inspections, most recent first.
Failure to document ordered wound care for a resident with an abdominal wound and cellulitis. The chart included orders for NPWT at 100 mmHg, backup NS dressing care if the wound vac was unavailable, and later Dakins wound care with packing and ABD pads. The February TAR had no documented evidence that the routine or PRN treatments were completed, and an LPN stated the care was done but not documented.
A facility licensed for 123 beds failed to employ a qualified full-time social worker for about two months. The current SSA was not a licensed social worker and had no social work degree or human services bachelor's degree, yet was completing admissions, discharges, and resident assistance while the Administrator, DON, BOM, management team, and sister facilities provided informal support.
The facility did not consistently offer alternate meal options of equal nutritional value to residents who declined the main meal, and failed to post the Always Available Menu as required. Multiple residents reported not being offered alternatives for vegetables or starches, and staff confirmed that only one alternate entrée was available per meal. These actions were not in accordance with facility policy or regulatory expectations.
Surveyors identified multiple deficiencies in food storage and preparation, including a walk-in freezer with excessive ice buildup, brown lettuce with an unreadable date, dirty fans in the food prep area, and dietary staff preparing food without required beard restraints. Facility staff were aware of these issues but did not address them prior to the survey.
The facility did not electronically submit complete and accurate direct care staffing information to CMS, as required, using payroll and other verifiable data sources.
Staff did not consistently implement Enhanced Barrier Precautions (EBP) for residents with wounds or indwelling medical devices, as required by facility policy. PPE and EBP signage were missing for multiple residents, and staff provided high-contact care activities such as wound care, catheter care, and tube feeding without donning gowns or gloves. Leadership and staff interviews revealed confusion and inconsistent application of EBP, and care plans lacked instructions for PPE use. Additionally, the only sink in the contaminated laundry area was non-functional, preventing proper hand hygiene after handling soiled laundry.
A widespread fly infestation was observed throughout the facility, with multiple residents and staff reporting persistent issues in resident rooms, hallways, dining areas, and the kitchen. Residents described using personal items to swat at flies and purchasing their own traps, while surveyors observed flies landing on food and residents during meals and treatments. Documentation showed lapses in scheduled pest control service visits, and the Maintenance Director was unaware of the extent of the problem.
Delayed Resident Mail Delivery: Residents did not always receive mail within the facility's stated 24-hour timeframe because Saturday mail was held in the BOM's office until it could be sorted by business office staff and delivered by Activities on Monday afternoon. During Resident Council, residents reported that Saturday mail was not delivered on Saturdays, and facility staff confirmed the weekend delay was due to no business office coverage.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Surveyors found that several residents with significant medical and cognitive needs did not receive required weekly showers or bathing assistance, as documented in their care plans and facility policy. Documentation was missing or inconsistent, and interviews revealed that some residents had not received showers since admission. The facility did not provide explanations or evidence to account for the missed hygiene care.
Several residents did not receive care and treatment as ordered by physicians and outlined in their care plans, including the application of compression stockings, timely wound care, and provision of an air mattress. Additionally, after an unwitnessed fall, required neurological checks were not completed or documented by staff, despite facility policy and staff acknowledgment of the requirement.
A resident with Alzheimer’s disease had documented wandering, exit-seeking, and elopement behaviors, but the admission MDS did not reflect any behavioral symptoms or wandering. Three other residents had PASARR Level 1 and Level 2 evaluations in the record, yet their Annual MDS assessments incorrectly stated that Level 2 PASARR had not been completed. Interviews showed the SW and MDS RN acknowledged the coding errors.
Insulin Labeling and Dating Deficiencies: Surveyors found multiple open insulin vials and pens in medication carts that were not labeled, not dated when opened, or were expired. Findings included unlabeled insulin pens, handwritten resident names on a pen, and several vials and pens for multiple residents that lacked opening dates across unit medication carts. Staff gave differing answers about how long insulin remains good after opening, and the facility policy provided did not include insulin dating or expiration dates.
A resident with an indwelling catheter was observed in public areas with their catheter bag uncovered and visible to others on multiple occasions. The resident expressed a preference for privacy, and facility staff confirmed that catheter bags should always be covered in public spaces. These actions failed to uphold the resident's dignity and privacy.
The facility did not adequately promote or facilitate resident self-determination, failing to support resident choice as required. This resulted in residents not being fully supported in making their own decisions regarding their care or daily activities.
Surveyors found that three residents were living in rooms with significant cleanliness and maintenance issues, including dirty walls, heat registers, and curtains, cloudy and dirty windows with cobwebs and dead flies, broken blinds, a detached air/heating unit with exposed dirty piping, and peeling bathroom flooring. Staff acknowledged missed cleaning and maintenance tasks, and there was confusion about responsibilities for certain cleaning duties.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
Three residents did not receive necessary pressure ulcer care according to professional standards, including one who developed a facility-acquired DTI that was incorrectly staged and not treated per updated recommendations, and two others who did not have required interventions such as heel floating or timely wound treatments. Staff failed to update care plans and did not consistently document or implement required interventions, leading to deficiencies in pressure injury prevention and management.
A resident did not receive appropriate care and services to maintain or improve their range of motion or mobility, and there was no documented medical reason for the decline.
Three residents with significant fall risks did not consistently receive required fall prevention interventions, including supervision during transfers, fall mats, body pillows, Dycem in wheelchairs, and accessible call lights. Staff left a resident alone in the bathroom despite care plan requirements, and multiple observations showed that fall prevention devices were not in place for two other residents. Staff interviews confirmed knowledge of required interventions, but these were not reliably implemented.
A resident in need of pain management did not receive safe and appropriate pain management services, as the facility failed to provide the necessary care to address the resident's pain.
Two residents received meals that did not match the posted or planned menus, and one resident was served food items listed on their dislike list, despite these preferences being documented. Staff interviews revealed confusion and breakdowns in the process for updating and communicating resident food preferences, resulting in meals not aligning with dietary orders or posted menus.
A resident with multiple chronic conditions had conflicting advance directive and code status documentation in the chart and EMR. The record included a full code form, DNR forms signed by the physician, an EMR banner showing DNR, and progress notes from the MD, NP, and SWA documenting both full code and DNR/CPR preferences, leaving the resident’s wishes unclear.
A resident with cerebral palsy who was cognitively intact and dependent for transfers reported that a CNA was rough and hurt the resident during a transfer. The resident told multiple staff members, including an LPN and OT, but the allegation was not logged as a grievance or incident and was not thoroughly investigated. The only documentation available was a UM note describing the event as a transfer preference issue rather than an abuse allegation.
The facility did not accurately complete PASARR Level I screening for two residents with mental health diagnoses, and neither resident had a completed PASARR Level II in the EMR. One resident with bipolar disorder was screened as not having a serious mental illness, while another resident with schizoaffective disorder and bipolar disorder was identified as having a serious mental illness on Level I but still had no Level II completed. The SW stated that schizophrenia or bipolar disorder does not always require Level II and referenced symptoms such as self-harm as a qualifier.
A resident receiving continuous O2 therapy was observed with the tank set below the ordered flow rate and with the humidifier bottle empty or nearly empty despite documentation that it had been changed. The resident later complained of sore nasal passages, and the nasal cannula was observed not positioned in the nose while the O2 remained at the incorrect setting.
Failure to Reassess Need and Consent for Enabler Bars: The facility had bilateral enabler bars in place for three residents with significant functional impairment, including one resident with a legal guardian, one cognitively intact resident with cerebral palsy and paraplegia, and one resident with dementia and an activated HCPOA. Although consent and physician orders were documented, the surveyor found no evidence of ongoing monitoring or quarterly reassessment of the need for the enabler bars, including review of safety and risks/benefits, after the initial evaluation.
A resident on hospice with stroke, epilepsy, depression, dementia, and lung cancer had an empty hospice binder and missing hospice documentation in the facility EMR. Surveyors found that hospice visit notes, the hospice POC, and hospice responsibilities were not kept in the binder, and a hospice wound care order was not entered into the facility’s physician orders. The resident was also observed in a wheelchair without the ordered cushion, while staff documented the cushion was not present.
Staff did not wear gowns as required during a pressure ulcer dressing change for a resident on enhanced barrier precautions, despite clear facility policy and signage. The LPN and CNA performed the procedure without donning gowns, and the DON/Infection Preventionist confirmed this was against expectations for EBP.
The facility did not have a qualified Dietary Manager overseeing food and nutrition services for about a month after the previous manager left. Staff interviews confirmed the absence of a full-time DM during this period, and the Administrator was aware of the vacancy. This affected all residents, as there was no designated individual to direct the food services department.
The facility did not follow the planned menu and failed to notify residents in advance when a listed dessert was not prepared and substituted with mixed fruit. Staff responsible for meal preparation confirmed the substitution was made without prior resident notification, contrary to facility policy and expectations.
Surveyors found that the facility did not maintain kitchen sanitation or proper food storage, with multiple food items lacking labels, open or use-by dates, and improper storage practices. The kitchen also had issues such as ice buildup in the freezer, no temperature logs, employee jackets stored with clean kitchenware, and a dish machine that did not reach the required rinse temperature.
Two residents were found with medications at their bedsides—one with Santyl ointment and another with an Albuterol inhaler—without documented assessments for their ability to safely self-administer these medications. Both residents were cognitively intact, but staff confirmed that required safety assessments had not been completed prior to allowing bedside access.
A resident dependent on hemodialysis did not have consistent documentation of pre- and post-dialysis assessments, and communication between the facility and the dialysis center was lacking. Staff interviews revealed confusion about responsibilities for completing and sending dialysis communication forms, and the resident's binder had not been updated for several months. Leadership confirmed that required documentation and communication had not occurred as expected.
Three residents did not receive their prescribed medications as ordered due to repeated unavailability, delays in pharmacy delivery, and issues with reordering and insurance authorization. Critical medications for conditions such as COPD, depression, and hypercholesterolemia were missed for multiple days, with staff and pharmacy interviews confirming ongoing challenges in medication procurement and contingency supply coverage.
A resident with COPD, pulmonary embolism, and asthma missed multiple doses of critical medications, including a blood thinner and inhalers, due to unavailability and delays in pharmacy delivery. Documentation and staff interviews revealed inconsistent medication reordering processes, lapses in communication, and lack of timely follow-up, resulting in significant medication errors as defined by facility policy. Leadership was unaware of the frequency of missed doses until after the incidents.
The facility failed to document medication and treatment administration for four residents, including those with chronic conditions and fractures. Missing documentation involved medications like insulin and gabapentin, and treatments such as tracheostomy care and wound care. The DON confirmed the missing documentation, emphasizing the expectation for staff to document administered care or reasons for non-administration.
The facility failed to promptly resolve grievances for several residents, as required by their policy. Residents expressed concerns that were not documented or investigated, and the grievance log lacked entries for these issues. The facility's leadership acknowledged the deficiency in handling grievances according to their policy.
The facility failed to conduct thorough investigations into two abuse allegations. In one case, a visitor reported inappropriate behavior by a housekeeper, but the facility did not interview enough residents or document the investigation's results. In another case, a resident reported rough care by a CNA, but the allegation was not promptly reported, and the investigation lacked necessary staff statements. These deficiencies potentially affected all residents.
The facility failed to provide accurate pharmaceutical services, affecting several residents. A resident received incorrect medication orders, leading to adverse effects, while another did not receive prescribed wound care supplies due to supply chain issues. Additionally, a glucose monitor was not labeled, and medications were left unattended, highlighting deficiencies in medication management.
A resident's POA was not notified when occupational and physical therapy were discontinued, despite the facility's policy requiring such notification. The resident, with multiple health conditions, had their POA activated, but there was no documentation of notification when therapies were stopped. The Director of Rehab acknowledged the lack of documentation, and the responsible therapist was no longer at the facility.
A facility failed to immediately report an abuse allegation involving two residents. A CNA reported to an RN that a resident alleged rough handling during care, but the RN dismissed it as the resident's behavior and did not report it to a supervisor or the NHA immediately. The allegation was only reported the next day by Social Services, violating the facility's policy requiring immediate reporting of abuse allegations.
A resident was discharged to an adult living home without a complete discharge summary, lacking vital information such as a medication list and post-discharge care plan. The resident had complex medical needs, including paraplegia and chronic respiratory failure. Facility staff interviews revealed no designated person to ensure discharge instructions were completed, resulting in multiple uncompleted sections in the discharge documentation.
The facility failed to provide appropriate care for two residents, one with congestive heart failure and another with a wound infection. Staff did not apply tubi grips as ordered for a resident with edema, and inaccurately documented their application. Another resident's non-pressure wounds were not assessed for seven days, and the facility lacked proper orders for PICC line care. Coban wraps were not used as ordered due to supply issues, leading to the use of ace bandages instead.
A resident with Traumatic Spinal Cord Dysfunction was left suspended in a Hoyer lift without adequate supervision during a transfer. The assisting RN left the resident to address a phone call, and later, the transfer attempt caused the wheelchair to become unstable. The resident was suspended for six minutes until additional help arrived. The incident highlighted the use of an incorrectly sized sling.
A resident with chronic kidney disease and end-stage renal disease was served a meal not compliant with their prescribed renal/LCS diet, including high-potassium items like french fries and a tomato slice. Interviews revealed gaps in communication and education among dietary staff regarding renal diet restrictions.
A resident with a tracheostomy did not receive the prescribed daily change of their HME trach valve due to a lack of awareness and communication among staff. The LPN was unaware of the HME trach valve, and the facility had never ordered or received the necessary supplies, leading to the resident not receiving the required respiratory care.
A resident in an LTC facility received multiple antibiotics simultaneously for UTI symptoms, despite not meeting the facility's criteria for antibiotic use. The resident was prescribed Rocephin, Bactrim, Macrobid, and Fosfomycin by different medical teams, leading to overlapping treatments. Facility staff acknowledged the issue, noting the resident's insistence on receiving antibiotics and the involvement of multiple medical teams.
A long-term care facility was found to have a medication error rate of 20%, significantly above the acceptable threshold. Errors included administering crushed delayed-release medications, incorrect medication types, and dosages, and failing to notify physicians of deviations from prescribed schedules. These issues were identified during a survey and were not addressed until highlighted by the surveyor.
A resident was administered an incorrect dosage of Carvedilol 69 times due to a failure in the facility's medication order review process. The resident, with a history of hypertension and congestive heart failure, was readmitted with a hospital order for Carvedilol 25 mg, but the facility continued the previous 12.5 mg dosage. The error was not identified until a surveyor's investigation.
Failure to Document Ordered Wound Care
Penalty
Summary
The facility failed to ensure that wound care was documented as completed according to physician orders for one resident with an abdominal wound. The resident was admitted with cellulitis of the abdominal wall and an open wound of the abdominal wall, and later transferred to the hospital. The record included multiple wound treatment orders, including negative pressure wound therapy to the abdominal surgical wound/incision at 100 mmHg with skin prep to the peri-wound area and tunneling packed, to be changed three times a week and as needed on Tuesday, Thursday, Saturday, and PRN. Additional orders directed that if the wound vac was not available, the abdominal surgical wound/incision was to be cleansed with normal saline, packed with moistened gauze, and covered with a dry dressing as needed. Another order directed cleansing the abdominal wound with full strength Dakins, packing it with Dakins-moistened gauze, and covering it with ABD pads every evening shift. Review of the resident’s February TAR showed no documented evidence that any routine or PRN wound treatment was completed as ordered. During interview, an LPN confirmed the wound care orders and stated that wound care was completed, but nothing was documented and that if it was not documented, it was not done.
No Qualified Full-Time Social Worker
Penalty
Summary
The facility failed to ensure a qualified social worker was employed on a full-time basis for approximately two months in a building licensed for 123 beds and serving 94 residents. During observation of the facility license and review of the Facility Assessment, the facility was confirmed to be licensed and certified for 123 beds. Review of the Social Services/Social Worker Assistant job description showed the role was intended to support the overall operation of the Social Services Department, but the employee in the position was a Social Services Assistant rather than a licensed social worker. Interviews and personnel record review showed the Social Services Assistant had been hired on 04/22/26 and did not have a social worker degree, certification, or bachelor's degree in a human services field. The SSA stated she had been working as the assistant social worker since mid-April 2026, had been completing admissions, discharges, and assisting residents, and that there had been no licensed social worker in the building since that time. The Administrator and DON stated the previous social worker left in late May or early April 2026, that the current person in the role was the SSA and was not a certified social worker, and that the facility had been relying on the BOM, management team, sister facilities, and borrowed help while trying to hire a social worker.
Failure to Provide Alternate Meal Options and Post Menus
Penalty
Summary
The facility failed to provide alternate meal options of equal nutritional value to residents who declined the main meal, as required by their own policy and regulatory standards. Record reviews, observations, and interviews revealed that three residents out of a sample of eighteen were not regularly offered alternate meals when they did not want the meal originally served. For example, one resident with a moderately impaired cognitive status and on a No Added Salt (NAS) diet was not offered an alternate vegetable when she declined carrots, and she confirmed that no other vegetable options were available. The posted menus only listed alternates for the main entrée, with no alternates for vegetables or starches, and the Always Available Menu was not posted in accessible areas as expected. Observations during meal service confirmed that residents were only offered the main entrée or a single alternate, which was often the same for both lunch and dinner, and no alternate vegetables or starches were provided. The Food Services Manager acknowledged that only one alternate entrée was available per meal and that the Always Available Menu was not posted as required. Residents on special diets were also not provided with alternate meal options. The Registered Dietician stated that her expectation was for alternates of equal nutritive value to be available for each meal and for menus to be posted where residents could access them. Resident interviews further supported these findings, with residents reporting that the alternative menu had been removed about a month prior and that staff did not offer alternatives if residents wanted something other than the main meal. The facility's own policy required that alternatives be immediately available if the primary menu was not to a resident's liking, but this was not being followed. These actions and inactions led to a deficiency in providing resident choice and adequate nutrition as required.
Deficient Food Storage, Preparation, and Sanitation Practices
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's kitchen related to food storage, preparation, and cleanliness. The walk-in freezer had a thick buildup of ice on the floor, walls, and ceiling, with boxes of food also covered in ice. The condition of the freezer was such that the surveyor could not enter due to safety concerns. In the walk-in cooler, an opened bag of lettuce salad was found with a faded, unreadable date and the lettuce appeared brown. Additionally, two fans in the food preparation area had a buildup of a red substance, making them appear dirty and in disrepair, and the exhaust fan above the stove was thick with dust. Dietary staff were observed not following facility policy regarding attire, as two staff members with facial hair were preparing food without beard restraints. Interviews with the Dietary Manager and Nursing Home Administrator confirmed awareness of the freezer's condition and acknowledged the presence of old salad, dirty fans, and lack of beard restraints. The Dietary Manager stated that the freezer had been set too cold after a recent replacement and that the freezer door had not been closing properly, leading to the ice buildup. The manager also indicated that expired or old food items are usually removed daily, but could not provide further explanation for the observed deficiencies.
Failure to Submit Accurate Direct Care Staffing Data
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS. The information was required to be based on payroll and other verifiable and auditable data. This deficiency was identified through review of the facility's records and submission practices, which did not meet the required standards for accuracy and completeness as mandated by CMS.
Failure to Implement Enhanced Barrier Precautions and Maintain Sanitary Environment
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program, specifically regarding Enhanced Barrier Precautions (EBP) for residents with wounds or indwelling medical devices. Despite having a policy that required EBP for residents with wounds or devices such as urinary catheters and feeding tubes, staff did not consistently apply these precautions. Observations revealed that on four of six units, EBP was not implemented, and staff did not use personal protective equipment (PPE) when providing high-contact care activities such as wound care, catheter care, and tube feeding. Multiple residents with wounds, indwelling catheters, or feeding tubes did not have EBP signage or PPE available, and staff were observed providing care without donning gowns or gloves as required by facility policy. Interviews with staff and leadership indicated a lack of understanding and inconsistent application of the EBP policy. The Director of Nursing (DON) and unit managers stated that EBP was only applied to residents with known multidrug-resistant organisms (MDROs) or those in proximity to such residents, contrary to the facility's written policy and CDC guidelines. Staff members, including CNAs, LPNs, and activity aides, demonstrated confusion about when PPE was required and were observed entering rooms and providing care without appropriate infection control measures. Documentation in care plans and Kardexes also failed to instruct staff to use PPE for residents who met EBP criteria. Additionally, the facility did not maintain a sanitary environment in the laundry department. The only sink in the contaminated laundry area was non-functional for one to two weeks, leaving staff without a means to perform hand hygiene after handling soiled laundry and removing PPE. Staff reported using a sink in the employee break room across the hall, which required leaving the contaminated area before performing hand hygiene, in violation of the facility's own laundry policy and standard infection control practices.
Failure to Maintain Effective Pest Control Program for Flies
Penalty
Summary
The facility failed to maintain an effective pest control program to address a significant fly infestation throughout the building. Multiple residents reported ongoing issues with flies in their rooms, common areas, and the dining room. Residents described using personal items such as washcloths and underwear to swat at flies, and some purchased their own fly traps due to the persistent problem. Surveyors directly observed flies in resident rooms, hallways, the dining area, conference room, and kitchen, including flies landing on food and residents during meals and treatments. Staff were also seen using fly swatters in attempts to control the flies. The facility's pest control program required a written agreement with an outside pest service for regular visits, appropriate use of chemicals, and a reporting system for pest issues between scheduled visits. However, record review revealed that the facility did not have pest control service visits for several months, specifically in May, June, and February of one year and July of the previous year. The Maintenance Director was unaware of the fly issue and stated that pest control visits occurred monthly, but this was not supported by documentation. Residents and staff consistently reported the fly problem, with some residents noting that flies landed on their food and bit them, and others stating that the issue was worse near exit doors or in rooms previously occupied by other residents. During the survey, flies were observed in the kitchen, where dietary staff attempted to cover food to prevent contamination. Resident council members also raised concerns about the large number of flies and the cleanliness of the facility. The persistent presence of flies was noted by surveyors throughout the entire survey period, affecting all areas of the facility and all residents present at the time.
Delayed Resident Mail Delivery
Penalty
Summary
The facility did not always provide residents reasonable access to their mail because mail delivered by the Postal Service on Saturdays was not delivered to residents until the following Monday afternoon. The facility policy titled Resident's Rights to Privacy in Communication defined promptly as delivery of mail to the resident within 24 hours of Postal Service delivery, except when there is no regularly scheduled postal delivery and pickup service. During Resident Council, two residents stated that mail was not delivered on Saturdays, and one resident reported that Saturday mail was delivered on Monday afternoon. The Business Office Assistant stated that Saturday resident mail was sorted by the business office and then held in the Business Office Manager's office until the Activities department could deliver it, explaining that the mail was not delivered on weekends because no one from the business office was present to sort it. The Business Office Manager confirmed that resident mail received on Saturday was stored in the office and sorted before being delivered on Monday. The Nursing Home Administrator acknowledged that there was no one from the business office on weekends and stated the facility was working on fixing the issues presented by the surveyor.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide Required Bathing Assistance to Dependent Residents
Penalty
Summary
Surveyors identified that the facility failed to provide necessary assistance with activities of daily living (ADLs), specifically bathing and showering, for seven out of eight residents reviewed. Multiple residents, each with significant medical conditions and varying levels of cognitive and physical impairment, did not receive showers at least once a week as required by facility policy and their individual care plans. Documentation was either missing, incomplete, or contained inconsistencies such as signatures from staff who were not present on the documented dates. In several cases, there was no evidence in the electronic medical record (EMR) or shower sheets to confirm that showers were provided, and some residents or their representatives reported not receiving showers since admission. Residents affected included individuals with diagnoses such as cerebral palsy, diabetes, depression, pressure injuries, and severe cognitive impairment. Interviews with residents and their representatives revealed that showers were not provided regularly, and in some cases, not at all. Observations by surveyors noted poor grooming, such as greasy hair, and residents expressed dissatisfaction with their hygiene care. For some residents, care plans indicated the importance of choosing their bathing method, but there was no documentation of these preferences being honored or of alternative hygiene measures being provided when showers were missed. The facility's own policies required that residents be offered showers at least weekly, either as requested or per the facility schedule, and that assistance be provided according to each resident's care plan. Despite this, there was a lack of consistent documentation and follow-through. In some instances, care plans were outdated or lacked specific instructions for staff, and there was no evidence of staff attempts to address refusals or barriers to bathing. The surveyors shared these concerns with facility leadership, but no explanations or additional documentation were provided to account for the missed showers or to demonstrate that residents' hygiene needs were being met as required.
Failure to Provide Care and Treatment According to Physician Orders and Facility Policy
Penalty
Summary
Multiple residents did not receive care and treatment in accordance with physician orders, care plans, and facility policies. Several residents with physician orders for compression stockings were repeatedly observed not wearing them, despite documentation in their care plans and treatment administration records indicating they should be applied daily. There was no documentation in the medical records to explain the absence of the stockings, and staff confirmed that the expectation was for the stockings to be applied or refusals to be documented. Residents themselves confirmed that staff had not been applying the stockings as ordered. One resident with a vascular/venous stasis ulcer did not receive a prescribed treatment on a specific date, and there was a delay in providing an ordered air mattress. The resident reported having to request the air mattress multiple times and experienced discomfort due to the delay. Documentation confirmed the air mattress was not provided until several days after the physician order, and the wound treatment was not completed as scheduled, with staff citing workload as a reason for the missed care. Another resident experienced an unwitnessed fall, and the facility failed to complete and document neurological checks as required by facility policy for unwitnessed falls. The fall packet and checklist were incomplete, and staff interviews confirmed that neuro checks should have been performed and documented but were not. The DON and other staff acknowledged the lack of documentation and completion of required post-fall assessments.
Inaccurate MDS Assessments for Behaviors and PASARR Status
Penalty
Summary
The facility did not ensure that MDS assessments accurately reflected residents’ status for four residents reviewed. For one resident with Alzheimer’s disease, obstructive sleep apnea, diabetes, and a court-appointed guardian, nursing notes documented confusion, wandering, exit-seeking, attempts to eat from other residents’ trays, picking up random items, and repeated elopement attempts beginning shortly after admission. The resident was placed on a Wanderguard, given one-on-one supervision, and had behavior and elopement care plans initiated, yet the admission MDS documented no behavioral symptoms or wandering behaviors. For three other residents, the Annual MDS assessments documented that they had not been evaluated by Level 2 PASARR even though the electronic medical record contained PASARR Level 1 and Level 2 evaluations. One resident had PASARR evaluations completed in 2022, another had a Level 1 completed on 1/3/23 and a Level 2 completed on 1/12/23, and the third had a Level 1 completed on 7/8/2010 and a Level 2 completed on 8/11/10. The MDS RN stated that social services completed that section, and the MDS RN later acknowledged that the PASARR question had been answered incorrectly for the residents reviewed. During interviews, the Social Worker stated she did not know why behaviors were not entered for the resident with wandering and elopement behaviors and suggested she may have been thinking of a different resident when completing the MDS. The MDS RN confirmed that the PASARR Level 2 items should have been coded as completed for the other residents and stated the question had been answered wrong. The NHA and DON were informed of the inaccurate MDS coding for the PASARR Level 2 evaluations.
Insulin Labeling and Dating Deficiencies
Penalty
Summary
Drugs and biologicals used in the facility were not labeled in accordance with accepted professional principles, and insulin products were found without required dating or with expired labeling in multiple medication carts. During observations of the unit 5 medication cart, surveyors found a Lispro insulin vial for R75 that was open and used but not dated when opened, a Lispro insulin pen with no label and a handwritten resident first name in black marker, and multiple open insulin pens for residents R6, R33, R3, and R75 that were not dated when opened. The nurse technician stated she thought insulin was good for 30 days once opened and confirmed the facility policy was to date insulin when opened. Surveyors also observed the unit 3 medication cart and found a Lispro insulin vial belonging to a deceased resident that was open and used but not dated when opened, along with two Lispro insulin vials for R1, one dated opened and one not dated when opened. On the unit 1 medication cart, surveyors found two Lispro insulin vials for R5, one dated and one not dated when opened. An LPN stated insulin was good for 28 days once opened, and the facility had a binder sheet titled Insulin 28-day Expiration Date Calculator. The nursing home administrator provided a medication storage policy that addressed unused medications and consultant pharmacist review for outdated or missing labels, but it did not include insulin dating or expiration dates. During the exit meeting, the DON reported they were trying to find additional information.
Failure to Maintain Resident Dignity by Not Covering Catheter Bag
Penalty
Summary
A resident with a diagnosis of neurogenic bladder and an indwelling urinary catheter was observed on multiple occasions in common areas of the facility with their catheter bag uncovered and visible to other residents, staff, and visitors. The resident's comprehensive care plan documented the presence of the indwelling catheter, and the expectation was for the catheter bag to be covered with a privacy bag at all times when in public areas. On two separate occasions, surveyors observed certified nursing assistants transporting and placing the resident in communal spaces with the catheter bag exposed and not covered by a privacy bag, making the contents visible to others. When interviewed, the resident expressed a preference for the catheter bag to be covered, questioning why others should see its contents. The unit manager confirmed that the facility's expectation is for catheter bags to always be covered in privacy bags when residents are in public areas. The deficiency was identified based on these observations and interviews, which demonstrated a failure to ensure the resident's dignity and privacy as required.
Failure to Support Resident Self-Determination and Choice
Penalty
Summary
The facility failed to honor the resident's right to self-determination by not promoting and facilitating resident choice. This deficiency was identified based on observations or findings that the facility did not adequately support or encourage residents to make their own choices regarding their care or daily life, as required by regulation.
Failure to Maintain Safe, Clean, and Homelike Resident Environment
Penalty
Summary
Surveyors identified that the facility failed to provide a safe, clean, comfortable, and homelike environment for three residents. In one case, a resident's room had a wall and heat register coated with dirt and a thick layer of dust, and the curtains hanging over the heat register were also dirty and had black spots. Another resident's room had windows with a thick white film on the inside, making them appear cloudy, and the outside of the windows was dirty. There was also a cobweb with two dead flies near the window, and the window blinds were broken and not functional. In a third instance, a resident's air conditioning and heating unit was observed to be disconnected and coming off the wall on one side, with an exposed metal pipe covered in dirt and cobwebs. The shared bathroom flooring in this room was peeling off the wall, exposing dirt and the drywall behind it. The resident reported that the air/heating unit was ancient, loud, and posed a risk of injury due to its position. The maintenance director confirmed that there was no scheduled work for this room and had not inspected it since the resident moved in. Housekeeping staff described daily and monthly deep cleaning routines, including cleaning windows and sills, but acknowledged that the inside sills and windows in one resident's room had been missed during the last deep clean. The broken blind in the same room prevented proper cleaning, and there was confusion among staff regarding responsibility for cleaning the outside windows. Facility staff acknowledged the concerns when they were brought to their attention by surveyors.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Provide Appropriate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide necessary treatment and services consistent with professional standards of practice to promote healing and prevent new pressure injuries for three of five residents reviewed. One resident developed a facility-acquired suspected deep tissue injury (DTI) that was incorrectly staged after it progressed to include slough, and the recommended change in wound treatment was not implemented in a timely manner. The care plan was not updated to reflect changes in the wound, and staff continued to use the previous treatment despite new recommendations. Additionally, multiple observations showed that the resident’s heels were not floated as required by the care plan, and staff interviews revealed a lack of awareness regarding this intervention. Another resident, who was at risk for pressure injuries and had a history of heel ulcers, was observed with heels resting directly on the bed and not being floated, contrary to the care plan. Documentation of turning and repositioning was incomplete, with several shifts indicating that the resident was not repositioned as required. Staff interviews further indicated uncertainty about the interventions in place for pressure injury prevention. A third resident did not consistently receive pressure injury treatments as ordered during the review period. The facility’s own policy required regular assessment, accurate staging, and timely updates to care plans and interventions based on wound changes, but these standards were not met. Documentation and communication lapses, incorrect wound staging, and failure to implement or update care interventions contributed to the deficiencies identified by surveyors.
Failure to Maintain or Improve Resident Range of Motion
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide appropriate care to maintain and/or improve a resident's range of motion (ROM), limited ROM, and/or mobility. The facility did not ensure that care and services were provided to prevent a decline in the resident's ROM or mobility, except in cases where such decline was due to a documented medical reason. This resulted in the resident not receiving necessary interventions to maintain or improve their physical function.
Failure to Implement and Maintain Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that three residents received adequate supervision and assistance devices to prevent accidents, as required by their individualized care plans and the facility's fall prevention policy. For one resident with hemiplegia and a history of falls, staff transferred the resident to the toilet and left them alone in the bathroom, resulting in an unwitnessed fall. Multiple staff interviews confirmed that the resident should not have been left unattended due to their need for assistance with transfers, and the care plan was not updated with new interventions following the incident. Documentation and interviews revealed that staff were aware of the resident's tendency to self-transfer, yet no additional measures were implemented to address this ongoing risk. For a second resident with severe cognitive impairment and high fall risk, surveyor observations repeatedly found that required fall interventions, such as a fall mat beside the bed and the call light within reach, were not consistently in place. On several occasions, the fall mat was folded against the wall or missing, and the call light was either out of reach or behind the resident's pillow. Nursing staff did not ensure these interventions were implemented, even after providing care in the resident's room. The resident's care plan and care card specified these interventions, but they were not reliably followed during the survey period. A third resident, also with severe cognitive impairment and high fall risk, was observed multiple times without key fall prevention interventions in place. These included the absence of a fall mat, body pillows, Dycem in the wheelchair, and the call light within reach, despite these being listed in the resident's care plan and care card. The resident's bed was not consistently kept in the low position as required, and personal items were not always within reach. Staff interviews indicated reliance on care cards for intervention information, but surveyor observations demonstrated that interventions were not consistently implemented for this resident.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
A resident who required pain management services did not receive safe and appropriate pain management. The facility failed to provide the necessary care to address the resident's pain needs as required.
Failure to Follow Posted Menus and Resident Food Preferences
Penalty
Summary
The facility failed to ensure that menus were followed and served as posted for two residents, resulting in meals that did not match the planned or posted menus and resident preferences. For one resident, multiple meal trays did not correspond with the posted or planned menus, with specific items such as cold cereal and Cream of Wheat missing from breakfast trays, and mixed vegetables substituted for listed menu items like Brussels sprouts and butternut squash at lunch. The resident reported that the facility did not inform them of menu changes, and observations confirmed discrepancies between the posted menus, planned menus, and what was actually served. Another resident, who was cognitively intact and had documented food dislikes, received meals that included items from their dislike list, such as white bread, despite these preferences being clearly noted on the meal tray ticket. This resident also did not receive all items listed on their meal ticket, such as yogurt, and their trays did not match the posted or planned menus on several occasions. Interviews with staff revealed a lack of clarity and breakdown in the process for updating and communicating resident food preferences, with the interim Dietary Manager stating that no new preference slips had been received and the front desk receptionist unaware of receiving any slips from nursing. The facility's policy required that menus be planned in advance, served as written unless substitutions were necessary, and posted in relevant areas. However, observations and interviews demonstrated that these procedures were not consistently followed, leading to residents receiving meals that did not align with their dietary orders, posted menus, or personal preferences. The deficiency was identified through direct observation, resident and staff interviews, and review of facility records and policies.
Conflicting Code Status Documentation
Penalty
Summary
The facility did not ensure that advance directives were documented accurately for one resident whose code status was unclear in the medical record. The resident was admitted with diagnoses including metabolic encephalopathy, diabetes, COPD, dementia, depression, anxiety, and coronary artery disease. The quarterly MDS documented the resident as cognitively intact with a BIMS score of 13, and the POA was activated. The facility policy required advance directives to be identified, clarified, reviewed, documented in the medical record, and communicated to staff. The resident’s record contained conflicting code status documentation. A Resident Code Status form documented the POA verbally elected full code, while State Emergency Care DNR forms documented the POA verbally elected DNR, and the physician signed the DNR form. The EMR dashboard listed the resident as DNR with a physician order, but progress notes from the physician and NP documented the resident as full code from admission, and a later note by SWA-I documented the resident chose CPR as code status. When the surveyor reviewed the physical chart, the first code status document seen was the full code form, with the DNR form filed further down among other papers, and the surveyor did not observe it in the chart at first. The NHA agreed the documentation was confusing and was not sure what the resident’s wishes were.
Failure to Thoroughly Investigate Allegation of Rough Handling by CNA
Penalty
Summary
The facility did not thoroughly investigate an allegation that a CNA was rough with a resident during care and transfer. The resident was admitted with cerebral palsy, was cognitively intact per the MDS, used a wheelchair, and was dependent for transfers. The resident reported that the CNA was "really, really rough" during a transfer and that the resident's feet got caught on the wheelchair footrests while the CNA yanked the chair back hard, causing pain. The resident also stated that the CNA had been rough on other occasions and was bossy and intimidating. The resident told three different facility staff members about the concern: a CNA, an LPN, and an OT. The CNA recalled that the resident said the CNA was rough during the transfer and that the resident yelled about the feet being caught. The OT stated the resident reported that the CNA pulled too hard during a transfer and hurt the resident, and the resident asked for help writing a grievance. The LPN stated the resident told her that the CNA was rough with cares and that the resident did not want that CNA as an aide. The LPN said she told the UM, but there was no evidence that the allegation was reported to the NHA at the time. Record review showed no grievance logged and no incident or investigation documented in the grievance log or Facility Reported Incident folders for the allegation. The only documentation provided was an undated note signed by the UM describing the resident's complaint as a transfer preference issue and stating that the resident had chronic discomfort with transfers due to cerebral palsy and leg pain. The note also stated that the resident agreed to speak with the CNA and that the CNA apologized. The NHA stated that the expectation was to follow the abuse policy and report the allegation, and acknowledged there was no other documentation of the event aside from the UM's note.
PASARR Screening Not Completed Accurately for Two Residents
Penalty
Summary
The facility did not accurately screen two residents for mental disorders on PASARR Level I review, and neither resident had a completed PASARR Level II in the EMR. One resident was admitted with a diagnosis of bipolar disorder, but the PASARR Level I screen completed on 5/21/24 documented that the resident was not suspected of having a serious mental illness or developmental disability. Surveyor review noted that bipolar disorder is a serious mental illness, and the resident did not have a PASARR Level II on file. A second resident was admitted with diagnoses of schizoaffective disorder and bipolar disorder. The PASARR Level I screen completed on 3/6/25 documented the resident as having a serious mental illness and was signed by the social worker, but there was no PASARR Level II in the EMR. During interview, the social worker stated she completed PASARRs and indicated that not everyone with schizophrenia or bipolar disorder requires a Level II, and that symptoms such as self-harm would be needed to qualify. The NHA and DON were notified of the concerns and acknowledged them.
Failure to Maintain Ordered Oxygen Therapy and Humidification
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident receiving oxygen therapy. R34 was admitted with diagnoses including Myasthenia Gravis, protein-calorie malnutrition, native coronary artery disease, and depression, and the MDS documented that R34 was cognitively intact and receiving O2 therapy. Physician orders directed continuous O2 at 2 liters via nasal cannula to keep saturations above 90%, and the care plan included humidified O2 at 2 liters continuous and monitoring for signs and symptoms of respiratory distress. Surveyors observed that R34’s O2 tank was set at 1.5 liters instead of the ordered 2 liters, and the humidifier bottle was almost empty and not dated. On a later observation, the humidifier bottle was completely empty while the O2 tank was running, even though the TAR documented that a new humidifier bottle had been signed out and placed on the tank. R34 was also documented as complaining of sore nasal passages, and later was observed with the nasal cannula not positioned in the nose while the O2 remained set at 1.5 liters. The DON and NHA were informed of the concern, and the record included a note that the resident reported sore nasal passages and that humidifier change and other measures had not relieved the discomfort.
Failure to Reassess Need and Consent for Enabler Bars
Penalty
Summary
The facility failed to assess the risk for possible entrapment, the continued need, review the risks and benefits, and obtain consent on a quarterly basis for three residents who had enabler bars in place. The report states that the facility’s policy required a person-centered approach before using bed rails or enabler bars, including attempting alternatives, obtaining informed consent, and completing ongoing monitoring and reassessment not less than quarterly. R24 was admitted with diagnoses including epileptic seizures, encephalopathy, dysphagia, and gastrostomy status, and had a legal guardian. R24’s MDS documented severely impaired daily decision-making, dependence for dressing, bathing, mobility, and transfers, bilateral upper and lower extremity ROM impairment, and use of a feeding tube. The care plan identified bilateral enabler bars for self-positioning, and the record showed consent was obtained and a physician order was entered. However, the surveyor found no documentation that ongoing monitoring or quarterly reassessment of the need for the enabler bars, including safety and risks and benefits, had been completed after the initial evaluation. R27 was admitted with cerebral palsy and paraplegia and was his own person. R27’s MDS documented a BIMS score of 13, indicating cognitive intactness, along with ROM impairment, dependence for mobility and transfers, and substantial to maximum assistance for dressing and showers. The care plan identified bilateral enabler bars for self-positioning, and consent and a physician order were documented. The surveyor found no documentation that ongoing monitoring or quarterly reassessment of the need for the enabler bars, including safety and risks and benefits, had been completed after the initial evaluation. R81 was admitted with dementia and had an activated health care power of attorney. R81’s MDS documented a BIMS score of 5, severely impaired daily decision-making, no ROM impairment, and dependence for dressing, bathing, mobility, and transfers. The care plan identified bilateral enabler bars for self-positioning, and consent and a physician order were documented. The surveyor found no documentation that ongoing monitoring and supervision, including quarterly reassessment of the need for the enabler bars, had been completed after the initial evaluation.
Empty Hospice Binder and Missing Hospice Communication
Penalty
Summary
The facility did not ensure hospice collaboration and communication processes were established to maintain continuity of care for a resident receiving hospice services. The resident had diagnoses including right-sided stroke, epilepsy, depression, and dementia, and the quarterly MDS documented a BIMS score of 12, indicating moderate cognitive impairment. The resident was also on hospice for malignant neoplasm of the left bronchus or lung, with a hospice physician note certifying terminal illness with a life expectancy of 6 months or less if the illness ran its course. During observation at the nurses’ station, surveyors found hospice binders for residents on hospice, but no hospice binder was available for this resident. An LPN could not locate the binder, and the unit manager also did not locate it. When surveyors later observed the unit manager’s office space, a binder with the resident’s name and the word hospice was found near the desk. The unit manager stated the binder was empty and was waiting for hospice to fax information, and also stated hospice emailed information weekly or bi-weekly because hospice could not directly upload to the facility’s EMR. The unit manager said orders were verified weekly with hospice and that staff used phone numbers for hospice and facility staff if information was needed. Surveyors reviewed hospice emails and found that hospice had sent information to the unit manager, including a wound care order for a toe wound directing cleansing with wound cleanser and covering with a bandage to prevent rubbing. However, that hospice order was not entered into the facility’s physician orders, and the facility had no documentation in the resident’s EMR regarding the wound care treatment ordered by hospice. Surveyors also noted the resident had an active facility order for a wheelchair cushion, but facility staff documented that the resident did not have a cushion, and the resident was observed in a wheelchair without one. The hospice documentation reviewed by surveyors did not document the wheelchair cushion. The empty hospice binder did not contain hospice visit documentation, the hospice plan of care, hospice responsibilities and services being provided, or daily hospice nursing visit notes.
Failure to Use Required PPE During Pressure Ulcer Dressing Change
Penalty
Summary
Staff failed to don the appropriate personal protective equipment (PPE) during a pressure ulcer dressing change for one resident who was under enhanced barrier precautions (EBP). Specifically, during an observed dressing change to a stage 4 pressure ulcer, neither the LPN nor the CNA wore a gown, despite facility policy and signage indicating that both gloves and gowns were required for high-contact care activities under EBP. The PPE bin and signage were present outside the resident's room, clearly stating the need for gown and glove use, but these were not followed during the procedure. The resident involved had a history of paraplegia, a stage 4 pressure ulcer, above the knee amputation, and heart failure, and was cognitively intact according to the most recent assessment. Physician orders required regular dressing changes to the ischium wound. The Director of Nursing/Infection Preventionist confirmed that the expectation was for staff to wear gowns during dressing changes for residents on EBP, which was not adhered to in this instance.
Failure to Maintain Qualified Dietary Manager for Food and Nutrition Services
Penalty
Summary
The facility failed to ensure that a qualified Dietary Manager (DM) was designated to act as the director of food and nutrition services when the DM position became vacant. According to the job description, the DM is responsible for assisting the Dietitian in planning, organizing, developing, and directing the overall operation of the Food Services Department in accordance with regulatory standards. The former DM ended employment on 04/02/25, and there was no replacement or acting DM for approximately one month. Multiple staff interviews confirmed that there was no full-time DM overseeing the kitchen during this period. Dietary aides and cooks reported the absence of a DM, and the Administrator acknowledged awareness of the vacancy, stating that a contracted company only recently took over management of the kitchen. This lapse had the potential to affect all 89 residents in the facility, as there was no qualified individual overseeing food and nutrition services during the vacancy.
Failure to Follow Menus and Notify Residents of Food Substitutions
Penalty
Summary
The facility failed to ensure that menus and menu extensions were followed as required, including providing appropriate, approved food substitutions and adhering to recipes for all 89 residents. During a tray line observation, kitchen staff served mixed fruit instead of the bread pudding listed on the menu, as the bread pudding had not been prepared the night before due to time constraints. Staff responsible for preparing the bread pudding confirmed it was not made and indicated that residents were not notified in advance of the substitution. The Dietary Manager stated that residents should be notified of any menu changes in advance, and the Administrator confirmed that residents needed to be alerted if there were changes to the menu. Review of facility policy and the weekly menu confirmed that the planned meal was not served as specified.
Failure to Maintain Kitchen Sanitation and Proper Food Storage
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary condition, as evidenced by improper labeling, dating, and storage of food items. During an inspection, surveyors observed a container of rice labeled with an expiration date, but a container of sugar was found without any label or date, and a plastic cup was in direct contact with the sugar. In the walk-in freezer, there was a partial sheet of ice, iced condensation on the ceiling, and frost on several boxes, with no temperature logs available for the month. The walk-in refrigerator contained multiple food items, such as fruit cocktail, yogurt, parmesan cheese, slaw, breaded chicken breasts, and an unknown product, many of which lacked open or use-by dates or labels. Seven bags of an unknown yellow product were also found without labels or dates. Behind the stove, disposable plates with slices of pie were left for approximately one month. Employee jackets were stored on racks with clean kitchenware, and the dish machine failed to reach the required rinse temperature, with no temperature logs maintained. The Dietary Manager confirmed several of these issues, acknowledging the lack of proper labeling, dating, and storage as potential infection control problems. The Dietary Manager was also unaware of a cleaning schedule for the kitchen. The Administrator, who had been in the position for three weeks, was aware that the kitchen required attention regarding sanitation. These findings indicate multiple failures to follow facility policies and FDA Food Code guidelines for food storage and kitchen sanitation.
Failure to Assess Residents for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to assess two residents for their ability to safely self-administer medications that were observed at their bedsides. One resident, admitted with a left ischium wound and determined to be cognitively intact, had a tube of Santyl ointment at the bedside and reported applying it as needed. Review of the resident's medical record showed no evidence of an assessment for safe self-administration of the medication. An LPN confirmed the medication was left at the bedside and was unaware of any assessment having been completed. Another resident, also cognitively intact and admitted with shortness of breath, was found with an Albuterol inhaler at the bedside. The resident stated she had been assessed for safe use of the inhaler, but review of the medical record did not show any such assessment, nor was there a physician order for the inhaler. The ADON confirmed that no safety assessment had been completed for this resident regarding self-administration of the inhaler, despite the resident having access to it for the past month.
Failure to Document and Communicate Dialysis Care
Penalty
Summary
The facility failed to ensure proper documentation and communication regarding dialysis care for a resident dependent on hemodialysis. Review of the resident's records showed that pre- and post-dialysis assessments, including vital signs and weights, were not consistently documented as required by facility policy and physician orders. The care plan for the resident did not address communication between the dialysis center and the facility, and there was a lack of completed dialysis communication forms in the resident's binder since October of the previous year. Interviews with nursing staff revealed confusion and inconsistency regarding who was responsible for preparing and sending the dialysis communication forms. Some staff members stated they completed the forms and sent them with the resident, while others denied involvement or were unsure of the process. The resident reported that vital signs were not always checked before and after dialysis and that the dialysis binder had not been updated or used by staff for several months. Further interviews with the Director of Nursing and Assistant Director of Nursing confirmed that the expectation was for staff to use the communication forms and document pre- and post-dialysis assessments. However, they acknowledged that no completed forms had been located for the resident since October, and that staff often relied on the dialysis center to monitor vital signs and weights. This lack of documentation and communication had the potential to affect the health of residents receiving dialysis.
Failure to Ensure Timely Availability and Administration of Medications
Penalty
Summary
The facility failed to ensure that medications were available and administered as ordered for three of four residents reviewed for medication availability. Multiple instances were documented where residents did not receive their prescribed medications due to unavailability, delays in pharmacy delivery, or issues with reordering and insurance authorization. For example, one resident with chronic conditions such as COPD, heart failure, and depression missed several doses of critical medications including blood thinners, antidepressants, antibiotics, steroids, and inhalers. Documentation in the electronic medical record and medication administration records showed repeated notations of medications being unavailable, on order, or pending delivery, with some medications not being delivered for multiple days. The resident confirmed missing important medications and staff interviews revealed challenges with the pharmacy's delivery system, insurance limitations, and the facility's reordering process. Another resident with mood disorder and depression did not receive a prescribed antidepressant because it was not available at the time of administration. The LPN responsible for medication administration noted the medication was on order and not delivered, and the pharmacy confirmed that while the medication was filled, it was not yet sent out. The facility's contingency supply was supposed to cover such gaps, but staff reported that it did not contain many needed medications. The DON and ADON acknowledged ongoing issues with medication availability, difficulties with the pharmacy's ordering system, and the need for frequent follow-up with the pharmacy to track and obtain medications. A third resident with hypercholesterolemia experienced multiple missed doses of a cholesterol-lowering medication due to unavailability and delays in pharmacy delivery. The MAR and clinical documentation indicated several days where the medication was not administered because it was either unavailable or waiting on delivery. The pharmacy records showed that insurance limitations sometimes restricted the amount dispensed, resulting in the need for more frequent reorders. Staff interviews confirmed that the resident often ran out of medication and experienced delays, and the contingency supply did not include the needed medication. The DON provided evidence of some training on medication availability but acknowledged that documentation was not specific enough to address the delays experienced by this resident.
Failure to Ensure Resident Free from Significant Medication Errors Due to Unavailable Medications
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as required by policy and physician orders. The resident, who had a history of chronic obstructive pulmonary disease (COPD), pulmonary embolism, and asthma, experienced multiple missed doses of critical medications, including a blood thinner (rivaroxaban), inhalers (umeclidinium bromide), roflumilast, and Dupixent injections. Documentation in the electronic medical record (EMR) and medication administration records (MARs) showed repeated instances where these medications were not available or not administered as ordered, with nursing staff noting the unavailability and pending pharmacy deliveries over several days. Interviews with staff and pharmacy personnel revealed that medication reordering processes were inconsistent, with reliance on fax or phone requests and a contingency supply (Pyxis) that did not contain the needed medications. The pharmacy indicated that some medications were sent according to insurance limitations, but there were lapses in communication and follow-through, resulting in missed doses. Nursing staff reported delays in medication delivery, even for STAT orders, and acknowledged that medications were sometimes not reordered in a timely manner or did not arrive as expected. The resident reported missing important medications for COPD and blood thinners, though he did not experience respiratory concerns or blood clots during the period in question. The physician and pharmacy both considered the missed doses of blood thinners and COPD medications to be significant medication errors. Facility leadership, including the DON and ADON, were not fully aware of the extent or frequency of the missed medications until after the fact, and expected staff to follow procedures for obtaining and administering critical medications.
Failure to Document Medication and Treatment Administration
Penalty
Summary
The facility failed to ensure proper documentation of care and services for four residents, leading to a deficiency in maintaining accurate medical records. The facility's policy requires that each resident's medical record accurately reflects their experiences and includes timely documentation. However, the review revealed that medications and treatments were not documented as administered per physician orders for residents with various medical conditions, including chronic respiratory failure, diabetes mellitus, hypertension, fractures, and quadriplegia. For one resident, multiple medications and treatments, such as beta blockers, hypertension medication, tracheostomy care, and heel checks, were not documented as administered. Another resident with a fractured tibia and diabetes mellitus had missing documentation for medications like insulin and gabapentin, as well as treatments for knee care and wound care. Similarly, a resident with a shoulder fracture and schizophrenia had missing documentation for treatments to the buttocks and ileostomy care. Lastly, a resident with quadriplegia and pressure ulcers had missing documentation for wound care and ostomy bag maintenance. The Director of Nursing confirmed the missing documentation during an interview and stated that the expectation is for staff to document when medications and treatments are administered. If unable to perform the tasks, staff are expected to document the reason. The lack of documentation does not ensure that treatments or medications were completed, potentially causing delays in care.
Failure to Resolve Resident Grievances Promptly
Penalty
Summary
The facility failed to ensure prompt resolution of grievances for five residents, as required by their grievance policy. On multiple occasions, residents R11, R15, and R16 expressed concerns during interviews, but there was no documentation of these grievances being investigated or resolved. The facility's grievance log did not contain any entries for these residents, indicating a lack of follow-through on the grievance process. This oversight was confirmed by the social worker and acknowledged by the nursing home administrator, director of nursing, and director of operations. Resident R7 also had multiple complaints documented in progress notes, but there was no evidence that these concerns were investigated or addressed. The director of nursing expected that any concerns raised by residents would be investigated by the nursing staff and reported to her, but this did not occur in R7's case. The nursing home administrator admitted to having verbal communication with R7 about the concerns but did not complete a formal grievance process. Additionally, a grievance filed by R3's representative was inadequately handled. The grievance log indicated a resolution, but there was no detailed investigation or documentation of the grievance's confirmation or the date a written decision was provided. The facility's leadership acknowledged the lack of a thorough investigation and documentation, further highlighting the deficiency in handling grievances according to their policy.
Incomplete Investigations into Abuse Allegations
Penalty
Summary
The facility failed to ensure a thorough investigation into allegations of abuse involving two separate incidents. In the first case, a visitor alleged that a housekeeper engaged in sexually inappropriate behavior. Although the housekeeper was suspended and the police were notified, the facility's investigation was incomplete. Only 7 out of 73 residents were interviewed, and there was no documentation summarizing the investigation's results. The facility did not determine if other residents had similar experiences with the housekeeper, who had been employed since 2022. In the second incident, a resident, identified as R10, reported rough care by a CNA to a registered nurse. The allegation was not immediately reported to a supervisor, and the investigation was insufficient. The facility's documentation lacked statements from the registered nurse and other staff members who worked the same shift. Additionally, the resident statements collected were from individuals residing on different units, not those under the care of the accused CNA. These deficiencies had the potential to affect all 73 residents in the facility. The facility's policies required immediate and thorough investigations of abuse allegations, including interviewing all involved parties and ensuring resident protection. However, the facility did not adhere to these policies, resulting in incomplete investigations and a lack of documentation to support the actions taken.
Deficiencies in Pharmaceutical Services and Medication Management
Penalty
Summary
The facility failed to provide accurate pharmaceutical services, affecting several residents. One resident, R3, was readmitted with a diagnosis of C. Diff and had a medication order for Bisacodyl suppository transcribed incorrectly. Instead of being administered as needed, it was scheduled every 24 hours, leading to episodes of loose stools. The error was identified by the resident's daughter, who is the POA, and was brought to the attention of the Director of Nursing. The order was eventually corrected, but not before the resident experienced adverse effects. Another resident, R7, did not receive the ordered Coban wraps for wound care as prescribed. The facility lacked the necessary supplies, leading to the use of alternative materials like Ace wraps, which were not in accordance with the physician's orders. This resulted in the resident experiencing pain and discomfort, and at one point, the resident had to order their own supplies. The facility's supply chain issues and lack of proper documentation for order requests contributed to this deficiency. Additionally, the facility failed to ensure the proper labeling and security of medical equipment and medications. R17's glucose monitor was not labeled, leading to confusion about its ownership. Furthermore, medications were left unattended on top of the medication cart, posing a risk to residents and staff. These lapses in protocol highlight significant deficiencies in the facility's pharmaceutical services and medication management practices.
Failure to Notify POA of Therapy Discontinuation
Penalty
Summary
The facility failed to notify a resident's Power of Attorney (POA) when there was a need to alter treatment, specifically when occupational therapy (OT) and physical therapy (PT) were discontinued. The resident, who had been diagnosed with congestive heart failure, diabetes mellitus, and end-stage renal disease, had their POA activated in July 2023. Despite the facility's policy requiring notification of changes to the resident's representative, the POA was not informed when OT was discontinued on June 26, 2024, and PT on July 2, 2024. The surveyor reviewed the resident's medical records and found no documentation indicating that the POA had been notified of these changes. During an interview with the Director of Rehab/Certified Occupational Therapy Assistant (DOR/COTA), it was revealed that the resident had been on and off therapy, with OT and speech therapy being resumed after a hospitalization and readmission. The DOR/COTA acknowledged that while therapists or the Director of Therapy are supposed to notify the POA, there was no documentation to confirm this had occurred for the discontinuation of OT and PT. The discharge summaries provided did not include any notes about notifying the POA, and the occupational therapist responsible for the discharge was no longer employed at the facility. The Nursing Home Administrator was informed of these findings, but no explanation was provided for the lack of notification to the POA.
Failure to Immediately Report Allegation of Abuse
Penalty
Summary
The facility failed to immediately report an allegation of abuse involving two residents, R10 and R8, as required by their policy. On 5/16/24, a CNA reported to an RN that R10 alleged the CNA was rough during care. The RN dismissed the allegation as R10's behavior and did not report it to a supervisor or the Nursing Home Administrator (NHA) immediately. The allegation was only brought to the attention of the NHA on 5/17/24 by Social Services, which was a violation of the facility's policy that mandates immediate reporting of such allegations. R10, who was cognitively intact and dependent on staff for most activities of daily living, reported the rough handling. The facility's policy requires that any suspicion or report of abuse be investigated immediately and reported to the appropriate authorities within two hours if it involves abuse or results in bodily injury. The delay in reporting and addressing the allegation of abuse indicates a failure to adhere to these protocols, potentially compromising the safety and well-being of the residents involved.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to provide a complete discharge summary for a resident, identified as R10, who was discharged to an adult living home. The discharge summary was incomplete, lacking essential information such as a list of medications, a final summary of the resident's status, and a post-discharge plan of care. This deficiency was identified during a surveyor's review of R10's records, which revealed that there was no discharge order or documentation of the steps taken to coordinate a successful discharge. R10 had multiple medical conditions, including paraplegia, morbid obesity, chronic respiratory failure, and depression, among others. The resident's care plan included various focused problems such as ADL deficits, potential for dehydration, risk of falls, and mood impairment. Despite these complex needs, the discharge instructions were incomplete, missing critical sections like respiratory and skin evaluations, diet recommendations, and a reconciled medication list. Interviews with facility staff, including social workers and nursing staff, indicated a lack of a designated person responsible for ensuring the completion of discharge instructions. The surveyor noted that the discharge instructions contained multiple uncompleted sections, and there was no documentation in the electronic medical record of R10's discharge. The facility's failure to provide a comprehensive discharge summary and coordinate care effectively was highlighted as a significant deficiency.
Deficiencies in Resident Care and Treatment
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards for two residents, R3 and R7. For R3, who has diagnoses including congestive heart failure, diabetes mellitus, and end-stage renal disease, the facility staff did not apply tubi grips to the resident's bilateral lower extremities as ordered by the physician. Despite the care plan and physician orders specifying the use of tubi grips for edema management, observations on two consecutive days revealed that the staff did not apply them, and the treatment administration record inaccurately indicated that the tubi grips had been applied. For R7, who was admitted for intravenous antibiotics due to a wound infection, the facility failed to comprehensively assess non-pressure wounds for seven days and did not have proper orders for the care of the resident's PICC line. The facility staff used ace bandages instead of Coban wraps as ordered by the physician, and there were no documented orders for flushing the PICC line with heparin or changing the PICC dressing. The facility also experienced a shortage of Coban, leading to the use of alternative materials, and the resident had to order their own supplies for wound care. The deficiencies in care for both residents highlight a lack of adherence to physician orders and professional standards of practice. The facility's failure to ensure the availability of necessary medical supplies and to accurately document and follow treatment protocols contributed to the inadequate care provided to the residents.
Inadequate Supervision During Resident Transfer
Penalty
Summary
The facility failed to ensure adequate assistance and supervision during the transfer of a resident, identified as R5, using a Hoyer lift. R5, who has a primary medical condition of Traumatic Spinal Cord Dysfunction and functional limitations in both upper and lower extremities, requires the assistance of two staff members for transfers. During an observed transfer, RN-L, who was assisting Hospice RN-CC with the transfer, left R5 suspended in the air to address a ringing phone in the hallway. This action left R5 in a potentially unsafe situation as the resident was suspended in the sling without adequate supervision. Further complications arose when RN-L and Hospice RN-CC attempted to lower R5 into the wheelchair, causing the front wheels of the wheelchair to lift off the ground. RN-L expressed concern about the potential for R5 to fall and left the room to seek additional help, leaving R5 suspended for approximately six minutes. During this time, Hospice RN-CC noted that R5 had been using an incorrectly sized sling, which was too small, and had brought an XL sling for the transfer. The deficiency was reported to the Nursing Home Administrator (NHA) by the surveyor.
Inappropriate Meal Served to Resident on Renal Diet
Penalty
Summary
The facility failed to provide a resident, identified as R3, with the appropriate food items for a renal/LCS (low concentrated sweets) diet as prescribed by the physician. R3, who has chronic kidney disease with heart failure and end-stage renal disease, was observed receiving a meal that included french fries and a tomato slice, both of which are high in potassium and not suitable for a renal diet. The physician's orders for R3 specified a Renal, LCS diet with regular texture and thin fluid consistency, yet the meal served did not comply with these dietary restrictions. Interviews with the Registered Dietitian (RD) and Food Service Director (FSD) revealed a lack of proper communication and education regarding the dietary needs of residents on a renal diet. The RD acknowledged the need for further education in the kitchen, especially with new cooks, and the FSD mentioned a book in the kitchen listing restricted foods, which was not effectively utilized. The surveyor's findings were communicated to the Nursing Home Administrator, but no explanation was provided for the dietary oversight.
Failure to Provide Prescribed Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care for a resident with a tracheostomy, as they did not change the resident's HME (heat moisture exchanger) trach valve daily according to physician orders. The resident, who was admitted with diagnoses including chronic respiratory failure, morbid obesity, and paralysis of vocal cords and larynx, had a physician order dated 5/17/24 for the daily change of the HME trach valve. Despite this order, the surveyor observed that the licensed staff were checking and initialing the medication administration record (MAR) indicating the HME trach valve was being changed daily, but the actual change was not performed. During the survey, it was revealed that the LPN responsible for the resident's care was unaware of what an HME trach valve was and could not locate it in the facility. The Medical Records/Central Supply staff also confirmed that the HME trach valves had never been ordered or received in the building. The Director of Nursing acknowledged that the necessary supplies were not ordered and that there was a lack of communication among the nursing staff regarding the HME trach valve. This oversight resulted in the resident not receiving the prescribed respiratory care as per the physician's orders.
Resident Received Unnecessary Multiple Antibiotics for UTI
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary antibiotics, leading to the administration of multiple antibiotics simultaneously. The resident, who was cognitively intact and dependent on staff for personal hygiene and transfers, began experiencing symptoms of a urinary tract infection (UTI) and was subsequently prescribed multiple antibiotics by different medical teams. Despite the facility's policy on antibiotic stewardship, the resident received Rocephin, Bactrim, Macrobid, and Fosfomycin over a short period, without meeting the McGeer's criteria for initiating antibiotic treatment. The resident's symptoms began with burning, itching, and pain during urination, prompting a urinalysis and culture test. However, the resident was prescribed Rocephin and Bactrim before the culture results were available, and later Macrobid was added based on the culture results. The facility's documentation indicated that the resident did not meet the McGeer's criteria for starting antibiotics, yet the resident was on three different antibiotics simultaneously. The facility's staff, including the Director of Nursing and Unit Manager, acknowledged the involvement of multiple medical teams in prescribing the antibiotics, which contributed to the overlapping treatments. Interviews with facility staff revealed that it was not standard practice to administer multiple antibiotics for a UTI, and concerns were raised about the potential harm of such practices. The facility's Director of Nursing and other staff members recognized the issue but noted that the resident insisted on receiving the antibiotics. The facility's failure to adhere to its antibiotic stewardship program and the lack of communication between medical teams led to the unnecessary administration of multiple antibiotics, which was not in line with the facility's infection control protocols.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with the observed rate reaching 20%. This deficiency was identified through multiple instances of improper medication administration. One resident received crushed Depakote, a delayed-release medication that should not be crushed, along with other scheduled medications at a time significantly later than prescribed. Another resident received their scheduled medications, Gabapentin and Tramadol, outside the prescribed time frame without proper documentation or notification to the physician. Additionally, a third resident did not receive the correct medication as per physician orders. The resident was supposed to receive Complex B-100 extended release with biotin and folic acid but was instead given a different B complex with B12. Furthermore, the resident received an incorrect dosage of Carvedilol due to a failure to update the medication list following a hospital discharge summary. These errors were not identified or corrected until brought to the facility's attention by the surveyor. The facility's policy requires medications to be administered within a specific time frame and mandates physician notification if this is not possible. However, these protocols were not followed, as evidenced by the lack of documentation and physician notification for the medication errors observed. The Director of Nursing and Unit Manager acknowledged the discrepancies and the failure to adhere to the established medication administration schedule, which contributed to the high medication error rate.
Medication Error in Carvedilol Dosage for Resident
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically involving the administration of Carvedilol. The resident, who was readmitted to the facility, had a discharge order from the hospital to receive Carvedilol 25 mg every 12 hours. However, the facility continued administering the previous dosage of 12.5 mg, resulting in the resident receiving the incorrect dosage 69 times over a period from August to September. The deficiency occurred due to a failure in the facility's process for reviewing and transcribing medication orders upon the resident's readmission. The Unit Manager and floor nurse were responsible for reviewing hospital records and verifying medication orders, but the change in Carvedilol dosage was not identified or corrected. The Director of Nursing later acknowledged the error and noted that the medication error variance was documented only after the surveyor's inquiry. The resident involved had a medical history that included bilateral lower extremity edema, hypertension, and congestive heart failure. At the time of readmission, the resident was stable and alert, with no respiratory distress. Despite the hospital's clear discharge instructions, the facility's oversight led to the continued administration of an incorrect medication dosage, which was not addressed until the surveyor's investigation.
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 527 citations issued within 25 miles in the last 12 months — including the 21 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 Burlington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wi Veterans Home-boland Hall | 9.5 mi | ★★★★★ | 22 | 4 |
| Golden Years Of Lake Geneva | 10.3 mi | ★★★★★ | 0 | 0 |
| Geneva Lake Manor | 10.3 mi | ★★★★★ | 9 | 1 |
| Oak Ridge Care Center | 10.4 mi | ★★★★★ | 3 | 1 |
| East Troy Manor | 11.4 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.