Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Eastview Health And Rehabilitation Center during CMS and state inspections, most recent first.
Kitchen Sanitation and Rodent Entry Concerns: Surveyors observed debris, crumbs, and rodent traps underneath kitchen equipment, along with unclean cooler and counter areas. They also found holes in the outer kitchen wall and near the employee entrance that could allow rodent entry. The DON/DM confirmed staff had seen rats, a rat had been caught in the kitchen about a month earlier, and bread and cake had been gnawed.
Ineffective Pest Control Program: Surveyors found multiple rodent traps in the kitchen and observed holes in walls and exterior openings near the building. Staff gave conflicting accounts about rats versus mice, who managed the traps, and when leadership learned of the problem. The dietary manager reported a rat had been caught weeks earlier, while the NHA said the concern was first known that week. Pest control records were incomplete, and staff education on pest control was not fully completed.
Incomplete bowel, bladder, nutrition, and repositioning care with delayed constipation response. A resident with a hip fracture, dislocated shoulder, severe malnutrition, immobility, pain medication use, and bowel/bladder incontinence had missing bowel and bladder tracking, incomplete intake documentation, and incomplete turning records. Staff did not consistently document bowel monitoring or provide timely bowel treatment, and the resident was later sent to the hospital with severe constipation, stercoral colitis, urinary retention, severe bilateral hydronephrosis, and acute kidney injury.
A resident with spastic quadriplegic cerebral palsy, contractures, impaired ROM, and total ADL dependence was supposed to be transferred with a full sling lift. While the resident was sliding in a wheelchair, a CNA and a BOM tried to reposition the resident, then used a fireman boost by lifting under both arms and pulling on the resident’s pants/briefs when the sling could not be placed correctly. A popping sound was heard in the resident’s arm, and an x-ray later showed a fracture of the surgical neck of the right humerus. The record showed no documentation supporting the fireman method, and the BOM was not a CNA.
Surveyors found multiple food service deficiencies, including a cook preparing food without a hair restraint and another without a beard net, along with unlabeled and undated items in the cooler and expired tortillas in the freezer. Surveyors also observed excessive frost and ice buildup in the freezer, including ice directly above food items. The DM acknowledged the concerns and stated the freezer issue had been ongoing.
Unqualified staff assisted with resident transfers and repositioning involving mechanical lifts. An Activity Aide with no CNA training helped operate a sit-to-stand lift for a resident who required lift assistance, and a BOM with no CNA training helped reposition another resident with severe contractures using a fireman method after staff could not safely position the Hoyer sling. During that repositioning, staff heard a popping sound in the resident’s arm, and an x-ray later showed a humerus fracture.
Residents were not correctly positioned for meals in bed. One resident with heart disease and RA was left at about a 40-degree angle after a CNA said the resident needed to be boosted, but the boost did not happen and the resident said it was very difficult to eat. Another resident with HF, COPD, and muscle weakness was found lying in bed with breakfast untouched and staff did not correct the position until a family member asked for help; the DON stated CNAs are expected to set up the meal and elevate the HOB to an appropriate height.
A facility failed to ensure residents with limited ROM and mobility needs received consistent restorative services. Several residents with diagnoses such as CP, stroke-related hemiparesis, contractures, CHF, CKD, and OA had ordered ambulation, exercise, ADL, and PROM programs, but CNA charting showed frequent missed or blank entries across multiple months. Interviews with staff and residents confirmed that the programs were not always completed, often due to staffing issues or lack of follow-up, and the DON acknowledged gaps in the charting.
A resident’s MDS assessments were not coded correctly for dental status. The resident stated he had no teeth and no dentures since admission, and the MDS Coordinator acknowledged awareness of this but did not know why the assessments after admission were marked incorrectly.
A resident with epilepsy, cerebral palsy, and congenital hydrocephalus had repeated seizure activity documented, but the EHR lacked the required post-seizure assessments, neuro checks, and detailed documentation called for in the care plan and seizure monitoring order. Staff interviews showed inconsistent understanding of seizure response expectations, and the DON acknowledged that the post-seizure directions and assessments were not being followed or completed.
The facility failed to provide complete PI assessments for a resident admitted with multiple PIs, severe malnutrition, MRSA, and severe cognitive impairment; several admission wound assessments were incomplete or unavailable for documented pressure injuries. In a separate observation, an RN provided wound care to another resident with a heel PI without performing hand hygiene after removing gloves, despite the facility policy stating that hand hygiene is required immediately after glove removal.
Medication Label Did Not Match Physician Order: The facility did not ensure proper medication labeling for one resident’s olanzapine. An LPN and the DON stated staff followed the EMR order even though the pharmacy-labeled medication cards all showed directions that did not match the current physician order, and the pharmacy label had not been corrected to reflect the updated directions.
Failure to ensure routine dental services for a resident who had no natural teeth or dentures and had been in the facility since admission. The resident’s record showed no documented dental visits, no refusal of dental services, and no evidence that the resident had been asked about dentures, while the UM and DON confirmed there were no past or scheduled dental appointments.
Two residents did not receive skin care and monitoring consistent with professional standards or their expressed preferences. One resident sustained a right knee abrasion from a fall that was noted on a fall report but not reflected in subsequent weekly skin assessments, MAR/TAR entries, or progress notes; the resident later showed the surveyor a visible wound and reported that staff had not followed up after the initial fall. Nursing staff gave conflicting accounts about the existence and monitoring of this wound, and the DON was unaware of it and unable to describe its progression, while relying on CNAs to observe and report changes. Another resident developed a U-shaped area on the left back that a CNA described as a previously bruised, weeping area and a family member described as a bruise, yet weekly skin checks continued to document intact skin with no open areas and no specific description of this site. A later photo taken by the DON showed a U-shaped scar on the back, but there were no prior measurements, photos, or detailed documentation to track its development or characteristics.
Two residents experienced deficiencies in transfer safety when staff did not follow or update care-planned transfer methods. One resident with CVA and hemiplegia, care-planned for a Lumex transfer with two staff, was transferred by a single RN using the Lumex and was lowered to the floor when unable to continue standing. Another resident with MS, CVA, and severely impaired cognition, care-planned for pivot disc transfers with one staff, was observed being transferred with a Lumex by a CNA, despite the care plan not being revised to reflect this method and no documented therapy re-assessment for renewed Lumex use.
A resident with stroke-related hemiplegia and documented colonization with carbapenem-resistant Pseudomonas aeruginosa (CRPA) was care-planned for Enhanced Barrier Precautions (EBP), and the facility’s policy required gown and glove use for high-contact activities such as transfers. Despite EBP signage on the door and PPE available, a CNA and the NHA transferred the resident with a mechanical lift, physically holding and positioning the resident, without wearing gowns or gloves, and then continued tasks in the room. In interviews, the CNA, NHA, and DON stated they believed EBP applied only to direct care and did not include transfers, resulting in noncompliance with the facility’s infection prevention and control program.
A resident with severe cognitive impairment and a history of falls developed bruising on the legs and buttocks from multiple falls and behaviors. Despite facility policy requiring notification, the POAHC was not informed of these injuries, and documentation confirmed the lack of notification. The DON acknowledged the failure to notify, and the POAHC only became aware of the bruising when the resident was sent to the ER.
A resident with severe cognitive impairment and a history of falls was admitted for rehabilitation after a traumatic brain injury. Despite being assessed as high risk for falls, no individualized fall interventions were included in the care plan upon admission, and the resident experienced multiple unwitnessed falls before any interventions were implemented. The DON confirmed that required fall interventions were not added to the care plan as per facility policy.
A resident with multiple medical conditions was admitted with hospital discharge instructions to hold clopidogrel (Plavix) prior to a scheduled stent removal. The facility failed to stop the medication and missed the stent removal appointment because key staff did not fully review all admission paperwork, resulting in continued administration of the medication against orders.
The facility failed to ensure food safety and sanitation, affecting all 52 residents. Staff did not monitor or document cooked food temperatures, test sanitizing solutions, or discard expired food items. Observations revealed improper hand hygiene during meal service and cold food items not maintained at safe temperatures. The Dietary Manager acknowledged these issues and was in the process of creating procedures to address them.
A long-term care facility failed to ensure safe medication administration for four residents, leaving medications at the bedside without proper assessments or physician orders for self-administration. Residents with varying levels of cognitive impairment were found with medications like miconazole nitrate and polyethylene glycol left unattended, and treatments were documented as administered without being completed. The Director of Nursing confirmed the lack of proper assessments and orders, indicating a systemic issue in the facility's medication administration practices.
A facility failed to maintain an effective infection prevention and control program. A resident with an open wound was not placed under Enhanced Barrier Precautions, and another resident with multiple infections was not included on the infection control line list. Additionally, an LPN did not perform hand hygiene between administering medications to different residents, highlighting lapses in infection control practices.
A resident with moderate cognitive impairment was transferred to the hospital for a left hip fracture without receiving a written transfer notice. The facility did not provide the notice to the resident or their emergency contact, and the Nursing Home Administrator confirmed that transfer notices are not issued, only bed hold notices. The facility also lacked a policy on transfer/discharge notices.
A resident with intact cognition and multiple medical conditions did not receive required bed hold notices for frequent therapeutic leaves, as the facility's DON was unaware of the requirement. The facility's census inaccurately documented these absences, leading to a deficiency in compliance with the Therapeutic Leave policy.
A resident admitted with a pressure ulcer did not receive appropriate care due to inaccurate wound assessments and documentation. The facility failed to include the pressure injury in the resident's MDS assessment and diagnoses list, and the resident was not placed on enhanced barrier precautions. The Director of Nursing and Registered Nurse Manager confirmed the assessments were incorrect, and the resident's request for a pressure-relieving cushion was initially unmet.
A resident with an indwelling catheter experienced a deficiency in care when their catheter was flushed without a physician's order, and the care plan lacked an intervention for flushing if obstructed. The resident's urine was often discolored, but documentation was insufficient, and the facility lacked standing orders for catheter flushing. The Director of Nursing confirmed the need for proper orders and documentation.
A resident experienced significant unplanned weight loss, but the facility failed to ensure proper weight monitoring as per policy. The resident's medical record lacked a current order for weight monitoring, and staff did not record weights after a certain date. Interviews with the RD and DON confirmed the oversight, acknowledging that more frequent weight checks should have been ordered following the resident's weight loss.
A resident with dementia and COPD was observed self-administering a nebulizer treatment incorrectly, with inadequate supervision and assessment by facility staff. The resident was left unsupervised during treatment, leading to improper use, and the facility's policies for medication administration were not followed. Despite an evaluation indicating the resident's inability to manage medications, they were still allowed to self-administer the nebulizer treatment.
A resident with end-stage renal disease did not have their pre and post-dialysis communication forms retained in their medical record. The facility's DON discarded these forms after a short period, and the information was only recorded if action was needed. This resulted in an incomplete medical record, contrary to the facility's policies.
A resident was admitted to the facility on an antibiotic without a specified stop date, contrary to the facility's Antibiotic Stewardship Protocol. The resident's MAR lacked a stop date for azithromycin, and staff interviews revealed a lack of awareness and communication regarding the antibiotic's duration. This indicates a failure to adhere to the established protocol for managing antibiotic use.
The facility failed to offer pneumococcal vaccines to two residents as per CDC guidelines. The residents' medical records lacked documentation of vaccine declination or discussions of risks and benefits. The Infection Preventionist identified residents due for the PCV20 vaccine, but the Medical Director instructed not to administer them, resulting in the residents not being offered the vaccines.
Kitchen Sanitation and Rodent Entry Concerns
Penalty
Summary
Food was not stored and prepared in a safe and sanitary manner in the kitchen, with debris, crumbs, and rodent traps observed underneath the stoves and oven. The cooler, counters, and areas underneath kitchen equipment were not kept clean, and the dietary manager confirmed that staff had seen rats and that a rat had been caught in the kitchen about one month earlier. The dietary manager also stated that morning staff had found bread and cake gnawed, and that kitchen staff had been using the microwave as a breadbox while a sign was posted on the bread rack instructing staff not to leave anything out overnight. During the kitchen tour, surveyors observed two holes in the outer kitchen wall next to a counter, including one hole toward the back of the counter that contained a pipe and another hole in the drywall between the kitchen and dish area. Surveyors also observed a hole large enough for a rodent to enter near the employee entrance door outside the main kitchen, and a pile of long grain and wild rice that was initially mistaken for rodent droppings. Maintenance staff was not aware of the holes when they were shown to him, and the dietary manager verified the importance of keeping areas underneath counters and equipment and behind boxes clean when rodents have been observed.
Ineffective Pest Control Program
Penalty
Summary
The facility did not maintain an effective pest control management program. Surveyors found multiple rodent traps in the kitchen, including traps in the dry storage area, dishwashing room, and main kitchen area under counters and equipment. The facility’s undated pest control policy required documenting problems found during inspections and the remedial actions taken, but the record did not show that the pest control company was called when rats were first observed in the kitchen. Staff gave inconsistent accounts about the rodent problem and who was managing the traps. A dietary aide reported rats were seen in the kitchen, bread products had been chewed, and maintenance staff had closed a hole under the dish area where rodents could enter. The dietary manager stated the rodent problem had been going on for a few months, that a large rat had been caught in a trap about 6 weeks earlier, and that the nursing home administrator had been told. In contrast, maintenance staff said only mice had been a concern, had not heard of rat concerns until that week, and was only responsible for some of the traps. The DON said a grainy video of a small animal had been received months earlier and passed to the administrator, while the administrator said the recent rat concern was first heard that week. Surveyors also observed holes in the drywall and exterior areas with openings and a bunny nest near the building. The administrator stated the pest control company had been contacted, but the facility did not have the pest control logs onsite and the bills provided did not show what concerns were identified, how many traps were maintained, where they were located, or what was completed during each visit. Staff education was incomplete, as one dietary aide who worked during the week was not educated and did not sign the education sheet. The report states that, due to the inconsistencies and incomplete staff education, the facility did not meet the standard for an effective pest control program.
Incomplete bowel, bladder, nutrition, and repositioning care with delayed constipation response
Penalty
Summary
The facility did not ensure the resident received appropriate treatment and care to maintain highest practicable physical well-being. The resident was admitted with a right acetabular fracture, dislocated right shoulder with sling, osteoarthritis, severe protein calorie malnutrition, weakness, reduced mobility, and was non-weight bearing. The resident’s MDS indicated the resident was rarely or never understood, always incontinent of bowel and bladder, required extensive toileting assistance, substantial to maximal assistance with mobility, supervision for eating and drinking, and a full body lift for transfers. The care plan identified risks related to pain medication, bowel function, bladder incontinence, nutrition, skin integrity, and communication. The resident’s record showed incomplete bowel monitoring, incomplete bladder/incontinence documentation, incomplete meal and fluid intake documentation, and incomplete repositioning documentation. The bowel record showed multiple shifts without documentation of bowel monitoring and no documented bowel movement for several days at the start of the stay, with the first documented bowel movement occurring after several days. Milk of Magnesia was not administered during the period reviewed, and bowel medications were not started until later in the stay. The DON confirmed there was no written bowel protocol and stated the facility expected Milk of Magnesia on day 3 without a bowel movement, a suppository on day 4, and a fleet enema on day 5. The DON also confirmed bowel monitoring was incomplete and that what was documented between admission and the morning of 4/21/26 indicated no bowel movement. The resident’s bladder monitoring also had missing entries, and output in milliliters was not documented for any of the entries. Meal and fluid intake documentation was incomplete on multiple days, and the resident’s ADL tracking contained missing entries, incorrect coding, and inconsistent documentation of intake. The nutrition evaluation noted poor appetite, meal intake of 0-25%, occasional acceptance of bedtime snack, and fluid intake of 0-1500 ml. The resident’s turning and repositioning documentation was also incomplete, and an initial wound assessment identified fragile skin and incontinence-associated dermatitis on the left buttock. On 4/25/26, the resident was sent to the hospital after no bowel movement despite enema and bowel aids, with the bladder palpable and a straight catheter yielding more than 1,400 ml of urine. Hospital records showed severe constipation with stercoral colitis likely related to narcotic use, immobility, dehydration, and acute kidney injury, along with urinary retention and severe bilateral hydronephrosis. CT imaging showed a prominent rectal stool burden with rectal expansion up to 7 cm and severe bladder distention with outlet obstruction. Family and staff interviews described poor intake, inability to lift the water mug independently, lack of consistent monitoring of solids and liquids, and incomplete documentation of bowel, bladder, snack, and repositioning care.
Unsafe Repositioning Resulted in Resident Humerus Fracture
Penalty
Summary
The facility did not ensure the resident environment remained as free of accident hazards as possible and did not provide adequate supervision and assistive devices to prevent accidents for one resident. The resident had spastic quadriplegic cerebral palsy, contractures of the left wrist and hand, cervical disc degeneration, impaired ROM in all extremities, and was dependent for all ADLs. The resident’s care plan required extensive total assist for bed mobility and total assist with a Hoyer lift for transfers, and the CNA Kardex directed transfers with total assist and a full sling lift. During an observed incident, the resident was sliding downward in a wheelchair. A CNA asked the BOM, who was not a CNA, to help reposition the resident. The CNA and BOM first tried to reposition the resident using the Hoyer sling, but the sling was too far down to safely move the resident. They then used a fireman boost, lifting the resident under each arm and pulling up on the resident’s pants/briefs to move the resident to a more upright position. As they lifted the resident, they heard a popping sound in the resident’s right arm. The provider was notified, and an x-ray showed a fracture of the surgical neck of the right humerus. The facility’s investigation identified staff being unaware of proper wheelchair device placement as the root cause. The surveyor also found no documentation that the fireman method was a safe method to boost the resident, no therapy evaluation supporting that method, and no CNA training or competency on using a fireman method for repositioning residents. The NHA stated non-nursing staff were allowed to assist with repositioning, and the BOM stated she had no CNA training and had only been shown repositioning by the NHA in the past.
Food Storage and Kitchen Hygiene Deficiencies
Penalty
Summary
The facility did not store, prepare, distribute, and serve food in accordance with professional standards. During kitchen observations, a cook with visible hair and facial stubble was preparing food without any hair restraint, and another cook with facial hair was preparing food without a beard net. In the cooler, surveyors observed glasses of liquid with lids that were not labeled or dated, as well as unlabeled and undated containers of cottage cheese, an undated sandwich, and two small containers of unknown food items that were also not labeled or dated. Surveyors also observed food storage concerns in the freezer. A pack of soft tortillas was past the use-by date and left open, and there was excessive frost and ice buildup in the freezer, including ice mounds on trays directly under the fans and frost and ice buildup on a pipe above a pumpkin pie. The Dietary Manager acknowledged the unlabeled and expired food items and stated the freezer frost buildup had been an ongoing issue. The Maintenance Director stated the freezer defrosting mechanism needed maintenance about every 28 days and that ice buildup occurred within a short time after checks.
Unqualified staff assisted with mechanical lift transfers and repositioning
Penalty
Summary
The facility did not ensure residents received services by qualified persons according to their written plans of care for two residents who required mechanical lift-related assistance. For one resident with dementia, Parkinson’s disease, and degenerative back and neck disorders, an Activity Aide who was not a CNA and had no documented competency for transfer assistance assisted a CNA with a sit-to-stand mechanical transfer. The aide pushed the button on the lift while transferring the resident on and off the toilet, and both the aide and the DON stated the aide was not trained to use the lift but could assist by pressing the button. For another resident with spastic quadriplegic cerebral palsy, contractures of the left wrist and hand, and cervical disc degeneration, the care plan directed a Hoyer total assist. During an incident, the resident was sliding down in a wheelchair and staff attempted to reposition the resident using a Hoyer sling, but the sling was too far down to safely move the resident. A CNA and the Business Office Manager, who had no CNA training, then used a fireman method to boost the resident by lifting under the arms and pulling on the resident’s pants/briefs. As they lifted the resident, they heard a popping sound in the resident’s right arm, and an x-ray the next day showed a fracture of the surgical neck of the right humerus. Interviews confirmed that non-nursing staff were involved in resident repositioning and lift-related tasks. The NHA stated non-nursing staff were allowed to assist with repositioning because it was not considered direct patient care, and the BOM stated she had no CNA training and had only been shown how to reposition residents by the NHA. The BOM also stated that non-nursing staff are allowed to help with boosts, and the DON stated that for sit-to-stand lifts, one staff member needs to be qualified while the other does not.
Residents Not Properly Positioned for Meals in Bed
Penalty
Summary
The facility did not ensure that residents who were eating in bed were correctly positioned to eat meals and receive assistance as needed. R7, who was admitted with heart disease and rheumatoid arthritis and whose care plan noted extensive assist of 1-2, assist as needed, and a nutritional concern related to inability to manage self-care, was observed in bed at about a 40-degree angle while breakfast was placed slightly below eye level. CNA F told R7 that s/he needed to be boosted up, but the boost did not occur, and R7 remained at the same angle during continued observation. When the tray was later removed, R7 had only eaten most of the hot cereal and stated that it was very difficult to eat while sitting so low in the bed. R40, who was admitted with heart failure, COPD, and muscle weakness and whose care plan included comfort care and a nutritional concern related to heart failure, COPD, therapeutic diet, and variable intake, was observed lying in bed sleeping with breakfast untouched and set up in front of him/her. R40 later woke up while still positioned diagonally in bed at about a 35-degree angle, with feet hanging off the edge and the tray at eye level, but staff did not check on, assist, or correct the position during the observation. A family member later asked CNA F to help sit R40 up because he/she could not eat like that, after which CNA F adjusted the resident so he/she could see the meal and begin eating. The DON stated that when a resident eats in the room, the CNA is expected to deliver the tray, offer a clothing protector, set up the meal, and elevate the head of the bed to a comfortable and appropriate height.
Restorative ROM and Mobility Programs Not Routinely Completed or Documented
Penalty
Summary
The facility did not ensure residents with limited ROM received appropriate treatment and services to maintain or improve ROM and mobility, or to prevent further decline, for 5 of 5 residents reviewed. The deficiency was based on repeated gaps in restorative nursing documentation and completion for ambulation, exercise, ADL, and ROM programs for residents identified as R20, R29, R32, R1, and R34. R20 had diagnoses including cerebral palsy, epilepsy, congenital hydrocephalus, and morbid obesity, and had a BIMS score of 11/15 indicating moderate cognitive impairment. R20 and a family member reported that ambulation was not being provided consistently and that it depended on which CNA was working. The record showed restorative programs for ambulation, ROM, and ADLs, but CNA documentation contained numerous shifts with no documentation and some shifts marked not applicable across February, March, and April. The DON acknowledged that charting was entered wrong and did not populate for CNAs to complete on some programs, and also acknowledged multiple holes in the charting. R29 had diagnoses including stage 3 CKD, major depressive disorder, CHF, muscle weakness, and PVD, and also had a BIMS score of 11/15. R29 stated that walking was not being done as scheduled and that R29 wanted to continue the walking program after therapy ended. Although CNA tasks included ambulation in the hallway with a walker and one assist, the documentation showed many shifts with no documentation and only limited completed entries. During interview, CNA L stated restorative or exercise programs were not completed every time when staffing was short, and RN M stated that when the facility was short staffed, the programs probably were not done and that RN M did not follow up to ask whether they had been completed. R32 had diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side. The CNA tasks included BLE exercises, RUE self-exercises, ambulation with a hemi walker, PROM to the right hand and wrist, and splint use, all scheduled every shift. The record showed extensive missing documentation across January, February, and March, with only partial documentation in April. R1 had spastic quadriplegic cerebral palsy and contractures of the left wrist and hand, with PROM ordered for both lower and upper extremities every shift; the record showed many shifts with no documentation in February, March, and April. R34 had bilateral osteoarthritis of the hip and was assigned active BLE ROM exercises twice daily, but the record showed repeated missing documentation across January through April. The DON stated the expectation was for CNAs to complete all restorative cares every shift and document completion or refusal, but the records reviewed showed that these programs were not routinely documented as completed.
Incorrect MDS Coding of Dental Status
Penalty
Summary
The facility did not ensure Minimum Data Set (MDS) assessments were coded correctly for 1 of 16 residents reviewed for MDS accuracy, involving R32. R32 was admitted to the facility and his admission MDS dated 03/18/23 documented that he had no natural teeth or tooth fragments. His most recent MDS noted no dental concerns, but surveyor interview and record review showed the dental status was not coded correctly as edentulous. During interview on 04/13/26, R32 stated he had no teeth and no dentures since admission to the facility in 2023. On 04/15/26, the MDS Coordinator stated awareness that R32 had no teeth or dentures and said she had no idea why the MDS assessments completed after admission were marked incorrectly.
Failure to Complete Post-Seizure Assessments and Documentation
Penalty
Summary
The facility did not ensure that R20 received seizure-related treatment and care in accordance with the comprehensive care plan and professional standards of practice. R20 was admitted with diagnoses including cerebral palsy, epilepsy, congenital hydrocephalus, and morbid obesity, and the MDS showed a BIMS score of 11/15 indicating moderate cognitive impairment. R20’s care plan directed staff to provide post-seizure treatment, including vital signs, neuro checks, and seizure documentation such as location of activity, type, duration, level of consciousness, incontinence, and post-ictal state. Record review showed multiple seizure-related events documented in progress notes, including reports of small seizure activity after supper, grand mal seizure activity in the gym, intermittent seizures despite medication adherence, and a seizure reported at 7:10 PM with the resident doing well afterward. However, the surveyor found that the seizure monitoring order in the treatment record was marked administered without being marked yes or no as instructed, and there were no noted neurological checks or assessments documented after the seizure activity for the dates reviewed. The EHR also did not contain assessments or progress notes reflecting the required post-seizure evaluation. Interviews confirmed that staff were not consistently following the seizure care plan. A CNA stated that if a seizure occurred, the resident would be rolled on their side and a nurse called, with vitals possibly obtained. An RN stated she would assess the resident, obtain vitals, administer PRN medication if appropriate, and report to the POA/guardian, but also stated she would need to look into R20’s seizure instructions further. The FM reported that staff occasionally obtained blood pressure during witnessed seizures but had never seen an actual assessment or neuro checks performed, and the DON acknowledged that the post-seizure directions and assessments in the care plan were not being followed or completed.
Incomplete PI Assessments and Hand Hygiene Lapses During Wound Care
Penalty
Summary
The facility did not ensure that pressure injury care was provided consistently with professional standards of practice for two residents reviewed for pressure injuries. One resident was admitted with multiple pressure injuries and severe protein-calorie malnutrition, MRSA, and a BIMS score of 7/15 indicating severe cognitive impairment. The resident had unhealed pressure injuries present on admission, including stage 3, stage 4, unstageable, and deep tissue injury areas. Initial wound assessments dated 03/30/26 were incomplete, and the facility was unable to provide complete admission assessments for several documented pressure injuries, including areas on the left foot, mid upper back, right lower extremity, left shin, and right great toe. The DON stated the nurse only completed assessments for the three major pressure injuries and did not complete a full assessment of all pressure injuries as instructed. For the second resident, the facility did not follow hand hygiene expectations during pressure injury treatment. During observed wound care, the RN washed hands, applied gloves, removed the resident's sock and wound dressing, removed gloves, and then continued care without performing hand hygiene before putting on new gloves and handling the wound supplies and dressing materials. The facility's hand hygiene policy stated that gloves do not replace hand hygiene and that hand hygiene should be performed immediately after removing gloves. During interview, the DON acknowledged that hand hygiene is expected with glove removal and stated the clinical manager had just reviewed hand hygiene with the RN prior to the wound care.
Medication Label Did Not Match Physician Order
Penalty
Summary
The facility did not ensure that drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 1 of 16 residents reviewed, involving R37 and the resident’s olanzapine medication. The facility policy stated that medication labels must include the resident’s name, prescribing physician’s name, medication name, dose, strength, quantity, and appropriate instructions and precautions, and that the pharmacy must be informed of order changes or changes in directions for use. R37’s physician orders showed olanzapine 2.5 mg with directions that included giving a half tablet at noon and 1 tablet every evening, while the current EMR order was described by the LPN as olanzapine 2.5 mg daily at 3 PM. When the surveyor reviewed the medication dispensing cards, four pharmacy-labeled olanzapine cards were found in the medication cart, and all carried the same label stating to give 1/2 tablet at noon and 1 tablet every evening. Two cards contained full tablets and two contained half tablets, and none of the half tablets were missing. The LPN stated staff used the EMR to verify orders and did not rely on the pharmacy label directions, and the DON stated it did not matter if the medication card did not match because staff were expected to follow the EMR order.
Failure to Ensure Routine Dental Services
Penalty
Summary
Provide or obtain dental services for each resident was not ensured for one resident who had been admitted in 2023 and had no natural teeth or tooth fragments on the admission MDS. The resident’s most recent MDS noted no dental concerns, and the resident’s BIMS score was 15/15, indicating intact cognition. Surveyor review of the medical record found no documented routine dental visits since admission, and the care plan contained no refusal of dentist services and no documentation that the provider had been notified of any refusal. During interview, the resident stated he came to the facility with no teeth or dentures and questioned why he would need to see a dentist, adding that he could not afford dentures but would want them if he could afford them. The Unit Manager reviewed the appointment binder and the chart and found no upcoming dental appointments and no past dental visits since admission. The DON stated the resident had no teeth and had not expressed interest in dentures, but also stated the resident had never been explicitly asked whether he would want dentures.
Failure to Assess and Monitor Skin Wounds and Scars for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care consistent with professional standards and resident preferences for two residents with skin impairments. For the first resident, who had diagnoses including cerebrovascular accident and hemiplegia and an intact BIMS score of 15, a fall report documented a right front knee abrasion at the time of a fall. Despite this, subsequent weekly skin assessments repeatedly documented intact skin with no indication of a right knee abrasion. When interviewed, the resident reported having a fall that caused a rug burn on the right knee and showed the surveyor a circular wound with a reddened periwound area, yellow center with visible depth, and red lines across the front of the knee. The resident stated staff looked at the wound when the fall occurred but did nothing afterward and expressed a desire for staff to look at and address the wound. Nursing staff interviews revealed inconsistent awareness and monitoring of this wound. An LPN initially stated the resident had no wounds or abrasions and confirmed there was no documentation or monitoring of a right knee wound in the medical record, despite the fall report noting an abrasion. The LPN later acknowledged the right knee wound was related to the fall and that the resident had been picking at it, describing a plan to keep it open to air and monitor, though this plan was not reflected in the record. Another nurse stated that if a wound or bruise is identified, it should be monitored and appear on the MAR or TAR until healed, but also indicated the resident did not have any wounds and only knew of a picked scab from report. The DON was not aware of the wound, found no documentation of it in progress notes, and later stated nurses were not expected to monitor the wound because CNAs observe wounds and report changes, while being unable to state whether the wound had changed in size or wound bed characteristics. For the second resident, who had diagnoses including heart failure and muscle weakness and a moderately impaired BIMS score of 12, the care plan identified potential or actual impairment to skin integrity related to multiple medical conditions. A CNA reported that this resident had a U-shaped area on the left back that had previously been a bruise and had been weeping, and stated this change had been reported to a nurse. A progress note documented a faded bruised area on the left back rib cage with scant blood related to a recent fall, but there was no further documentation of this area in the medical record. Weekly skin check forms over several months repeatedly documented skin as intact, dry, and fragile, with no open areas, and did not identify the U-shaped area on the back. A family member reported observing a U-shaped mark on the resident’s left back rib cage that appeared to be a bruise. Later, the DON presented a photo showing a U-shaped scar on the left back, approximately one inch wide with a line about 1/8 inch thick, but there were no prior photos or measurements to compare, and the scar’s details and location had not been documented on weekly skin assessments. The DON acknowledged that more thorough documentation on the skin check forms would have been helpful and stated that information for these forms was based on CNA observations and nursing assessments, which might not cover all skin areas depending on resident positioning.
Failure to Follow and Update Transfer Care Plans Leading to Unsafe Transfers
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free of accident hazards and to provide adequate supervision during transfers for two residents. One resident with a history of cerebral vascular accident and hemiplegia, and with intact cognition per a BIMS score of 15/15, had a care plan dated 2/11/26 specifying transfers with a Lumex (manual stand assist lift) and assistance of two staff. Despite this, on 2/15/26 the resident was transferred from a chair to a shower chair by a single RN using a Lumex, during which the resident could no longer stand and was lowered to the ground. The DON confirmed that the care plan required two staff for transfers and that only one staff assisted during the incident, and the RN acknowledged transferring the resident alone, stating they believed only one staff was required. The second resident, with diagnoses including multiple sclerosis and cerebral vascular accident and a BIMS score of 7/15 indicating severely impaired cognition, had an ADL self-care performance care plan dated 2/11/26 that specified transfers with a pivot disc and one staff. However, surveyor observation on 3/31/26 showed a CNA transferring this resident from bed to wheelchair using a Lumex, which the resident successfully completed by following verbal cues. The DON reported that staff had used a Lumex with this resident for four years and verified that the care plan still indicated use of a pivot disc, acknowledging the care plan was incorrect. Therapy documentation showed that a pivot disc had been trialed and recommended for toilet transfers due to a custom-fit wheelchair that did not accommodate the Lumex, and that prior to this trial the resident had used a Lumex for transfers. The DON could not locate therapy notes indicating the resident had been re-assessed for renewed Lumex use, and the care plan had not been revised to reflect the resident’s current transfer method.
Failure to Follow Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically its Enhanced Barrier Precautions (EBP) policy, for a resident colonized with carbapenem-resistant Pseudomonas aeruginosa (CRPA). The facility’s EBP policy, revised 9/9/25, requires gown and glove use during high-contact resident care activities, including transfers, and specifies that EBP should be followed outside the resident’s room when performing transfers. The resident had a diagnosis of stroke with hemiplegia and an MDS assessment showing intact cognition with a BIMS score of 15/15. A care plan dated 2/18/26 documented CRPA colonization and included an intervention to observe EBP for infection control. On observation, an EBP sign was posted on the resident’s door and PPE was available next to the room. Despite this, a CNA entered the room without donning a gown or gloves and attached a lift sling to a mechanical lift. The Nursing Home Administrator then entered without gown or gloves and operated the lift while the CNA held the resident in the sling and maneuvered the resident into a wheelchair, including holding the resident’s leg and guiding the resident into the chair. After the transfer, the NHA sanitized the lift while the CNA provided the resident a hat and made the bed. In interviews, both the NHA and CNA stated they did not believe EBP was required because they did not consider the transfer to be direct care, and the DON reported being told that EBP was only required for direct care, which they understood did not include transfers.
Failure to Notify POAHC of Resident Injuries After Multiple Falls
Penalty
Summary
A deficiency occurred when the facility failed to notify a resident's Power of Attorney for Healthcare (POAHC) of injuries resulting from multiple falls. The resident, who was severely cognitively impaired with a BIMS score of 0 and had diagnoses including nontraumatic subarachnoid hemorrhage, Lewy body dementia, depression, and a history of falls, developed bruising on the legs and buttocks. Progress notes documented the presence of bruising and falls, but there was no indication that the POAHC was informed about the injuries, despite facility policy requiring notification of such changes in condition. Interviews and record reviews confirmed that the POAHC was not made aware of the bruising until the resident was sent to the emergency room, where the injuries were observed. The DON acknowledged that there was no documentation of notification to the POAHC regarding the bruising. The POAHC expressed distress at not being informed of the injuries, and the facility's own investigation and skin assessments confirmed the bruising was consistent with multiple falls and behaviors, yet notification was not provided as required.
Failure to Implement Fall Interventions for High-Risk Resident
Penalty
Summary
The facility failed to implement fall interventions for a resident with a known history of falls and significant cognitive impairment. Upon admission, the resident was assessed as high risk for falls due to diagnoses including nontraumatic subarachnoid hemorrhage, Lewy body dementia, depression, and a previous traumatic subdural hemorrhage. Despite this, the baseline care plan did not include any fall interventions, and the comprehensive care plan was not updated with fall interventions until several days after admission. The resident experienced multiple unwitnessed falls within the facility shortly after admission, yet no individualized fall interventions or safety measures were implemented following these incidents. Interviews with the resident's Power of Attorney for Healthcare (POAHC) and the Director of Nursing (DON) confirmed that fall interventions were not added to the care plan upon admission or after the initial falls. The DON acknowledged that 15-minute checks were conducted as a standard practice for new admissions but were not individualized fall interventions. The facility's own Fall Reduction Policy required individualized interventions and care plan updates after each fall, which were not followed in this case.
Missed Medication Hold and Appointment Due to Incomplete Review of Admission Orders
Penalty
Summary
A resident with diagnoses including acute kidney injury, bladder cancer, complicated UTI, and atrial fibrillation was admitted to the facility following a hospital stay. The resident's hospital Discharge Summary included an order to stop clopidogrel (Plavix) on a specific date pending a scheduled urinary stent removal. The After Visit Summary (AVS) also indicated a follow-up appointment for stent removal and other specialist visits. Despite these instructions, the facility continued to administer clopidogrel to the resident from admission through discharge, as documented in the Medication Administration Record (MAR), and did not stop the medication as ordered. The deficiency occurred because the facility failed to accurately review and implement the hospital discharge instructions and AVS. The stent removal appointment and the order to hold clopidogrel were missed during the admission process. Key staff, including the Admissions Director and Director of Nursing, did not see the relevant orders, as some paperwork was only scanned into the medical record without being reviewed in paper form. The oversight was only discovered after the resident's family brought the missed appointment to staff attention.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored and prepared in a safe and sanitary manner, potentially affecting all 52 residents. Staff did not monitor or document cooked food temperatures, as required by the 2022 FDA Food Code and the facility's own policies. During an initial tour of the kitchen, the Dietary Manager (DM) confirmed that kitchen staff only completed one set of temperatures prior to meal service and did not consistently monitor or document cooking temperatures. The DM acknowledged awareness of this requirement only recently and had not yet implemented a procedure to address it. Additionally, the facility did not test or document the parts per million (PPM) of the quaternary sanitizing solution as per the manufacturer's instructions. The DM admitted that kitchen staff did not use test strips to test the sanitizing solution in the sanitizing buckets. This oversight was also recently recognized by the DM, who was in the process of creating a procedure to rectify the issue. The facility also failed to discard food items beyond their expiration or use-by dates and did not store them in a manner to prevent cross-contamination. During the kitchen tour, the surveyor noted several expired items, including sour cream and heavy cream, which the DM intended to discard but had forgotten. Furthermore, staff did not complete appropriate hand hygiene during meal service, as observed when a cook and a dietary aide handled food and utensils with contaminated gloves. Cold food items were not maintained at a proper temperature during meal service, with butterscotch pudding observed at temperatures above the safe limit, which was acknowledged by the DM.
Medication Administration Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure safe and accurate administration of medication for four residents, resulting in medication being left at the bedside without proper assessments or physician orders for self-administration. Resident 15, who had intact cognition, was found with miconazole nitrate 2% powder at the bedside and reported not receiving prescribed treatments for a rash under the breasts. The medical record indicated treatments were documented as administered, but the resident confirmed they were not completed, and the Licensed Practical Nurse (LPN) admitted to signing off on the treatment without administering it. Resident 6, with moderately impaired cognition, was observed with polyethylene glycol left on their wheelchair tray after medication administration. The resident did not have an order or assessment for self-administration, and it was unclear if the medication was consumed. Similarly, Resident 12, also with moderately impaired cognition, had polyethylene glycol left at the bedside with a portion remaining in the cup, despite not having an order or assessment for self-administration. Resident 7, with severely impaired cognition, was left with polyethylene glycol at the bedside after medication administration, with a quarter of the medication still in the cup. Like the other residents, there was no order or assessment for self-administration. The Director of Nursing confirmed that medications should not have been left with these residents without proper assessments and orders, highlighting a systemic issue in medication administration practices at the facility.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. One resident, identified as R207, had an open wound on the buttocks but was not placed under Enhanced Barrier Precautions (EBP) as required by the facility's policy. Despite having daily wound care orders, there was no order for EBP, and staff did not wear gowns during care. Interviews with the nursing staff, including the Director of Nursing and the Nursing Home Administrator, confirmed that R207 should have been on EBP due to the open wound. Another resident, R42, was not included on the facility's infection control line list despite having multiple diagnoses, including necrotizing fasciitis and several stage 4 pressure ulcers, and being on IV antibiotics. The Infection Preventionist confirmed that R42 was missed on the line list, although the resident was on contact precautions and had a sign indicating such on the door. The oversight in documentation and tracking of R42's infection status highlights a lapse in the facility's infection surveillance practices. Additionally, a Licensed Practical Nurse (LPN) failed to perform hand hygiene between administering medications to different residents, specifically R12 and R7. This breach of protocol was observed by the surveyor and later confirmed by the Director of Nursing, who acknowledged that hand hygiene should be completed between residents. These findings collectively indicate significant gaps in the facility's adherence to infection control policies and procedures.
Failure to Provide Written Transfer Notice
Penalty
Summary
The facility failed to provide a written transfer notice to a resident, identified as R52, who was transferred to the hospital. R52 was hospitalized for a left hip fracture, and neither the resident nor the emergency contact received a written transfer notice. The resident had a history of moderate cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 8 out of 15, but was still making their own healthcare decisions. During the survey, the Nursing Home Administrator acknowledged that the facility provides bed hold notices but does not issue transfer notices. Additionally, the facility did not have a policy related to transfer/discharge notices available for review.
Failure to Provide Bed Hold Notice for Therapeutic Leave
Penalty
Summary
The facility failed to provide a bed hold notice to a resident, identified as R42, who frequently left the facility for therapeutic leave. According to the facility's Therapeutic Leave policy, residents or their representatives should receive written information about a bed hold prior to or upon notice of transfer. However, R42, who left the facility for therapeutic leave approximately every other week from October 2024 to January 2025, did not receive any bed hold notices. This oversight was identified during a surveyor's review of R42's medical records and interviews with facility staff. R42 was admitted to the facility with diagnoses including septicemia, paraplegia, anxiety, depression, and post-traumatic stress disorder, and had an intact cognitive status as indicated by a BIMS score of 15 out of 15. Despite having multiple therapeutic leaves, the Director of Nursing (DON) acknowledged that no written bed hold notices were provided to R42, as the DON was unaware that such notices were required for therapeutic leaves. The facility's census inaccurately documented R42's absences as hospitalizations, further complicating the situation.
Inadequate Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide appropriate care and treatment for a pressure injury for one resident, identified as R207, among 24 sampled residents. R207 was admitted with a pressure ulcer on the buttock, but the facility did not complete accurate weekly wound assessments or include the pressure injury diagnosis on the resident's Minimum Data Set (MDS) assessment and diagnoses list. The facility's Wound Care Policy required weekly documentation of skin impairments, but initial and weekly assessments inaccurately indicated no skin alterations. R207's medical record review revealed inconsistencies, as the hospital discharge paperwork noted an active pressure ulcer with a treatment order for Silver Sulfadiazine cream. However, the initial admission skin assessment and subsequent weekly assessment failed to document the wound. Interviews with the Director of Nursing (DON) and Registered Nurse Manager (RNM) confirmed the assessments were incorrect, and the wound assessments were not properly documented in the medical record. Additionally, R207 was not placed on enhanced barrier precautions (EBP) for the open wound, and the resident's request for a pressure-relieving cushion was initially unmet. The DON acknowledged being behind in charting and confirmed that the wound assessments were not entered correctly. The MDS Coordinator relied on the facility's inaccurate assessments, leading to the omission of the pressure injury from the MDS assessment and diagnoses list. The Nursing Home Administrator admitted that the wound care information was missed, and the assessments should have been accurate to ensure proper care and follow-up. The failure to document and assess the wound accurately hindered the facility's ability to monitor the wound's condition and provide appropriate care.
Deficiency in Catheter Care for Resident
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with an indwelling catheter, leading to a deficiency. The resident, who had intact cognition and was their own decision-maker, was admitted with a Foley catheter in place since 2018 due to conditions such as benign prostatic hypertrophy, urinary retention, and neurogenic bladder. The care plan for the resident included monitoring and reporting signs of urinary tract infection and changes in urine color but did not include an intervention for flushing the catheter if obstructed with clots. On one occasion, the resident's catheter was flushed without a physician's order after the resident exhibited dark cherry-colored urine, which was not documented in the medical record. The resident's urine was often light pink or cherry-colored, attributed to the resident pulling on the catheter. Despite the presence of clots and poor drainage, there was no documentation of the catheter being flushed or the urine's discoloration until a phone order was received later to allow flushing as needed. The Director of Nursing confirmed that there should have been an order to flush the catheter before the intervention and that the care plan lacked an intervention for flushing the catheter if obstructed. Additionally, the facility did not have standing orders for flushing catheters, and there was a lack of documentation regarding the urine color, which should have been reported and documented according to the Director of Nursing.
Failure to Monitor Resident's Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a resident, identified as R43, received the necessary care and services to monitor significant weight loss. R43 experienced an unplanned weight loss of 15.72% between September 13, 2024, and January 1, 2025, with a 5.26% weight loss between December 9, 2024, and January 1, 2025. Despite this significant weight loss, R43's medical record did not contain a current order for weight monitoring, and staff did not monitor R43's weight according to the facility's policy. The facility's Weight Monitoring policy requires a weight monitoring schedule to be developed upon admission, with weekly monitoring for residents experiencing weight loss. However, R43's order for weekly weights was discontinued on December 9, 2024, and no additional weights were recorded after January 1, 2025. Interviews with the Registered Dietitian (RD) and the Director of Nursing (DON) confirmed the lack of a current order for weight monitoring and acknowledged that more frequent weights should have been ordered following R43's significant weight loss. The RD confirmed that R43 should have had a more recent weight than January 1, 2025, and typically, weekly weights for four weeks are ordered in such cases. The DON was aware of R43's weight loss but was unable to provide further information to confirm that R43's weight had stabilized since January 1, 2025. R43, who had intact cognition, was aware of the weight loss and expressed a goal to regain weight but was uncertain of the current weight and did not recall the last time they were weighed.
Inadequate Supervision and Assessment for Nebulizer Treatment
Penalty
Summary
The facility failed to ensure that a resident received appropriate respiratory care and services for a nebulizer treatment. The resident, who had been admitted with diagnoses including dementia, COPD, and hypertension, was observed self-administering a nebulizer treatment incorrectly on two occasions. On the first occasion, the resident was found asleep with the nebulizer mouthpiece hanging out of their mouth, not fully inhaling the treatment. On the second occasion, the resident was left unsupervised during the treatment, repeatedly removed the nebulizer to talk, and eventually placed it on the table while it was still running. The resident's self-administration of medication evaluation indicated they could not correctly identify medication names, side effects, or dosages, yet they were deemed able to self-administer the nebulizer treatment. The facility's policies and procedures for administering medications and nebulizer use were not followed. The Licensed Practical Nurse (LPN) and Director of Nursing (DON) indicated that the resident was assessed as able to self-administer the nebulizer treatment, but the evaluation was completed after the surveyor's initial observation. The DON acknowledged that the facility's policy was incorrect regarding the need for a respiratory assessment before or after nebulizer treatments. The resident's self-administration evaluation was re-evaluated, revealing further deficiencies in the resident's ability to manage their medications, yet a physician's order for self-administration of nebulizer treatments was obtained upon admission.
Incomplete Medical Record for Dialysis Resident
Penalty
Summary
The facility failed to ensure that a resident's medical record was accurate and complete, specifically for a resident with end-stage renal disease who received dialysis services. The resident, who had intact cognition and made their own medical decisions, did not have their pre and post-dialysis communication forms retained in their medical record. The facility's Medical Record Release Policies and Procedures require documentation to accurately describe the resident's condition and any changes in treatment, but this was not adhered to in the case of the resident. The Director of Nursing (DON) and a Licensed Practical Nurse (LPN) described the process for documenting and communicating dialysis information, which involved faxing a Dialysis Pre and Post Communication form to the dialysis center and providing a copy to the DON. However, the DON admitted to discarding these forms after a short period, and the information from the forms was only entered into the resident's medical record if the DON had to take action. This practice resulted in the absence of critical documentation in the resident's medical record, leading to the deficiency identified by the surveyor.
Failure to Follow Antibiotic Stewardship Protocol
Penalty
Summary
The facility failed to consistently follow its antibiotic stewardship program, as evidenced by the case of a resident who was admitted on an antibiotic without a specified stop date. The resident, who had intact cognition and was diagnosed with type 2 diabetes mellitus with neuropathy, congestive heart failure, and chronic respiratory failure with hypoxia, was prescribed azithromycin 250 mg to be taken three times weekly. However, the medication administration record (MAR) did not include a stop date or duration for the antibiotic, which is a requirement under the facility's Antibiotic Stewardship Protocol. Interviews with facility staff revealed a lack of awareness and communication regarding the antibiotic's duration. The Nursing Home Administrator was unaware of the stop date, and the Director of Nursing confirmed that the nursing staff should have sought clarification from the resident's physician upon admission. The Infection Preventionist also verified the absence of a stop date and acknowledged that antibiotics should have specified durations. This oversight indicates a failure to adhere to the established protocol for reviewing and managing antibiotic use within the facility.
Failure to Offer Pneumococcal Vaccines
Penalty
Summary
The facility failed to ensure that pneumococcal vaccinations were reviewed, offered, or administered to two residents, R24 and R34, as per CDC guidelines. The medical records for these residents did not contain declination forms for the pneumococcal vaccines, nor did they indicate that the risks and benefits of the vaccines were discussed with the residents or their representatives. Specifically, R34 should have been offered the PCV20 vaccine in 2020, five years after receiving the PCV13 vaccine in 2015, and R24 should have been offered the PCV20 vaccine in 2022, five years after receiving the PPSV23 vaccine in 2017. The Infection Preventionist (IP)-K had compiled a list of residents due or past due for the PCV20 vaccine and presented it to the Medical Director (MD)-T. However, MD-T instructed not to administer the vaccines, and as a result, the residents were not given the option to receive the vaccine. This decision led to the failure in offering the vaccines to the residents, as confirmed by interviews with the Director of Nursing (DON)-B and IP-K. The facility's policy required that residents be offered the recommended vaccines upon admission, with documentation of education and the opportunity to refuse, which was not adhered to in this case.
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What surveyors actually found near you
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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.
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Nursing homes near Antigo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| North Central Health Care | 25.9 mi | ★★★★★ | 22 | 0 |
| Amethyst Health Of Wausau | 26.1 mi | ★★★★★ | 37 | 4 |
| Pine Crest Health And Memory Care | 26.3 mi | ★★★★★ | 1 | 0 |
| Wood Aven Health And Rehabilitation | 26.8 mi | ★★★★★ | 14 | 0 |
| Rennes Health And Rehab Center-weston | 26.9 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.