Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Heartland Country Village during CMS and state inspections, most recent first.
The facility failed to provide weekend activities for residents, as activity staff did not conduct activities on weekends despite being scheduled. The activity schedule was not followed, and there was no documentation of residents participating in activities. Interviews revealed a lack of awareness and adherence to the schedule, resulting in unmet activity preferences and needs for three residents.
The facility was found deficient in providing adequate food and nutrition services due to the absence of a full-time qualified dietician or director of food and nutrition services. This led to insufficient dietary support staff, failure to follow food safety standards, and inability to ensure residents received proper diets. The Nursing Home Administrator had to step in to manage meal preparation and ordering due to these staffing issues.
The facility failed to maintain sufficient dietary support staff, leading to non-dietary staff preparing meals without proper training. This resulted in residents not receiving proper nutrition, with meals often served late or not at all. Staff and residents expressed concerns about the lack of a full-time registered dietician or certified dietary manager, and the absence of essential supplies like Thick-It for residents with swallowing issues.
The facility failed to provide food in the appropriate form for two residents on altered diets, leading to an Immediate Jeopardy situation. The absence of dietary staff and lack of training resulted in unqualified personnel preparing meals, causing residents to receive incorrect diets. This deficiency posed a significant risk to the health and safety of residents with specific dietary needs.
A resident admitted for short-term rehab with intact skin developed a stage 3 pressure ulcer on the coccyx due to the facility's failure to implement preventive measures. Despite being at risk, the resident did not have a turning and repositioning schedule, and staff were unaware of the pressure injury until it reached stage 3. The facility's lack of documentation and intervention led to the development of the ulcer.
The facility failed to maintain a safe and sanitary environment for food preparation, storage, and distribution, affecting all 22 residents. The NHA served scrambled eggs without verifying the temperature due to a non-functioning thermometer. Additionally, the kitchen had an unclean stove top, incomplete temperature logs for freezers and refrigerators, and improper storage of sugar near chemicals.
The facility's assessment failed to include specific training and competency requirements for kitchen staff, including the dietary manager, potentially affecting all 22 residents. The Nursing Home Administrator acknowledged the need for comprehensive staff training details.
The facility failed to identify and address deficiencies in the kitchen and meal service through a QAPI plan. The NHA provided a QAPI document initiated on the day of the survey, acknowledging it should have been started earlier. This oversight potentially affects all 22 residents.
A resident in an LTC facility, who is dependent on staff for mobility and self-care, was neglected by a nurse and two CNAs who refused to assist her in transferring from a wheelchair to a bed. Despite the resident's requests and a 911 call, staff did not provide necessary care, leaving her in soiled incontinence products. An EMT confirmed the neglect, and the incident was not reported to the State Agency as required.
Two residents experienced misappropriation of their hydrocodone-acetaminophen tablets by an RN, who administered the medication without their request. The discrepancy was discovered during a narcotic count, leading to the RN's termination. However, the incident was not reported to the State Survey Agency promptly. Both residents were cognitively intact and had not requested the medication. The facility failed to review the RN's license thoroughly before hiring, which had previous restrictions due to narcotic administration issues.
A facility failed to report allegations of neglect and misappropriation in a timely manner. A resident reported neglect when staff refused to assist her with a transfer, and the incident was not reported to authorities despite a 911 call. Additionally, a narcotic count discrepancy involving missing hydrocodone tablets was not reported to the State Survey Agency within the required timeframe. The facility's policies and state regulations for reporting were not followed, leading to deficiencies.
A resident reported neglect when staff refused to assist her in transferring to bed, leading to a 911 call. The facility failed to investigate or report the incident as required by policy. The NHA, unaware of any investigation, confirmed the incident was not reported to the State Agency, and no documentation was available.
A resident with multiple health conditions was not weighed according to physician orders, missing three specific dates, and was not assessed following multiple complaints of chest pain. This indicates a failure to adhere to the care plan and respond to the resident's symptoms.
A resident with dementia and Alzheimer's disease experienced an unwitnessed fall in their room, which the facility failed to investigate or analyze for root cause until three days later. Despite having a care plan to minimize falls, the facility did not adhere to its policy on timely investigation, contributing to a deficiency.
A resident with ileostomy status experienced frequent leaks due to inadequate ostomy supplies at the facility. Despite a physician's order for regular bag changes, the facility failed to maintain necessary supplies like rings and paste, leading to frequent appliance changes and family intervention to provide supplies. The Nursing Home Administrator, lacking knowledge in ostomy care, did not order the required paste, despite being informed by the resident's family.
Two residents in the facility did not receive their prescribed medications as required, with one resident missing doses of Benazepril and Furosemide, and experiencing delays in Nitroglycerin patch application. Another resident did not receive an inhaler and a weekly injection due to medication unavailability. The facility's policy mandates timely medication administration, which was not followed, and staff interviews revealed a lack of clarity in the medication ordering and administration process.
A facility failed to secure medications properly, as observed when an RN left a medication cup, including a controlled substance, unattended on a cart. A cognitively impaired resident had access to the cart, which was against the facility's policy requiring carts to be locked when out of sight. The RN admitted that medications should not be left unattended, leading to a deficiency.
The facility did not have a qualified Food Services Manager (FSM) to supervise the dietary department, affecting all residents. The FSM had been absent for a week, and the Administrator was temporarily overseeing the department. Cook1 confirmed the absence of an FSM, and the Registered Dietitian was on vacation, reducing oversight. The Administrator acknowledged the struggle to find a new FSM and implement necessary training and policies.
The facility failed to ensure proper sanitation of thermometers and appropriate thawing practices in the kitchen, affecting all residents. Observations revealed that kitchen staff did not sanitize thermometers between uses and improperly thawed and stored food, posing a risk of cross-contamination. The facility's administrator acknowledged ongoing struggles with dietary management and the need for proper training.
The facility failed to meet residents' nutritional needs due to improper portion sizes and lack of adherence to specialized diets. Observations revealed incorrect scoop sizes were used, leading to inconsistent meal portions. Staff were unaware of dietary requirements, and menu discrepancies were noted. The administration acknowledged issues in the dietary department, but improvements were not yet implemented.
The facility failed to maintain safe and clean equipment for two residents, with one using a wheelchair with cracked armrests and another having a chipped overbed table. Despite requests for replacements, the facility did not provide them, and no maintenance policy was available. The Administrator confirmed the expectation for equipment to be in safe condition.
The facility failed to provide written transfer notices to two residents during emergent hospital transfers. One resident, who was cognitively intact, did not recall seeing the transfer form, while another resident's records lacked evidence of a transfer notice. The facility's administrator acknowledged the expectation for such notices, indicating a gap in protocol adherence.
The facility failed to provide written bed hold notices to two residents upon their emergent hospital transfers, as required by policy. Despite obtaining verbal consent for a bed hold for one resident, there was no documentation of written notices for either resident, as confirmed by the Regional Nurse Consultant.
The facility failed to ensure accurate MDS assessments for three residents, affecting care planning. One resident's antidepressant was misclassified as an anti-anxiety medication. Another resident's MDS inaccurately coded anticoagulant use and omitted hospice services. A third resident's pressure ulcer was not correctly documented. These errors were confirmed by staff.
The facility failed to conduct and document care conferences for three residents, impacting their participation in care. Resident 4 had only two care conferences since admission, with one undocumented and lacking interdisciplinary input. Resident 12, receiving hospice services, reported no care conferences, confirmed by the Hospice Home Care Manager. Resident 13 also did not recall any care conferences, with no documentation found by the Regional Nurse Consultant.
A facility failed to provide a discharge summary with a recapitulation of a resident's stay, as required by policy. The resident, who had intact cognition, was discharged with a diagnosis related to orthopedic aftercare. The discharge note mentioned the resident's excitement to return home and plans for outpatient rehab but lacked a comprehensive summary. The absence of this summary was confirmed by the Administrator and Regional Nurse Consultant.
A facility failed to ensure proper cleaning of a resident's CPAP machine, masks, and tubing, as required by both facility policy and manufacturer guidelines. The resident, who has chronic obstructive pulmonary disease and sleep apnea, expressed fear of using the CPAP due to concerns about germs. Facility records lacked documentation of CPAP cleaning, and the Director of Nursing confirmed the resident's non-use of the machine.
The facility failed to ensure an opened vial of Aplisol tuberculin purified protein derivative (PPD) was properly dated and discarded within the manufacturer's specified timeframe. An LPN observed an undated open vial in the medication room, and the Regional Nurse Consultant confirmed the vial was past the 30-day usage period. The facility's policy did not address outdated medication, leading to this deficiency.
A resident with Alzheimer's and dementia was not provided with the prescribed mechanical soft diet and thickened liquids, leading to potential safety risks. Observations revealed the resident received regular texture foods and non-thickened liquids, contrary to physician orders. Staff interviews indicated a lack of awareness and understanding of the resident's dietary needs, with the facility administrator acknowledging challenges in dietary management and training.
The facility failed to maintain proper infection control in the laundry area, with no barrier between clean and dirty areas and washing machine drainpipes below floor level. Observations included mineralization and a dripping liquid on the washer hose. The Maintenance Director had not assessed the area, and the Administrator acknowledged the need for improvements.
The facility failed to maintain a pest-free environment in the kitchenette, as fruit flies were observed in a cabinet with food items. The Maintenance Director was unaware of the issue until it was pointed out, despite having heard about it a week earlier. He removed the contaminated food but acknowledged the need for further intervention as fruit flies were still present during a follow-up observation.
The facility did not post accurate daily nurse staffing information as required by policy. An observation found that the posted information was outdated and lacked necessary details such as the facility name and current census. The Administrator confirmed the deficiency, which could affect the understanding of staff availability for resident care.
A resident with severe cognitive impairment and multiple diagnoses expressed increased leg and hip pain. Despite recognizing the change in condition and ordering an x-ray, the facility failed to provide ongoing monitoring and assessment until the x-ray results revealed a left hip fracture. The lack of documentation and monitoring led to a delay in identifying the fracture and ensuring appropriate care.
The facility failed to adequately assess and manage a resident's increased pain, lacking proper documentation and care planning for non-verbal pain indicators and acceptable pain levels. Despite the resident's severe cognitive impairment, the facility did not follow its policy for acute pain assessment, leading to unmanaged pain and insufficient interventions.
The facility did not adhere to professional standards for food service safety, resulting in several deficiencies. One resident was served non-pasteurized eggs with runny yolks, increasing the risk of Salmonella infection. The facility lacked a policy on the use of unpasteurized eggs and safe handling procedures for shell eggs. Staff were uncertain if the eggs served were pasteurized and acknowledged serving eggs with runny yolks upon request. Observations also noted improper hand hygiene practices by a cook and inadequate labeling of frozen food items. Additionally, food temperatures were not consistently recorded before placing items in hot holding, posing a risk of foodborne illness to residents.
The facility failed to ensure a clean and homelike environment for its residents, as evidenced by observations of dust and debris buildup in resident rooms and common areas. Residents and a representative voiced concerns about cleanliness, and staff interviews revealed that housekeeping was expected to clean daily but was understaffed.
The facility failed to ensure that two residents received scheduled showers, as required by their care plans. Documentation was inconsistent, and staff did not always record refusals or provided showers, leading to lapses in personal hygiene care.
Failure to Provide Weekend Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing program to support resident choice of activities based on comprehensive assessments and care plans for three residents. The activity staff did not conduct activities on weekends in November, December, and January, despite scheduling staff to come in. There was no schedule for residents on these weekends, and no documentation of the residents participating or being offered activities during these months. The facility's activity schedule was distributed to residents and posted in the main hallway, but weekend activities were left to the discretion of the manager on duty, which changed every weekend. The Activity Director confirmed that she only worked a few weekends and that other managers did not conduct activities as scheduled. Interviews with various staff members, including the Nursing Home Administrator, revealed a lack of awareness and adherence to the weekend activity schedule, resulting in no activities being conducted on most weekends. The residents involved had specific activity preferences and needs documented in their care plans, but there was no evidence of these being met. One resident preferred in-room activities and occasional musical events, another enjoyed morning activities and served as the resident council president, and the third resident liked socializing and required assistance to attend activities. Despite these documented preferences, there was no record of activities being offered or attended by these residents during the specified months.
Deficiency in Food and Nutrition Services Due to Lack of Qualified Staff
Penalty
Summary
The facility was found to be deficient in providing adequate food and nutrition services due to the absence of a full-time qualified dietician or a director of food and nutrition services. This deficiency was identified through observations, interviews, and record reviews, revealing that the facility lacked a full-time registered dietician (RD) or a certified dietary manager (CDM) to ensure effective nutritional and dietary services for all 22 residents. The deficiency was considered an immediate jeopardy situation, indicating a reasonable likelihood for serious harm, which began on October 30, 2024. The surveyors noted that the facility did not have dietary policies readily available, and the Nursing Home Administrator (NHA) was unable to locate them when requested. Interviews with staff, including a dietary aide and a new employee, confirmed the absence of a dietary manager and a full-time RD. The NHA was observed cooking meals due to the lack of qualified dietary staff, and there were issues with meal ticket management and food ordering, which the NHA had to address personally. The deficiency led to several problems, including insufficient dietary support staff to provide meals, failure to follow accepted standards of practice for food safety and sanitation, and the inability to ensure residents received proper diets as ordered. These issues were compounded by the lack of a system to ensure meal tickets were available and the absence of necessary dietary products like Thick-It for residents with specific dietary needs.
Removal Plan
- All staff will be educated prior to their next working shift.
- CDM started working.
- We currently employ a registered dietician who works. The RD will review and sign off on all competencies initiated by the CDM prior to QAPI Meeting.
- Prior to food and nutritional service staff working, a competency to be completed by the CDM, with sign off by the RD.
- Competency checks for all food and nutritional services employees will be completed until all dietary staff are checked off. No dietary staff will work until competency checked.
- All staff were trained on Serve Safe food handling and sanitation of kitchen and dishroom. All new staff will be required to complete training and competency checkoff by the CDM with subsequent sign off by the RD.
- In the event of a staff call off, the staff shall first contact the CDM. If the CDM cannot be reached, all staff will contact the NHA for staffing assistance.
- In the event of a call in, only qualified staff will work in the kitchen (Serve Safe certified and competencies checked off).
- The schedule will be developed by the certified dietary manager and provided in advance for the food and nutritional services employees.
- The dietary schedule will remain posted and updated by the CDM as needed in a visible area of the kitchen.
- The CDM will provide education to all dietary staff on the following: emergency preparedness plan, scheduling, competencies and audits.
- The CDM/Administrator/Designee will conduct audits.
- All staff working in the dietary department will have the competency checks completed.
- Schedule completed for dietary staffing.
- The results of these audits will be reviewed by the facility Quality Assurance Performance Improvement committee for patterns, trends, and continued recommendations for process monitoring and improvement.
Inadequate Dietary Staffing and Training Leads to Immediate Jeopardy
Penalty
Summary
The facility failed to ensure there were sufficient dietary support staff to carry out the functions of the food service department, which affected all 22 residents. Observations revealed that the Nursing Home Administrator (NHA) and other non-dietary staff were preparing and serving meals without proper training or competencies. This situation led to an immediate jeopardy finding, as the facility did not have a full-time registered dietician or certified dietary manager, and the kitchen was short-staffed. The NHA was observed cooking meals on multiple occasions, and there were instances where no dietary aide was present. Interviews with staff and residents highlighted the severity of the staffing issues. A dietary aide confirmed being the only one at the facility, and a registered nurse reported that meals were often served late due to the lack of a cook. A certified nursing assistant mentioned that resident diets were not being followed, and another CNA admitted to cooking meals without receiving any training or competency checks. Residents expressed concerns about not receiving proper nutrition, with one resident stating that their health was at risk due to incorrect diets being served. The deficiency was further evidenced by an incident where residents did not receive supper on time due to the absence of kitchen staff. Nursing staff had to prepare makeshift meals, and there was a lack of essential supplies like Thick-It for residents with swallowing issues. Family members and staff expressed concerns about the quality of care and the anxiety caused by the late meals. The facility's failure to maintain adequate dietary staffing and ensure staff competency led to a reasonable likelihood of serious harm to the residents.
Removal Plan
- All staff will be educated prior to their next working shift.
- The CDM and Administrator will ensure dietary staff are competent and sufficient to meet resident needs to include: Resident needs and preferences are met, food supply is available to meet resident needs.
- There are sufficient staff to prepare and serve meals in a timely manner and to maintain food safety.
- Dietary staff received education on preparing altered diets per physician orders by the Certified Dietary Manager (CDM).
- In the event of a staffing concern, staff are to contact the CDM.
- Back-up staffing will include dietary staff and department head staff that have completed dietary department competencies.
- Back up emergency food supply put together with location and menu items to meet nutritional servings and portions.
- The administrator/designee will conduct audits to include the following: Observed and interview residents to determine if dietary needs are being met and dietary orders are followed.
- Complete observations and/or interviews indicate there are sufficient staff to prepare and serve meals in a timely manner and to maintain food safety.
- The results of these audits will be reviewed by the facility Quality Assurance Performance Improvement (QAPI) committee for patterns, trends, and continued recommendations for process monitoring and improvement.
Failure to Provide Altered Diets as Ordered
Penalty
Summary
The facility failed to ensure that food was prepared in a form designed to meet the individual needs of residents on altered diets. Specifically, two residents, both with severe cognitive impairments and requiring specialized diets, did not receive meals in the appropriate texture and consistency as per their physician orders. The facility lacked the necessary Thick-It product to thicken liquids for residents with swallowing issues, and staff were not trained or competent in preparing altered diets. This deficiency led to an Immediate Jeopardy situation, indicating a reasonable likelihood for serious harm. The deficiency was observed through multiple instances where the Nursing Home Administrator and other untrained staff were cooking meals due to the absence of dietary staff. The facility had no dietary manager for several months, and the agency cook was unreliable, leading to situations where meals were not served on time or in the correct form. Staff, including CNAs and nurses, reported that they had to step in to prepare meals without proper training or competency checks, resulting in residents receiving incorrect diets. Interviews with staff revealed that there were ongoing issues with meal tickets not being available or accurate, and residents were sometimes served thin liquids instead of the required thickened consistency. The lack of proper dietary management and training led to residents with specific dietary needs not receiving the appropriate meals, which posed a significant risk to their health and safety.
Removal Plan
- The NHA/Director of Nursing (DON)/ Certified Dietary Manager (CDM) or designee immediately checked to ensure that the identified residents received the correct altered diet.
- The NHA/DON/CDM or designee completed an audit of all tray tickets to ensure that all diet orders match the tray tickets for all facility residents and reviewed all resident diets to ensure residents received the correct diet as ordered by the physician.
- The NHA/DON/CDM or designee reviewed all residents who receive altered texture diets. Orders were verified and updated as deemed appropriate.
- Dietary care plans were reviewed for accuracy and updated to reflect any new orders and recommendations for all residents by the DON/CDM/NHA or designee.
- All staff education initiated to ensure that physician order, including appropriate dietary recommendations are in place for all residents. Staff will receive education prior to starting their next working shift by DON/Administrator.
- All staff educated initiated on the procedure on tray ticket system for resident meal delivery and appropriate diet. Competency and validation will be completed on staff to ensure that tray ticket is present on meal tray, that the meal validates what the tray ticket indicates is the appropriate diet for the resident. Staff will receive education prior to starting their next working shift by CDM/DON/ or Administrator. Education will also include what to do if there is no ticket or if the tray ticket does not match what is on the actual resident plate or tray.
- All staff education initiated on the procedure on tray ticket system for resident meal delivery and appropriate diet. Competency and validation will be completed on staff to ensure that tray ticket is present on meal tray, that the meal validates what the tray ticket indicates is the appropriate diet for the resident. Staff will receive education prior to starting their next working shift by CDM/DON/NHA. Education will also include what to do if there is no ticket or if the tray ticket does not match what is on the actual resident plate/tray.
- All staff education initiated regarding immediate steps to take if the tray ticket does not match the meal on the tray and what immediate steps to take to ensure that resident receives appropriate therapeutic diet. Staff will receive education prior to starting their next working shift NHA/DON.
- Dietary staff educated on menus and recipes to properly make any altered textured diets per the physician orders by the CDM.
- Staff will be able to verbalize where the menus are located and where they can obtain the recipe for making therapeutic altered diets.
- Tray ticket system has been created to reflect current diet orders for all residents by facility CDM.
- Facility policies and procedures including: (Acceptance of Therapeutic Diet) reviewed by CDM and remain up-to-date.
- QAPI (Quality Assurance and Performance Improvement) for cooks to understand how to follow the recipes specific to altered textured diets and where they would obtain those recipes. Audit 2 times per week, and monthly times 6 months to ensure correct consistency for altered diets. All results will be reviewed by the QAPI Committee for trends and ongoing process improvement.
Failure to Prevent Pressure Ulcer Development
Penalty
Summary
The facility failed to ensure that a resident received care consistent with professional standards to prevent pressure ulcers. A resident, admitted for short-term rehabilitation, initially had intact skin but developed a stage 3 pressure injury on the coccyx during their stay. The facility's policy required assessment and documentation of risk factors for pressure sores, but there was no evidence of a pressure injury upon admission, and the injury was not identified until it reached stage 3. The resident had several medical conditions, including COPD, type 2 diabetes, and chronic pain syndrome, which could contribute to skin integrity issues. Despite being at risk for pressure sores, as indicated by Braden Scale scores, the facility did not implement necessary interventions such as turning and repositioning schedules. The resident refused an air mattress, but there was no documentation of alternative measures being taken to prevent pressure injury development. Interviews with facility staff revealed a lack of awareness and documentation regarding the resident's pressure injury and the absence of a turning and repositioning schedule. The facility's failure to implement preventive measures and adequately monitor the resident's skin condition led to the development of a facility-acquired stage 3 pressure injury.
Deficiency in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for food preparation, storage, and distribution, potentially affecting all 22 residents. During an observation, the Nursing Home Administrator (NHA A) was seen preparing scrambled eggs and attempted to take the temperature with a non-functioning thermometer. Despite acknowledging the issue, NHA A proceeded to serve the eggs without verifying the temperature. Later, a working thermometer was presented, indicating the previous one needed new batteries. Additionally, during a kitchen tour, the surveyor noted that the stove top was unclean, with burnt food and crumbs present, and was informed by NHA A that it would not be used until cleaned. Temperature logs for the freezers and refrigerators had multiple gaps, showing that temperatures were not consistently recorded. Furthermore, a container of sugar was improperly stored below the sink next to chemicals, which NHA A acknowledged was incorrect. These observations highlight the facility's failure to adhere to its policy on preventing foodborne illness through proper food handling and storage practices.
Incomplete Facility-Wide Assessment for Staff Competency
Penalty
Summary
The facility failed to ensure that its facility-wide assessment included all relevant details necessary to provide care and services to meet the individual needs of its residents. The assessment, updated on November 3, 2024, outlined various services provided based on resident needs, such as individualized dietary requirements, specialized diets, and cultural or ethnic dietary needs. However, it did not specify the training and competency requirements for kitchen staff, including the dietary manager. This omission was identified during an interview with the Nursing Home Administrator, who acknowledged the need for the facility assessment to include comprehensive staff training and competency details, particularly for kitchen staff. This deficiency has the potential to affect all 22 residents residing in the facility.
Failure to Implement QAPI Plan for Kitchen and Meal Service
Penalty
Summary
The facility did not identify issues requiring quality assessment and assurance activities, nor did it develop and implement appropriate plans of action to correct identified quality deficiencies. This oversight has the potential to affect all 22 residents. Specifically, the facility failed to identify key areas of deficient practice in the kitchen and meal service and did not implement action plans to address these deficiencies. During a survey, the Nursing Home Administrator (NHA) was asked about any ongoing Quality Assurance Performance Improvement (QAPI) activities related to the kitchen and meal areas. The NHA provided a QAPI plan document that was initiated on the same day of the survey, indicating that the plan was not in place prior to the surveyors' arrival. The NHA acknowledged that a QAPI plan for the kitchen should have been started earlier.
Neglect of Resident by Nursing Staff
Penalty
Summary
The facility failed to protect a resident from neglect by a nurse and two CNAs, as evidenced by an incident where the resident was refused assistance in transferring from a wheelchair to a bed. The resident, who is cognitively intact and dependent on staff for mobility and self-care, reported feeling lost and fearful for her safety, leading her to call emergency services for help. The facility's policy on abuse prevention and reporting was not followed, as the incident was not documented in the grievance log, and there was no evidence of a thorough investigation or reporting to the proper authorities. The resident, who has multiple medical conditions including congestive heart failure, anxiety disorder, and chronic kidney disease, was left in her wheelchair for an extended period without assistance, despite her requests for help. The resident also reported being left in soiled incontinence products, which staff refused to change. An EMT who responded to the 911 call confirmed the resident's account and noted that the nurse involved refused to assist the resident even with EMS present, citing fear for her safety and nursing license. The incident was not reported to the State Agency as required, and the new Nursing Home Administrator was unaware of any investigation or corrective actions taken following the incident. The EMT's professional opinion was that the incident constituted neglect, and the facility's failure to address the situation appropriately highlights a significant deficiency in protecting residents from neglect and ensuring their well-being.
Misappropriation of Resident Medications by RN
Penalty
Summary
The facility failed to protect residents from misappropriation of property, specifically involving the wrongful use of hydrocodone-acetaminophen tablets prescribed to two residents, R1 and R10. Between November 26 and November 28, 2024, three tablets for R1 and two tablets for R10 went missing. The discrepancy was discovered during a narcotic count on November 28, 2024, which revealed that the count was incorrect. The facility's investigation concluded that RN S was responsible for the misappropriation, leading to her termination. However, the incident was not reported to the State Survey Agency in a timely manner. R1, who was admitted with multiple diagnoses including congestive heart failure and chronic pain, was found to have been administered hydrocodone tablets by RN S on three occasions, despite not requesting them. R1's Medication Administration Record indicated that she had not requested her PRN Norco in the last 30 days, and she declined narcotics due to side effects. Similarly, R10, who was also cognitively intact, did not request his PRN hydrocodone on the dates it was administered by RN S. Both residents were cognitively intact, as indicated by their Brief Interview of Mental Status scores. The facility's failure to report the incident promptly was highlighted during interviews with staff, including the Nursing Home Administrator (NHA) and the Assistant Director of Nursing (ADON). The NHA acknowledged that the self-report was submitted late, and there was uncertainty about the required reporting timeframe. Additionally, the facility did not conduct a thorough review of RN S's license prior to her employment, which had previous restrictions due to narcotic administration issues. This oversight contributed to the hiring of RN S, who was later found to have misappropriated the medications.
Failure to Timely Report Allegations of Neglect and Misappropriation
Penalty
Summary
The facility failed to report allegations of neglect and misappropriation of resident property in a timely manner, as required by state law and facility policy. The first incident involved a resident who reported neglect on 10/31/24, when staff refused to assist her in transferring from her wheelchair to her bed. This incident was not reported to the State Survey Agency or law enforcement, despite the resident having called 911. The Nursing Home Administrator (NHA) was unaware of the incident until informed by the Chief Executive Officer (CEO) and mistakenly believed it had been reported. The second incident involved the misappropriation of narcotics, specifically three hydrocodone tablets, discovered missing during a narcotic count on 11/28/24. The facility suspended the involved nurses pending investigation and notified the County Sheriff's Department. However, the incident was not reported to the State Survey Agency until 12/11/24, well beyond the required 24-hour reporting window. The NHA acknowledged the delay and confirmed that medication diversion is considered misappropriation, which requires prompt reporting. Both incidents highlight the facility's failure to adhere to its own policies and state regulations regarding the timely reporting of abuse, neglect, and misappropriation. The facility's policy mandates immediate reporting of such allegations to the administrator and relevant authorities, yet these procedures were not followed, resulting in deficiencies noted by the surveyor.
Failure to Investigate Allegation of Neglect
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of neglect involving a resident. On 10/31/24, the facility became aware of an incident where a resident alleged neglect by staff, specifically that they refused to assist her in transferring from her wheelchair to her bed. The resident, visibly upset, reported the incident to Emergency Medical Services (EMS) and the sheriff, who responded to her 911 call. The EMS report labeled the situation as possible elder abuse. Despite this, the facility did not assess or interview residents, take statements, conduct a facility audit, or report the incident to law enforcement as required by their policy. The facility's policy mandates that all allegations of abuse or neglect be thoroughly investigated and reported to the appropriate authorities. However, the Nursing Home Administrator (NHA), who started employment after the incident, was unaware of any investigation or documentation related to the incident. The NHA confirmed that the incident was not reported to the State Agency, as required. Additionally, there was no evidence of any education or audits conducted to prevent recurrence. The facility was unable to produce any documentation related to the incident upon request by the surveyor.
Failure to Monitor Weight and Assess Chest Pain
Penalty
Summary
Facility staff failed to provide care and treatment in accordance with professional standards of practice for one resident. The resident, who was admitted with multiple diagnoses including congestive heart failure, chronic kidney disease stage 4, and atrial fibrillation, was not weighed according to the physician's order. The physician's order required daily weight monitoring with specific instructions to update the medical doctor if there was a weight change of 3 pounds in a day or 5 pounds in a week. However, the resident was not weighed on three specific dates, which is a deviation from the prescribed care plan. Additionally, the resident reported experiencing chest pain on several occasions, but there was no documented assessment by the facility staff following these complaints. The lack of assessment occurred despite the resident's comprehensive care plan, which included monitoring and documenting vital signs and notifying the medical doctor of significant abnormalities. This oversight indicates a failure to adhere to the care plan and respond appropriately to the resident's symptoms.
Failure to Investigate Resident Fall Timely
Penalty
Summary
The facility failed to ensure a safe environment free from hazards and did not provide adequate supervision and assistive devices for a resident, leading to a deficiency. The resident, who was admitted with diagnoses including dementia with behavioral disturbance, Alzheimer's disease, and unsteadiness on feet, sustained an unwitnessed fall in their room. The fall occurred early in the morning, and the facility did not investigate or attempt to determine a root cause analysis until three days after the incident. The facility's policy on Fall Prevention and Risk Assessment emphasizes the importance of providing a safe environment and minimizing potential injuries due to falls. It also highlights the need for early identification of risk factors and staff intervention to reduce fall risks. However, in this case, the facility did not adhere to its policy, as evidenced by the lack of timely investigation and analysis of the fall incident involving the resident. The resident's care plan indicated a history of falls, with interventions such as a toileting program and early get-up list to minimize falls. Despite these measures, the resident experienced a fall, and the facility's failure to promptly investigate and analyze the incident contributed to the deficiency. The Assistant Director of Nursing acknowledged that falls should be investigated timely to determine a root cause analysis, which was not done in this instance.
Inadequate Ostomy Supplies for Resident
Penalty
Summary
The facility failed to provide adequate colostomy supplies for a resident, identified as R3, who required such services. R3 was admitted with multiple diagnoses, including ileostomy status, and had a physician's order to change the ileostomy bag every three days or as needed. However, due to high output and frequent leaks, the facility was changing R3's ostomy appliance multiple times per shift. Despite this need, the facility did not maintain an adequate supply of necessary ostomy supplies, such as rings and paste, which are crucial for securing the ostomy bag and extending its wear time. This deficiency was highlighted by the fact that R3's family member, FM E, had to order paste from Amazon due to the facility's failure to provide it. The facility's supply ordering policy was not effectively implemented, as the Nursing Home Administrator, who was responsible for ordering supplies after the abrupt departure of the previous Director of Nursing, lacked knowledge about ostomy supplies. Despite being informed by FM E about the specific needs and item numbers for R3's ostomy care, the facility's orders did not include the necessary paste. This ongoing issue led to FM E expressing frustration and concern over the inadequate supply, which had been communicated to the facility multiple times without resolution. The lack of a specific policy and procedure for colostomy/ileostomy care further contributed to the deficiency.
Medication Administration Deficiency
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of two residents, R1 and R2, as evidenced by missed and delayed medication administration. R1 did not receive her prescribed Benazepril on two occasions and her Nitroglycerin patch was administered late multiple times. Additionally, R1 missed a dose of Furosemide. The facility's policy requires medications to be administered in a timely manner, within one hour of the prescribed time, which was not adhered to in these instances. R1, who was admitted with multiple diagnoses including congestive heart failure and hypertension, was cognitively intact as per her recent MDS assessment. Despite this, there were no documented reasons for the missed doses of Benazepril and Furosemide, and the Nitroglycerin patch was consistently applied and removed late. The Assistant Director of Nursing (ADON) was unable to provide a reason for the missed medications and confirmed that medications should be administered as ordered. R2, admitted for short-term rehabilitation, also experienced issues with medication availability. R2 did not receive a prescribed inhaler and a weekly injection on the specified dates due to the medications not being available. Interviews with the ADON and other nursing staff revealed a lack of clarity and follow-up regarding the process for ensuring medication availability and administration. The facility's failure to ensure timely medication delivery and administration for R2 was evident, with no follow-up notes or actions documented to address the unavailability of medications.
Unsecured Medication Cart and Inadequate Drug Storage
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were labeled and stored according to accepted professional principles. During a survey, it was observed that a registered nurse (RN K) dispensed several medications, including a controlled substance, into a medication cup and left it unattended on a medication cart. This cart was accessible to a cognitively impaired resident, who was using the cart to self-propel down the hallway. The facility's policy requires that medication carts be kept closed and locked when out of sight of the medication nurse or aide, and no medications should be left on top of the cart. The surveyor observed multiple instances where RN K prepared and administered medications to different residents, leaving the medication cup unsecured and accessible in the hallway. This included a controlled substance, tramadol, which should be stored behind at least two differently keyed locks. Despite being aware of the policy, RN K admitted that medications should not be left unattended. The repeated inaction of securing the medication cart and leaving medications accessible to residents and others in the hallway led to the deficiency.
Lack of Qualified Food Services Manager in Dietary Department
Penalty
Summary
The facility failed to employ a qualified Food Services Manager (FSM) to supervise the dietary department, potentially affecting all 23 residents. The facility's policy requires the daily functions of the Food Services Department to be under the supervision of a qualified FSM. However, interviews revealed that the FSM had been absent for about a week, and the Administrator had been overseeing the department in the interim. Cook1 confirmed the absence of an FSM and mentioned relying on other cooks for guidance. The Administrator acknowledged the lack of an FSM and stated that they were in the process of hiring a new one. Additionally, the Registered Dietitian, who typically visits once a week, was on vacation, further impacting the department's oversight. The Administrator admitted that the dietary department was struggling to find a manager willing to implement the necessary training and policies.
Improper Food Safety Practices in Kitchen
Penalty
Summary
The facility failed to ensure proper sanitation of thermometers and appropriate thawing practices in the kitchen, affecting all 23 residents. Observations revealed that Cook1 and Cook2 did not sanitize thermometers between uses, instead wiping them with dry or damp cloths, which is not in accordance with the facility's guidelines or the 2022 FDA Food Code. Cook1 admitted to not being instructed on proper sanitation methods, while Cook2 was unaware of the location of alcohol wipes and believed running the thermometer under water was sufficient. Additionally, improper thawing and storage practices were observed. Frozen turkey lunchmeat was left thawing on a counter instead of under refrigeration, and raw beef was stored above uncovered raw potatoes in the walk-in refrigerator, posing a risk of cross-contamination. Cook2 acknowledged the error and moved the meat to a lower shelf. The facility's administrator admitted to ongoing struggles with dietary management and the need for proper training and policy implementation.
Deficiencies in Dietary Management and Meal Preparation
Penalty
Summary
The facility failed to adhere to dietary requirements and portion sizes as outlined in their menu and diet extensions, affecting the nutritional needs of residents. Observations and interviews revealed that the facility did not provide the correct portion sizes for meals, as evidenced by the use of incorrect scoop sizes for serving food. Residents reported inconsistencies in meal portions, with some meals being undersized and others oversized. Additionally, the facility did not provide the correct foods for specialized diets, such as a renal diet, as ordered by the attending physician. Interviews with residents and staff highlighted a lack of awareness and understanding of dietary requirements and menu extensions. One resident on a renal diet reported not receiving the appropriate meals, and staff members were unsure of the dietary needs of residents, including those on specialized diets. The facility's menu and diet extensions did not match, leading to discrepancies in meal preparation and serving. Staff members, including cooks, were not familiar with the concept of menu extensions and were unsure of the correct portion sizes to serve. The facility's administration acknowledged the issues within the dietary department, citing challenges in finding a manager to provide proper training and implement necessary policies. The administrator admitted to being aware of the problems and indicated that the facility was in the process of improving the dietary department. However, at the time of the survey, these deficiencies in dietary management and meal preparation had not been addressed, resulting in potential interference with residents' medical conditions and nutritional needs.
Deficiency in Equipment and Furniture Maintenance
Penalty
Summary
The facility failed to maintain a safe and clean environment for two residents, leading to potential risks of injury and infection. One resident was observed self-propelling a wheelchair with cracked and worn vinyl armrests, which had been in that condition for about a year. Despite the resident's request for new armrests, the facility did not provide replacements. Another resident, who was blind, had an overbed table with a chipped surface, creating a non-cleanable and rough area. These conditions were confirmed by the facility's Administrator and Maintenance Director during their observations. The surveyor requested the facility's policy on resident equipment and furniture maintenance, but no policy was provided. The Administrator expressed an expectation that the overbed tray and wheelchair armrests should be in a cleanable and safe condition. The lack of maintenance and replacement of damaged equipment and furniture led to the deficiency, as it compromised the residents' right to a safe, clean, and comfortable environment.
Failure to Provide Written Transfer Notices for Emergent Hospital Transfers
Penalty
Summary
The facility failed to provide a written transfer notice containing all required information to two residents or their representatives during emergent hospital transfers. Resident 6, who was cognitively intact, was transferred to the hospital after being found with unstable vitals and unresponsive. Although a transfer notice was documented in the electronic medical record with a handwritten note indicating verbal consent, the resident later stated she did not recall seeing the form. This indicates a lack of proper communication and documentation regarding the transfer. Similarly, Resident 23, who had multiple medical diagnoses including acute and chronic respiratory failure, was transferred emergently after an incident where the resident was found on the floor. The facility's records did not show evidence of a written transfer notice being provided. The Regional Nurse Consultant could only provide an E-Interact Transfer form intended for hospital staff, not a proper transfer notice for the resident or their representative. The facility's administrator acknowledged the expectation for a written notice to be provided upon emergency transfer, highlighting a gap in adherence to this protocol.
Failure to Provide Written Bed Hold Notices
Penalty
Summary
The facility failed to provide written bed hold notices to two residents, R6 and R23, upon their emergent transfers to the hospital, as required by their policy. The policy mandates that residents or their representatives receive written information about bed hold policies at least twice: once in advance of any transfer and again at the time of transfer or within 24 hours if the transfer is an emergency. However, during the review, it was found that R6, who was transferred to the hospital due to unstable vitals and a dislodged catheter, did not receive a written bed hold notice. Although verbal consent for a bed hold was obtained, there was no documentation of a written notice being provided. Similarly, R23, who was transferred to the hospital after an incident involving unsteady gait and a fall, also did not receive a written bed hold notice. The facility's records, including the Miscellaneous and Assessment tabs of R23's electronic medical record, showed no evidence of such a notice being provided. The Regional Nurse Consultant confirmed that there was no information found regarding the provision of written bed hold notices for these emergent transfers, indicating a lapse in following the facility's policy.
Inaccurate MDS Assessments for Three Residents
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for three residents, which could potentially affect their care planning and services. For one resident, the MDS inaccurately coded an antidepressant medication, Sertraline HCl, as an anti-anxiety medication. This error was confirmed by the MDS Coordinator during an interview. Another resident's MDS inaccurately coded the use of anticoagulant medication, despite the resident only receiving aspirin, which should not be coded as an anticoagulant according to the RAI Manual. Additionally, the resident was on hospice services with a terminal prognosis, but this was not accurately reflected in the MDS assessments. The MDS Coordinator and RNC confirmed these inaccuracies during interviews. The third resident had a stage three pressure ulcer on the heel that was not correctly coded in the MDS since admission. The resident reported the pressure injury started before admission, and the RNC confirmed the coding error. The RAI Manual provides specific guidelines for coding pressure ulcers, which were not followed in this case.
Failure to Conduct and Document Care Conferences
Penalty
Summary
The facility failed to ensure that care conferences were conducted for three residents, which affected their right to participate in their care. The facility's policy required care conferences to be conducted quarterly, annually, and upon admission, involving a team of health professionals. However, for Resident 4, only two care conferences were conducted since admission, with one not documented, and no other interdisciplinary staff were documented as attending. Resident 4 expressed concerns about weight gain and dietary preferences, and the Social Worker noted an increase in behaviors, but the care conference lacked comprehensive interdisciplinary input. Resident 12, who was receiving hospice services, reported that care conferences were not held, and the facility's records lacked documentation of such meetings. The Hospice Home Care Manager confirmed that they had not been invited to any care conferences for this resident. Similarly, Resident 13 did not recall being invited to any care conferences, and the facility's records showed no documentation of such meetings. The Regional Nurse Consultant was unable to find any care conference documentation for Resident 13, indicating a systemic issue in conducting and documenting care conferences as per the facility's policy.
Failure to Provide Comprehensive Discharge Summary
Penalty
Summary
The facility failed to provide a discharge summary that included a recapitulation of the resident's stay for one resident, identified as R19, who was reviewed for discharges among a sample of 16 residents. The facility's policy, effective 02/21/24, mandates that the discharge summary should include a recapitulation of the resident's stay and a final summary of the resident's status at discharge. R19 was admitted and later discharged with a diagnosis related to orthopedic aftercare. The discharge Minimum Data Set indicated that R19 had intact cognition with a BIMS score of 15 out of 15. A progress note labeled as a Discharge Summary mentioned the resident's discharge to home and plans for outpatient rehabilitation but lacked a comprehensive summary of the resident's stay and status. During an interview, the Administrator and Regional Nurse Consultant confirmed the absence of the required discharge summary for R19.
Failure to Maintain CPAP Equipment Cleanliness
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident by not ensuring the CPAP machine, masks, and tubing were cleaned according to guidelines. The facility's policy and the manufacturer's guidelines both emphasize the importance of regular cleaning to prevent contamination and infection. However, the resident expressed fear of using the CPAP machine due to concerns about germs in the tubing, indicating a lack of proper cleaning. The resident's medical history includes chronic obstructive pulmonary disease, sleep apnea, and other conditions that necessitate the use of a CPAP machine. The facility's records, including the Medication Administration Record and Treatment Administration Record, showed no documentation of CPAP equipment cleaning. Despite orders for CPAP use, there were no specific orders for cleaning the equipment. The Director of Nursing confirmed the presence of the CPAP machine at the resident's bedside but acknowledged that the resident did not use it. This oversight in maintaining the CPAP equipment according to the required standards led to the deficiency identified during the survey.
Failure to Properly Date and Discard Opened Aplisol Vial
Penalty
Summary
The facility failed to ensure that an opened vial of Aplisol tuberculin purified protein derivative (PPD) was not available for resident use, as it was undated and potentially outdated. During an observation of the long-term care medication room, a medicine bottle labeled Aplisol, dated 08/14/24, was found with vials of PPD inside. One of these vials was open, with the cap removed from over the rubber stopper, and lacked a date indicating when it was opened or when it would expire. This was confirmed by a Licensed Practical Nurse (LPN) during the observation. The facility's policy on medication storage did not address outdated medication, and the policy on medication labeling and storage required that multi-dose vials be dated and discarded within 28 days unless the manufacturer specified otherwise. The manufacturer's instructions on the Aplisol box indicated that once entered, the vial should be discarded after 30 days. The Regional Nurse Consultant confirmed that the open vials were good for 30 days, and the Administrator expressed an expectation that medications would be dated when opened and not stored past the manufacturer's expectations of life after opening.
Failure to Provide Prescribed Mechanical Soft Diet
Penalty
Summary
The facility failed to provide a resident with the appropriate mechanically altered diet and thickened liquids as ordered by the physician. The resident, who had diagnoses including Alzheimer's disease, dementia, and mild-protein calorie malnutrition, was supposed to receive a mechanical soft diet with nectar thick liquids to prevent aspiration. However, during multiple meal observations, the resident was served regular texture foods and non-thickened liquids, contrary to the dietary orders. On several occasions, the resident received meals that did not match the prescribed minced and moist texture or thickened liquid consistency. For instance, during a lunch observation, the resident was served regular texture chicken and rice instead of the prescribed minced and moist items. Similarly, during breakfast, the resident received regular scrambled eggs and bacon instead of the mechanically altered diet. The dietary staff, including a cook and a CNA, were unaware of the resident's special dietary needs, leading to the resident being served inappropriate meals. Interviews with facility staff revealed a lack of awareness and understanding of the resident's dietary requirements. The CNA and cook both admitted to not knowing the resident was on a special diet, and the cook was unfamiliar with the term 'minced and moist.' The facility administrator acknowledged ongoing struggles with dietary management and training, indicating systemic issues in ensuring compliance with dietary orders.
Infection Control Deficiency in Laundry Area
Penalty
Summary
The facility failed to maintain a proper infection prevention and control program in the laundry processing area. During a tour with the Infection Preventionist, it was observed that there was no barrier between the clean and dirty laundry areas. Clothing was hanging on a rod and a linen cart was covered with a mesh blue cart cover, both located near the washing machines. The Infection Preventionist confirmed the lack of a barrier between the dirty and clean areas. Additionally, the washing machine drainpipes were below floor level, which could lead to contamination in the event of a sewer backup. A blue substance and mineralization were observed on the corrugated hose tubing of the commercial washer, with a light brown liquid dripping from it. The Infection Preventionist was unaware of the purpose of the plastic attached to the pipe. The Laundry Aide was unable to explain the condition of the commercial washer hose, and the Maintenance Director attributed the mineralization to the water softener running without salt. The Maintenance Director had not assessed the washer or the laundry area since his employment began in February. He expressed doubt about the possibility of sewage backing up in the floor sink. The Administrator acknowledged the need for a barrier between clean and dirty areas, cleaning of the washer hose, and ensuring the drainpipes are not exposed to sewage. No policies regarding laundry area maintenance or clean-dirty designation were provided by the Maintenance Director.
Pest Control Deficiency in Kitchenette
Penalty
Summary
The facility failed to maintain a pest-free environment in the kitchenette attached to the dining room, as required by their pest control policy. During an observation, fruit flies were found in a cabinet containing hot dog buns and corn tortillas, with some flies inside one of the bags of buns. The Maintenance Director, who was the sole maintenance worker, was unaware of the pest issue until it was brought to his attention during the observation. He admitted to hearing about a fruit fly problem a week prior but had not investigated it. Upon seeing the flies, he acknowledged the issue and removed the food. However, during a follow-up observation, fruit flies were still present, and the Maintenance Director recognized the need for an intervention.
Failure to Post Accurate Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the daily nurse staffing information was posted with the required details for residents, visitors, and staff. The policy mandates that within two hours of the beginning of each shift, the number of licensed and unlicensed nursing personnel responsible for direct care must be posted in a prominent location. This information should include the facility name, current date, resident census, shift schedule, and the type and category of nursing staff. However, an observation on September 17, 2024, revealed that the staffing information posted was outdated, showing the date as September 14, 2024, and lacked the facility name and a place to update the census for each shift. During interviews, the Administrator confirmed that the posted information was not current and acknowledged that the staff posting should be updated daily with all required elements. This oversight could potentially affect the knowledge of staff availability for the care of the 23 residents, their family members, or their representatives. The failure to post accurate and timely staffing information is a deviation from the facility's policy and could impact the understanding of staffing levels available for resident care.
Failure to Monitor and Assess Resident's Change in Condition
Penalty
Summary
The facility did not ensure that a resident received treatment and care in accordance with professional standards of practice when the resident experienced a change in condition. The resident, who was severely cognitively impaired and had multiple diagnoses including vascular dementia and osteoporosis, expressed increased leg and hip pain. Despite recognizing the change in condition and ordering an x-ray, the facility failed to provide ongoing monitoring and assessment from the time the pain was reported until the x-ray results were obtained, which revealed a left hip fracture. The resident's progress notes and hospice notes indicated that pain management medications were administered, and an x-ray was ordered. However, there was no documented monitoring or assessment of the resident's condition from the time the pain was first reported until the x-ray results were reviewed. The Director of Nursing confirmed that ongoing monitoring and assessment should have been documented but were not. This lack of documentation and monitoring led to a delay in identifying the resident's hip fracture and ensuring appropriate care was provided in a timely manner.
Inadequate Pain Management and Assessment
Penalty
Summary
The facility failed to adequately assess and provide necessary care and services for a resident (R1) experiencing increased pain in the left leg and hip. Despite R1 expressing increased pain on 4/16/24, the facility did not document or reassess R1's pain levels during this period. Additionally, the care plan for R1 did not include goals regarding an acceptable level of pain or non-verbal indicators of pain, which are crucial for a resident with severe cognitive impairment and an activated power of attorney. The facility's policy on administering pain medications requires acute pain to be assessed every 30 to 60 minutes until relief is obtained, but this was not followed for R1. R1's care plan mentioned various conditions such as chronic pain, arthritis, and other ailments, but it lacked specific details on how R1 expresses pain and what non-verbal indicators to look for. The progress notes from 4/16/24 to 4/23/24 show that R1 was given scheduled and PRN pain medications, but there was no consistent documentation of pain monitoring or assessment. The facility's Director of Nursing (DON) indicated that pain is documented in progress notes and that the effectiveness of PRN pain medications is recorded, but this information was not readily accessible or consistently monitored. The facility's failure to ensure ongoing monitoring and assessment of R1's pain, especially during a change in condition, led to inadequate pain management. The DON and Nursing Home Administrator (NHA) were unaware of additional documentation regarding PRN pain medications and non-pharmacological interventions, highlighting a gap in the facility's pain management practices. This deficiency in care planning and pain assessment resulted in R1 experiencing unmanaged pain and a lack of appropriate interventions during a critical period.
Deficiencies in Food Safety Practices Identified
Penalty
Summary
The facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety, leading to a deficiency in food safety practices. Specifically, one resident was served non-pasteurized eggs with runny yolks that were not fully cooked, putting them at risk for Salmonella infection. The facility did not have a policy regarding the use of unpasteurized eggs or safe handling procedures for shell eggs, and staff were unsure if the eggs served were pasteurized. Observations revealed that the facility had unpasteurized shelled eggs in stock, and residents were allowed to order eggs with runny yolks. Staff, including the cook and dietary aides, acknowledged serving eggs with runny yolks to residents upon request, without ensuring they were fully cooked or pasteurized. Additionally, deficiencies were noted in hand hygiene practices, as a cook was observed handling food with bare hands and not performing appropriate hand hygiene before food preparation. Further deficiencies were identified in the facility's food storage practices, as frozen food items were not properly labeled with open dates or use by dates. The facility also failed to consistently record food temperatures before placing items in hot holding, indicating lapses in monitoring and maintaining safe food temperatures. These deficiencies collectively posed a risk of foodborne illness to residents, particularly those in the highly susceptible population served by the facility.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility did not ensure a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations of dust and debris buildup in resident rooms and common areas. Residents R2, R5, R6, and R1, along with a resident representative, voiced concerns about the cleanliness of their rooms. Specific observations included cobwebs, dust balls, and pieces of a broken vase in R2's room; clusters of dust under the bed and along the baseboards in R5's room; and general dust and debris throughout R6's room. R1's room was noted to have a layer of dust on the bed foot covers and dust buildup along the floorboards and behind the door. Additionally, the facility's elevator and foyer were observed to have accumulated dirt and cobwebs in the corners and along the perimeter, respectively. The facility's housekeeping checklist did not include a schedule for daily cleaning of resident rooms or a description of what deep cleaning entails. Interviews with staff revealed that housekeeping is expected to clean resident rooms daily, but the facility was down one housekeeper at the time of the survey. The facility's policy on homelike environments emphasized providing a clean, sanitary, and orderly environment, but the observations and resident reports indicated that this policy was not being effectively implemented. The lack of a clear cleaning schedule and the observed deficiencies in cleanliness contributed to the failure to maintain a homelike environment for the residents.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility did not ensure that residents who are unable to carry out activities of daily living (ADLs) received the necessary services to maintain personal hygiene. Specifically, two residents, R2 and R3, were not receiving showers as scheduled. R3, who has multiple diagnoses including muscle weakness, unsteadiness on feet, and congestive heart failure, reported not having had a shower for two months. The facility's records corroborated this, showing a lack of documentation for scheduled showers or refusals over several months. Interviews with CNAs and the Nursing Home Administrator revealed inconsistencies in documenting showers and refusals, with staff acknowledging that refusals were not always recorded as required. Similarly, R2, who has diagnoses including muscle weakness, dementia, and depression, also did not receive showers as scheduled. R2's medical records showed gaps in documentation for both given showers and refusals. Despite the care plan indicating that R2 requires moderate assistance with bathing, a CNA incorrectly stated that R2 is mostly independent. This discrepancy highlights a failure in communication and adherence to care plans. The Director of Nursing and the Nursing Home Administrator confirmed that the expectation is for staff to document all showers and refusals, which was not being consistently followed.
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Illustrative
What surveyors actually found near you
We read the 298 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Black Earth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ingleside Manor | 8.8 mi | ★★★★★ | 52 | 1 |
| Maplewood Of Sauk Prairie | 9.4 mi | ★★★★★ | 14 | 0 |
| Middleton Village Nursing And Rehab | 13.4 mi | ★★★★★ | 21 | 0 |
| Waunakee Valley Senior Living | 14.5 mi | ★★★★★ | 15 | 0 |
| Hebron Oaks | 14.7 mi | ★★★★★ | 3 | 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.