Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Rivers Edge Nursing And Rehab during CMS and state inspections, most recent first.
The facility failed to follow its abuse/neglect policy requiring notification of law enforcement for alleged violations when a resident with severe cognitive impairment slapped another cognitively impaired resident in the face in a common area. Staff witnessed the altercation, intervened immediately, and nursing assessed the affected resident with no injuries noted. The incident was self‑reported to the state, but the NHA documented that law enforcement was not contacted and later acknowledged that law enforcement should have been notified and that this step was forgotten.
A resident with severe cognitive impairment, multiple comorbidities, and a high fall risk had care-planned fall precautions, including a requirement to remain within line of sight when up in a Broda chair and to receive frequent neuro checks after falls. Despite this, the resident experienced multiple unwitnessed falls, including one from a wheelchair in a hallway while staff were at the nurses’ station and not continuously observing her, indicating the line-of-sight intervention was not maintained. After this unwitnessed fall, the resident was found with a forehead hematoma and pain, but neuro assessments were repeatedly documented as "asleep" and were not completed at times when the resident was known to be awake, contrary to facility policy and staff statements that a proper neuro exam requires waking the resident and assessing pupils and other parameters.
A resident with dementia and moderate cognitive impairment was slapped in the face by another resident with dementia while sitting in a lobby area. Nursing staff immediately assessed the affected resident and found no physical injury but documented that the resident was shaken and worried she had done something wrong, repeatedly bringing up the incident for several hours. Facility policies required protection from psychosocial harm and provision of medically related social services, including emotional support, counseling, and documentation in the medical record. The SW, DON, and NHA all acknowledged that psychosocial follow-up and documentation should have occurred, but there was no documented psychosocial assessment or social services intervention related to the incident, resulting in a deficiency for failure to provide medically related social services.
A resident with multiple cardiac and pulmonary diagnoses, including CHF, HTN, and A-fib, had an order for Metoprolol Succinate ER 150 mg daily with instructions to hold the dose if SBP was below 110 or HR below 55. Over a period of weeks, staff documented at least 20 administrations of this medication when the resident’s SBP was below the ordered parameter, as shown on the MAR. Interviews with a med tech, an RN, the NHA, and the DON confirmed that vital sign parameters are displayed in the MAR, that medications should be held when parameters are not met, and that such administrations are considered medication errors, yet the medication was still given on multiple occasions with low SBP.
A resident with impaired mobility and a history of falls did not have a required floor mat in place as a fall prevention intervention while in bed. After being found outside the facility and later on the floor in his room, staff failed to document the fall, complete a fall investigation, or notify the physician as required by facility policy.
Food was not consistently held and served at a safe, appetizing temperature. A Dietary Cook measured steam-table items at 100 degrees F and 70 degrees F and stated food was only checked when it came out of the oven, not again before plating. The DM and NHA stated food should be temped when removed from the oven and again before serving, but calibration logs were not available. Several residents reported receiving cold or undercooked food, including eggs, toast, and French fries.
Food storage, sanitation, and dishwashing practices were not maintained according to professional standards. Surveyors observed expired cereal, thawed Mighty Shakes with no thaw dates, opened and resealed cookie dough without an open date, and a cup used as a scoop in the sugar bin. They also found dust and grime on kitchen surfaces, ice buildup in the freezer, unclean equipment and dishware storage, a dirty microwave that staff continued to use for resident food, broken floor tiles, and a dietary aide handling dirty and clean dishes without hand hygiene while using a dirty rag on clean trays.
Infection Prevention and Control Program Not Established and Maintained: The facility lacked infection control surveillance documentation before August 2025, had undated or outdated infection control policies and procedures, and had no documentation of monthly infection control rates. The DON/IP stated monthly rates were not being tracked due to lack of access to the infection control system. The facility also had no documentation of Legionella testing despite the Water Management Plan requiring biannual testing, and it did not have access to NHSN to complete monthly reporting and confer rights.
Resident PHI was left visible on a med cart when a form containing names, room numbers, medications, and other protected information for four residents was observed face up and only partially covered. MT M acknowledged the information was PHI and said the form is usually covered, while RN K and the DON stated resident-identifiable information should not be left unattended and visible on medication carts.
A resident with moderate cognitive impairment and multiple health conditions alleged to hospital staff that a nurse had thrown him onto his bed. The facility administrator received this report but, after speaking with involved staff and the resident, did not report the allegation to the state agency or law enforcement as required by policy.
A resident with multiple medical and mental health conditions reported to hospital staff that a nurse had thrown him on the bed. The Nursing Home Administrator was notified and spoke with the involved nurse, CNA, and the resident, but did not interview other staff or residents. The investigation was not thorough, as required by facility policy and regulations.
A resident with severe cognitive impairment made inappropriate sexual remarks and verbalized intentions of sexual misconduct toward an LPN in a shared area, with other residents and staff present. Although law enforcement was involved and another resident was removed, the facility did not update the resident's care plan to address or monitor these behaviors, and no interventions were implemented.
A resident with diabetes, mobility issues, dementia, and mild cognitive impairment had medications left in a cup at the bedside even though there was no physician order or competency assessment for self-administration. The resident said staff routinely leave the meds on the table until she is ready to take them, while the med tech and DON confirmed she was not safe to self-administer and that staff should have stayed to observe ingestion.
Failure to Provide SNFABN and Medicare Liability Notice: The facility did not provide the required SNFABN or accurate financial liability information to three residents whose Medicare A coverage was ending. The BOM stated she did not know the ABN was needed, had just completed training on NOMNCs/ABNs, and printed unsigned CMS-R-131 forms instead of the correct SNFABN; the NHA stated residents should receive a SNFABN.
Failure to complete a PASRR Level II screen for a resident with a major mental disorder who was receiving psychotropic meds. The resident had diagnoses of Major Depressive Disorder and Schizoaffective disorder, and the PASRR Level 1 screen indicated a positive mental disorder finding with no applicable exemption. The SW stated the Level II screen should have been completed and reported not yet being trained on PASRR policy and procedure.
Failure to complete RN assessment and monitor significant weight gain: A resident with MS and paraplegia had a wheelchair transport incident in which a foot came off the footrest and was injured, but no RN assessment was documented and the MD was not notified at the time. A second resident with CHF had a rapid 23-pound weight gain, yet the chart lacked an RN assessment, monitoring for edema or lung sounds, and timely notification of the MD and RD.
Failure to Address Severe Weight Loss: A resident with DM, dysphagia, protein-calorie malnutrition, and cognitive impairment experienced severe unintended weight loss, including a 22.6-pound loss in 1 month and a 32-pound loss over 6 months. Although the care plan included diet orders, fortified cereal, meal monitoring, encouragement, and weight monitoring, staff did not obtain a reweigh for accuracy, did not update the care plan, and did not notify the MD or RD when the large weight loss occurred. Interviews showed staff and leadership knew a significant weight change should trigger reweighing and notification, but this did not happen.
The facility did not ensure that 3 residents receiving hypnotic medications for sleep had documented sleep assessments or routine monitoring of sleep patterns and medication effects. One resident with diagnoses including major depressive disorder, dementia, and insomnia had orders for amitriptyline and trazodone at bedtime, while two other residents with diagnoses including insomnia had orders for zolpidem/Ambien at bedtime. The DON stated residents on hypnotic medications should have a sleep assessment and routine monitoring, but the facility did not provide the requested assessment documentation for two residents and failed to complete sleep assessments before starting the medications.
Two residents experienced significant deficiencies in care, including failure by nursing staff to assess and monitor a change in condition despite reports from CNAs, incomplete documentation of intake and output, and lack of timely provider notification. One resident deteriorated over several days and died after being hospitalized for severe sepsis and UTI. Another resident underwent straight catheterization by an LPN without a physician’s order and had wounds that were not consistently assessed or treated per orders. These actions and inactions were not consistent with professional standards of practice.
Staff observed a CNA recording a resident with Parkinson's disease and encouraging the resident to dance in a manner perceived as demeaning. Despite staff concerns and facility policy requiring immediate reporting of alleged abuse, the administrator did not report the incident to the State Survey Agency after an internal investigation failed to substantiate the claim.
The facility did not conduct thorough investigations into allegations of abuse and neglect involving two residents. In one case, a CNA reported verbal and sexual abuse, but not all involved staff or residents were interviewed. In another case, a resident died from sepsis after a change in condition, but the facility's investigation lacked staff interviews and care audits. These actions did not meet the facility's policy for investigating such incidents.
A resident who is totally dependent for transfers was assisted with a Hoyer lift by only one CNA, contrary to facility policy and the resident's care plan, which require two staff for all mechanical lift transfers. The CNA acknowledged sometimes transferring the resident alone due to staffing shortages, and both the DON and NHA confirmed that the expectation is for two staff to be present during such transfers.
Surveyors identified that the medication error rate in the facility was 5 percent or greater, indicating a failure to maintain proper accuracy in medication administration.
A registered nurse was observed crushing and administering an extended-release Divalproex tablet to a resident for seizure management, contrary to physician orders and facility policy, which prohibit crushing extended-release medications.
The facility did not provide pharmaceutical services to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in noncompliance with regulatory requirements.
A resident experienced a significant medication error due to a failure in the medication administration process.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not provide adequate nursing staff daily to meet all residents' needs and failed to have a licensed nurse in charge on every shift, as required.
The facility did not notify law enforcement after an allegation that a nurse misappropriated a resident's narcotic medication, despite conducting an internal investigation and reporting the incident to the State Agency. The NHA confirmed that police notification was required but was not completed.
The facility did not provide complete discharge documentation for three residents who were transferred to other care settings or discharged home. In each case, required sections of the discharge summary were left incomplete, and essential information such as care during stay, recapitulation of illness, and discharge planning was missing. The lack of coordination and documentation was confirmed by the DON, and in one instance, the discharge was delayed due to confusion over procedures and missing information.
Staff did not follow proper hand hygiene and standard precautions during catheter care for two residents with indwelling catheters, including failing to change gloves and use barriers when required, and not adhering to facility policy or CDC guidelines. Both a CNA and an LPN admitted to lapses in infection control practices during care, and the DON was unsure if her instructions to staff aligned with CDC recommendations.
A resident with multiple complex medical conditions did not receive several scheduled medications on multiple days, including when leaving for an appointment, and there was missing documentation in the MAR. Medications were also administered late or at the same time as other scheduled doses, contrary to facility policy. Staff interviews confirmed that required procedures for medication administration and documentation were not consistently followed, and no progress notes explained the omissions.
A resident was not protected from a significant medication error, as required, due to a failure in medication administration or management.
A resident with an indwelling Foley catheter, at risk for infection, was placed on Enhanced Barrier Precautions (EBP) per care plan and physician orders. Despite clear signage and policy requiring gloves and gowns for high-contact care activities, an LPN was observed performing catheter care and changing briefs without wearing a gown. The LPN acknowledged knowledge of the EBP protocol but did not comply, and the DON confirmed staff had been educated on these requirements.
The facility did not ensure that daily nurse staffing postings accurately reflected the actual staff working each shift, with discrepancies found between posted information and schedules. Staff responsible for postings included the DON even when not providing direct care, and both the staff member and administrator confirmed the postings were inaccurate, affecting the reported staffing for all residents.
Three residents experienced significant harm due to the facility's failure to follow professional standards of practice, including not completing RN assessments, not following provider orders, and not documenting or implementing required care. One resident swallowed a foreign object and was not properly assessed or sent to the hospital promptly, resulting in a surgical intervention. Another resident's foot infection progressed to gangrene and amputation due to delayed antibiotics and lack of wound care. A third resident's vascular ulcer worsened and became infected after missed treatments and delayed antibiotics, leading to hospitalization.
Two residents were not provided with adequate supervision or a safe environment, resulting in one resident suffering a hip fracture after repeated unwitnessed falls despite a PT's recommendation for 1:1 supervision, and another resident charging a power wheelchair in their room without a facility policy or proper safety measures in place.
Surveyors found that food items, including milk, mandarin oranges, barbecue sauce, and magic cups, were opened or removed from original packaging without required open or thaw dates. The Dietary Manager and other staff confirmed that these items should have been labeled according to facility policy, but could not verify when they were opened or thawed. This failure to properly date mark food had the potential to affect all residents.
Surveyors found that multiple residents lived in unclean and cluttered rooms, with soiled linens, debris, and personal items scattered on the floors. Several residents and their representatives reported dissatisfaction with the cleanliness of rooms and equipment, such as wheelchairs, which were observed to be dirty. Staff interviews revealed confusion about cleaning responsibilities, and maintenance issues like water-damaged ceilings and cobwebs were also present.
The facility did not ensure that alternatives were attempted before installing bed rails, failed to assess and document entrapment risks—especially with air mattresses—and did not provide or document education, risk/benefit review, or informed consent for several residents. Staff interviews revealed confusion over responsibilities, and there was no evidence of required safety checks or ongoing monitoring, resulting in multiple deficiencies in bed rail safety.
Surveyors found that food and drink, specifically milk, were served to residents at unsafe temperatures above the required 41°F, with the milk tasting warm. The Dietary Manager demonstrated a misunderstanding of safe temperature ranges, and facility practices did not align with established food safety policies, as no plate warmers or ice were used to maintain proper temperatures.
A resident with significant medical needs reported a missing clothing item to laundry staff, but the complaint was not documented, investigated, or escalated according to facility grievance policy. Staff did not keep a log of lost items or follow the required process, resulting in the grievance remaining unresolved for an extended period.
A resident with multiple risk factors for pressure ulcers returned from two hospitalizations without having the required full body skin assessments completed by nursing staff, as mandated by facility policy. Documentation and staff interviews confirmed that these assessments were not performed, despite the resident's ongoing risk and changes in wound condition.
Two residents with diabetes did not consistently receive routine foot checks as ordered by physicians and required by facility policy. Documentation showed multiple missed foot checks, and staff interviews confirmed that checks were sometimes not performed or were rushed. In one case, a podiatry dressing remained unchanged for several days despite documentation indicating foot checks had been completed.
A resident with a history of diabetes, ankle fracture, and dementia was prescribed an antibiotic for toe cellulitis following an ER visit, but the facility delayed entering the order and administering the first dose, resulting in a significant medication error.
Staff did not follow Enhanced Barrier Precautions (EBP) for two residents requiring infection control measures. In one case, two CNAs assisted a resident with a urinary catheter during a transfer and personal care without wearing gloves or gowns. In another case, the Interim DON removed a wound dressing from a resident with multiple ulcers without wearing a gown, despite facility policy requiring both gown and gloves for such care.
A resident with severe cognitive impairment and multiple medical conditions had ongoing care concerns voiced by their POA, particularly about hydration. The facility did not document, investigate, or resolve these grievances as required by its policy, and leadership could not provide grievance records for the relevant period.
The facility did not conduct complete investigations or timely reporting for multiple abuse allegations, including failure to interview all potentially affected residents and lack of documented psychosocial assessments. In each case, required final reports were not submitted to the State Agency within the mandated timeframe.
A resident with complex medical needs did not receive all prescribed doses of cancer and pain medications due to missed administrations and incomplete documentation on the MAR. Nursing staff interviews confirmed that blank entries and unexplained codes indicated medications were not given, and required nurse's notes were often missing. Issues with prior authorization for pain medication and inconsistent adherence to medication administration policies contributed to the deficiency.
A resident's request to change their primary care physician was not honored due to the facility's extensive and prohibitive requirements for the new physician. Despite the resident's cognitive intactness and expressed dissatisfaction with the current physician, the facility's demands for documentation and lack of follow-up communication hindered the process. The new physician found the requirements excessive and declined to proceed, leaving the resident with the facility's medical director as their PCP.
Failure to Notify Law Enforcement of Resident-to-Resident Altercation
Penalty
Summary
The facility failed to ensure that an alleged incident of abuse involving two residents was reported to law enforcement as required by facility policy and regulatory expectations. The facility’s Abuse/Neglect/Exploitation policy, dated 11/2017, states that all alleged violations are to be reported to the Administrator, state agency, adult protective services, and other required agencies, including law enforcement when applicable, within specified timeframes. A misconduct incident report submitted on 12/30/25 documented that one resident (R4), who had dementia with severe cognitive impairment per an admission MDS assessment, slapped another resident (R3) in the face while R3 was sitting in the lobby and R4 was walking to the dining room. Staff witnessed the event, immediately intervened, and nursing assessed R3, with no injuries noted. The incident report identified R3 as the affected person and R4 as the accused person. The same misconduct incident report indicated that law enforcement was not contacted regarding this resident‑to‑resident altercation. During an interview on 1/21/26, the Nursing Home Administrator (NHA A), who prepared and submitted the misconduct incident report, stated that law enforcement should be notified with every facility self‑report and acknowledged that law enforcement had not been notified for this incident and that it “should have been,” attributing the omission to it having been forgotten. As a result, the alleged abuse incident involving R3 and R4 was not reported to law enforcement in accordance with the facility’s written procedures and reporting requirements.
Failure to Maintain Line-of-Sight Supervision and Complete Neuro Checks After Unwitnessed Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and implementation of fall-prevention interventions for a resident at high risk for falls, as well as failure to complete required neurological assessments after an unwitnessed fall with head injury. The resident had multiple diagnoses including inflammatory spondylopathy of the lumbar region, COPD, acute on chronic systolic CHF, type 2 diabetes with diabetic polyneuropathy, post-stroke cognitive symptoms, muscle wasting and atrophy, unsteadiness on feet, and bilateral age-related cataracts. An MDS assessment showed a BIMS score of 99, indicating severe cognitive impairment. Fall Risk Evaluations conducted on several dates showed the resident was consistently at risk for falls, with scores of 10, 19, 15, and 11. The resident’s care plan identified her as at risk for falls related to medications, dizziness, cognitive impairment, and unawareness of safety, and included multiple interventions such as use of an appropriately sized Broda chair, environmental monitoring, low bed position, call light within reach, use of a gait belt, and later, a “Falling Star” check every 60 minutes. Following an unwitnessed fall on 9/25, the resident’s care plan was updated on 9/26 to include the specific intervention that she must remain within eyesight when up in her Broda chair. Additional fall-related care plan updates on 9/28 included directions to evaluate fall risk on admission and as needed, to alert the provider if a fall occurs, and to initiate frequent neurological and bleeding evaluations per facility protocol after a fall. The facility’s Fall Management Process policy required a complete head-to-toe assessment before moving a resident after a fall, neurological checks for any unwitnessed fall or any fall with evidence of head injury, and documentation of physician and family notification. Despite these policies and care plan directives, the resident experienced further unwitnessed falls, including one on 11/1 while walking unsupervised in her room and attempting to self-transfer from bed, and another on 11/2 when she fell from her wheelchair in the hallway. On the night of 11/2, the resident was in her Broda chair and was supposed to be kept within line of sight of staff per her care plan. A CNA’s written statement indicates the CNA and another staff member were at the nurses’ station gathering paperwork while the resident was on the other side of the nurses’ station near the medication cart and within the CNA’s view. The CNA reported that less than five minutes after last seeing the resident, she noticed the resident was no longer by the medication cart, saw the wheelchair down the hall without the resident in it, and then found the resident lying on her right side on the floor in front of a room. A progress note documented that the fall was unwitnessed and occurred in the hallway. A subsequent assessment identified a hematoma on the resident’s forehead measuring 6.5 x 5 (unit not specified), and progress notes documented the presence of pain. Although neurological assessment forms were completed at multiple time points, many entries simply recorded the resident as “asleep” for all categories, and there were no neurological assessments documented at specific times when the resident was known to be awake (such as when she received morphine and lorazepam or when she self-transferred to the bathroom). Interviews with facility staff, including a medication tech, an RN, the NHA, and the DON, confirmed that “in line of sight” means staff must be able to physically see the resident, and that a proper neurological exam cannot be performed if the resident is asleep because pupils and other parameters must be assessed. The surveyor noted that the facility could not provide documentation showing the resident was in line of sight at the time of the fall from the Broda chair, and that neurological checks were not completed in accordance with policy after the unwitnessed fall with head injury. Interviews with the NHA and DON further confirmed that residents with fall precautions are identified by star pictures on their doors and interventions listed on care plans and closet Kardexes, and that residents with “in line of sight” interventions must be physically visible to staff. The DON stated she would wake a resident to complete a neurological assessment because otherwise she would not know if there had been a change in mental status, and she identified pupil size and vital signs as pertinent findings on neurological assessments. Despite these expectations, the documentation for this resident showed repeated use of “asleep” entries in place of full neurological assessments, even after an unwitnessed fall with a documented forehead hematoma. The surveyor allowed additional time for the NHA and DON to locate any alternative evidence that the resident had been kept within line of sight at the time of the 11/2 fall, but none was provided. These findings demonstrate that the facility did not ensure the resident received adequate supervision in accordance with her care plan and did not complete neurological checks as required by facility policy after an unwitnessed fall with evidence of head injury.
Failure to Provide and Document Psychosocial Follow-Up After Resident-to-Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to provide medically related social services and psychosocial follow-up to a resident after a resident-to-resident altercation. Facility policy on Abuse/Neglect/Exploitation requires protection of residents from physical and psychosocial harm during and after an investigation, including providing emotional support and counseling. The Social Services Director policy further requires identification and provision of medically related social services and adequate documentation of social services actions in the medical record. Despite these policies, there was no documented psychosocial assessment or follow-up for the affected resident after the incident. The incident occurred when one resident with dementia (R4) walked into the lobby and slapped another resident (R3) in the face while R3 was sitting in the lobby. Staff witnessed the event, immediately removed R4, and nursing assessed R3, documenting no physical injuries but noting that R3 was “shaken up.” The facility’s Misconduct Incident Report recorded that R3 was concerned she had done something wrong, required reassurance that she was safe, and continued to bring up the incident for a few hours afterward before forgetting about it. R3’s medical record, including a progress note from the date of the incident, documented the physical assessment and that she was shaken, but contained no follow-up documentation addressing her psychosocial needs related to the altercation. R3 had been admitted with dementia and associated psychotic, mood, and anxiety disturbances, and her most recent MDS showed moderate cognitive impairment. During interviews, the social worker stated she had heard about the incident but was not directly informed of her role, was unsure what her responsibilities would be, and acknowledged that any conversations she had with R3 about the incident were general and not documented. The DON and the Nursing Home Administrator both acknowledged awareness of the incident and indicated they would have expected psychosocial follow-up and documentation for R3 after the altercation. The absence of documented psychosocial assessment or follow-up, despite policies requiring such services and the resident’s expressed distress, formed the basis of the cited deficiency.
Repeated Administration of Metoprolol Outside Ordered Blood Pressure Parameters
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors related to the administration of Metoprolol Succinate. The resident had a physician’s order for Metoprolol Succinate ER 150 mg by mouth once daily for essential hypertension, with explicit parameters to hold the medication if the systolic blood pressure (SBP) was below 110 or the heart rate (HR) was below 55. Despite this order, the Medication Administration Record (MAR) shows that nursing staff repeatedly administered the medication when the resident’s SBP was below the ordered threshold. The facility’s own “Medication Errors” policy defines a medication error as administration not in accordance with the prescriber’s order and states that the facility shall ensure medications are administered according to physician orders. The resident involved was admitted with multiple diagnoses, including secondary parkinsonism, COPD, type 2 diabetes mellitus, acute on chronic systolic congestive heart failure, essential hypertension, atrial fibrillation, and a coronary angioplasty implant and graft. A recent BIMS score of 15/15 indicated the resident was cognitively intact. The MAR documented that Metoprolol Succinate was administered on at least 14 occasions in December and 6 occasions in January with SBP readings below 110, including readings such as 91/45, 98/47, 88/58, and several others under the ordered SBP parameter. These administrations were counted as 20 significant medication errors between early December and late January, as they did not follow the physician’s hold parameters. Interviews with staff and leadership further established that the facility’s processes and staff knowledge acknowledged the requirement to follow vital sign parameters but did not prevent or correct the repeated errors. A medication tech stated that the MAR displays vital sign parameters, that medications should be held when vital signs fall outside those parameters, and that any such occurrence should be reported to the charge nurse with physician notification and monitoring. An RN who frequently worked on the resident’s hall confirmed that vital sign parameters are listed in the MAR, that medications should be held when parameters are not met, and that if a medication is given despite out-of-range vital signs, the physician should be called and the resident closely monitored. The NHA and DON both stated that parameters are written on the MAR, that medications should be held and physicians notified when parameters are not met, and agreed that the administrations in question were medication errors and that the Metoprolol should have been held on those occasions. Despite this, the MAR shows the medication was administered multiple times with SBP below the ordered threshold, constituting the cited deficiency.
Failure to Implement Fall Prevention Interventions and Complete Required Fall Investigation
Penalty
Summary
The facility failed to ensure that a resident received adequate supervision and that fall prevention interventions were in place, as required by facility policy. A resident with a history of falls, bilateral amputation, impaired mobility, and cognitive intactness was care planned to have a floor mat and Dycem in the wheelchair seat as fall interventions. On observation, the floor mat was not in place while the resident was in bed, and staff confirmed that it should have been present according to the care plan. The Director of Nursing acknowledged that the intervention was missing and that staff education would be initiated. Additionally, the resident experienced an incident where he was found outside the facility in his wheelchair, appeared intoxicated, and later was found on the floor in his room. Staff interviews and documentation revealed that after the resident was assessed and returned to bed, there was no mention of a fall in the progress notes, and the required fall investigation was not completed. The nurse involved did not document the fall or complete the necessary event documentation, fall risk assessment, or pain assessment as outlined in the facility's Falls Management Process policy. Furthermore, the physician was not updated regarding the fall, as required by facility policy. The only communication to the physician referenced the resident's intoxication and return to the facility, with no mention of the fall event. The Director of Nursing confirmed that a fall investigation should have been completed and that the physician should have been notified, but these actions were not taken at the time of the incident.
Food Held Below Safe Hot-Holding Temperature
Penalty
Summary
The facility did not ensure that each resident received food that was palatable and at a safe and appetizing temperature. Survey observation found food held in the steam table below the required hot holding temperature. On 9/26/25 at 11:15 AM, a Dietary Cook stated the food had been taken out of the oven at 10:45 AM, and when the surveyor asked for temperatures, hamburgers measured 100 degrees F and French fries measured 70 degrees F. The cook stated the temperatures were too low and said there may not have been enough water in the steam table or in the pan with the hamburgers. The Dietary Cook also stated she only took temperatures when food came out of the ovens and did not recheck temperatures before serving from the steam table. On 9/25/25 at 1:05 PM, she said food could be in hot holding at 10:30 AM and start plating at noon, and that she did not re-temp the food in hot holding prior to plating. She stated she would have used the original oven temperatures and not re-temped before serving. The Dietary Manager later stated thermometers should be calibrated weekly and food should be temped when it comes out of the oven and again before serving, but she did not have calibration logs available. The NHA also stated thermometers should be calibrated weekly and food should be temped both coming out of the oven and before serving. Four residents voiced concerns about cold food. One resident with a BIMS score of 15 said food was hot only 50% of the time and that eggs and toast were always ice cold. Another resident with moderately impaired cognition and a BIMS score of 10 said he received hot food cold at times, a few times a week. A cognitively intact resident with a BIMS score of 14 said his hot food came cold and at an undesirable temperature. Another cognitively intact resident said the food was lousy, really bad, and not edible, and stated that most of the food was not hot, with French fries never coming hot and always undercooked.
Food Storage, Sanitation, and Dishwashing Deficiencies
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards in the kitchen, freezer, refrigerator, and dishwashing areas. Surveyors observed hairlike dust built up in the frame of the drop ceiling, along electrical covers, and on top of outlets in the main kitchen, freezer, and refrigerator units. They also observed frozen drips on and in boxes of food that were no longer sealed by the manufacturer, ice built up inside the walk-in freezer over opened boxes of food, and a stored stand mixer that was unclean. Staff removed a pan from the clean dishware storage rack that was stored unclean, and the microwave had different colored food particles on the inside top and a large orange spill while staff continued to use it to heat resident food without covering it and without cleaning the spills and splashes. Surveyors also observed food dating and storage problems, including cereal in large plastic containers with expired use-by dates, Mighty Shakes in the refrigerator that were thawed with no thaw dates, a cup left in the sugar bin that had been used as a scoop, and cookie dough that had been opened and resealed without an open date. During dishwashing, a dietary aide rinsed dirty dishes and then handled clean dishes without washing her hands between tasks, and she used a dirty rag from her pocket to dry clean trays before placing clean dishes on them. Broken tiles were observed on the floor around the sink, near the refrigerator, and under the coffee pot, and staff stated there was no way to sanitize the cracked tiles.
Infection Prevention and Control Program Not Established and Maintained
Penalty
Summary
The facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of communicable diseases and infections, affecting a census of 39. Survey review found no infection control surveillance documentation prior to August 2025, and the only infection control documentation the facility could locate was from August 2025 forward. On interview, the DON/IP stated that they started on August 1 and did not know about prior documentation, and that the infection control binder from the previous DON could not be found. The facility also lacked documentation that infection control policies and procedures were reviewed annually. Several policies were undated, including Infection Control Program, Infection Surveillance, Antibiotic Stewardship, Influenza vaccine, Pneumococcal vaccine, and COVID vaccine, while the Norovirus policy was dated 3/1/19, the Hand hygiene policy 1/8/20, and the Legionnaire's disease policy 6/1/24. The facility had no documentation of monthly infection control rates by type, and the DON/IP stated they had not been tracking monthly rates because they did not have access to the infection control part of the computer system. In addition, the facility had no documentation of Legionella testing despite the Water Management Plan requiring at least two tests per year, and the Maintenance Director stated no Legionella testing had been done since February 2025. The facility also did not have access to NHSN to complete monthly reporting and confer rights, with the NHA stating access had been unavailable since the receivership took place and the DON/IP stating no one had access to complete reporting.
Resident PHI Left Visible on Medication Cart
Penalty
Summary
The facility did not ensure medical records were maintained in accordance with accepted professional standards when resident-identifiable information was left visible and accessible on a medication cart. On 9/24/25 at 11:14 AM, the surveyor observed a form lying face up on the 100 hallway medication cart, partially covered by another piece of paper, with the names of R27, R28, R44, and R3 uncovered. The form contained these residents’ names, room numbers, medications, and other protected health information. During the observation, the surveyor interviewed MT M, who was passing medications on the 100 hall, and MT M stated that the information was protected health information and that the form is usually flipped over or covered while left on top of the med cart. RN K stated that identifiable resident information should not be left unattended and visible on medication carts. DON B also acknowledged that the visible information was resident protected health information and stated that staff should protect residents’ private information and should not leave paperwork with private information out and accessible to other residents or visitors.
Failure to Report Alleged Abuse to State Agency and Law Enforcement
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported to the State Survey Agency and law enforcement as required by policy. Specifically, a resident with a history of bipolar disorder, antisocial personality disorder, kidney disease, and diabetes, who was moderately cognitively impaired, reported to hospital staff that a nurse at the facility had thrown him onto his bed. This allegation was communicated to the facility's Nursing Home Administrator (NHA) by a hospital care coordinator. The NHA acknowledged receiving the report and stated she would follow up. Upon receiving the allegation, the NHA spoke with the nurse and CNA who were present during the incident, and their statements matched. The NHA also spoke with the resident, who expressed no current concerns, felt safe, and could not recall the incident. Despite recognizing that the resident's statement could be considered an allegation of abuse and should be investigated and reported, the NHA did not report the incident to the state agency or law enforcement. This omission was identified during a review of five investigations, with this case being the only one where the required reporting did not occur.
Failure to Thoroughly Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to thoroughly investigate and report an allegation of abuse as required by policy and regulation. A resident with a history of bipolar disorder, antisocial personality disorder, kidney disease, and diabetes, who was moderately cognitively impaired and had an activated power of attorney, reported to hospital staff that a nurse at the facility had thrown him on the bed. The hospital care coordinator communicated this concern to the Nursing Home Administrator (NHA), who stated she would follow up and report back. The NHA spoke with the nurse and CNA who were working with the resident on the night in question, and their statements matched. The NHA also spoke with the resident, who did not recall the incident and expressed feeling safe at the facility. However, the NHA did not conduct further investigation, such as interviewing other residents or staff. The NHA acknowledged that the resident's statement could be considered an allegation of abuse and should have been thoroughly investigated, but this was not completed.
Failure to Develop Behavior Care Plan for Inappropriate Sexual Conduct
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan that addressed the behavioral needs of a resident who exhibited inappropriate sexual behaviors. Specifically, a resident with severe cognitive impairment, as indicated by a BIMS score of 8 out of 15, was involved in an incident where he made sexual remarks and verbalized intentions of sexual misconduct toward an LPN in a shared gathering room. The incident was witnessed by other residents and staff, and law enforcement was involved, resulting in the arrest and removal of another resident who also participated in the behavior. Despite the incident and the resident's documented cognitive impairment, the facility did not update the resident's comprehensive care plan to include goals or interventions related to inappropriate sexual behaviors. The care plan, last reviewed after the incident, lacked any mention of monitoring or addressing such behaviors. Facility leadership acknowledged that no interventions or monitoring had been implemented for the resident's inappropriate sexual comments, despite recognizing that such measures should have been in place.
Medications Left at Bedside Without Self-Administration Order or Assessment
Penalty
Summary
The facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals, for one sampled resident. The resident had diagnoses including Type 2 diabetes mellitus, muscle wasting and atrophy, muscle weakness, reduced mobility, unsteadiness on feet, unspecified dementia, major depressive disorder, and mild cognitive impairment of unknown etiology. Although the resident’s most recent MDS showed a BIMS score of 15 out of 15, indicating cognitive intactness, the resident’s clinical health status assessment stated that she did not wish to self-administer medications, and there was no physician order or competency assessment in the record for self-administration. Surveyors observed the resident in bed with a cup of medications sitting on the bedside table, and the resident stated that these were her morning medications and that she was not ready to take them yet. The med tech confirmed that the resident did not have an order to self-administer medications and stated that she would normally stay in the room to ensure the resident swallowed all medications before leaving. The DON also confirmed that the resident was not safe to self-administer medications and stated that medications should not have been left at the bedside. The resident stated that staff always leave medications in a cup on the table until she is ready to take them, explaining that she waits because of her colostomy and needs to wait until her stomach feels good before taking medications.
Failure to Provide SNFABN and Medicare Liability Notice
Penalty
Summary
The facility did not provide the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) and did not provide accurate potential financial liability information to residents whose Medicare coverage was ending for 3 of 3 residents reviewed. R2, R8, and R50 were each receiving Medicare A benefits, but none of them were provided with the SNFABN form or informed of their entire potential liability and the reason for the ending of benefits. The facility policy titled Advance Beneficiary Notice dated 10/01/22 states that the current CMS-approved version of the forms shall be used at the time of issuance to the beneficiary and that for Part A items and services, the facility shall use the Skilled Nursing Facility Advance Beneficiary Notice, Form CMS-10055. Surveyor review found that R2's Medicare coverage ended on 7/3/25, R8's on 5/7/25, and R50's on 8/20/25, yet no SNFABN forms were provided. The Business Office Manager wrote that she did not know she needed the ABN and had just completed training on NOMNC/ABNs, and she printed unsigned CMS-R-131 forms for each resident, which were not the correct forms. During interview, the BOM stated she started completing SNFABNs in June 2025 and had just completed training the prior week, and the NHA stated she would expect residents to receive a SNFABN form.
Failure to Complete PASRR Level II Screening for Resident with Major Mental Disorder
Penalty
Summary
The facility did not complete a PASRR Level II screening for a resident with a major mental disorder who was receiving psychotropic medications for behaviors or symptoms of that disorder. Record review showed that R8 had diagnoses of Major Depressive Disorder and Schizoaffective disorder and was receiving Aripiprazole and Escitalopram. The resident’s PASRR Level 1 screen, dated 4/7/23, indicated “Yes” for having a major mental disorder and “Yes” for having received psychotropic medications to treat symptoms or behaviors of a major mental disorder. The PASRR Level 1 screen instructions required referral to the PASRR contractor for a Level II screen when the resident screened positive and did not meet an exemption. R8’s PASRR showed no hospital discharge exemption, no emergency placement exemption, and no respite care exemption. During interview, the Social Worker stated R8 should have had a Level II screen completed and said she had not yet been trained on PASRR policy and procedure; she also stated she had been completing PASRR Level 1 forms after admission and thought they should be done prior to admission. The Nursing Home Administrator stated R8 should have had a PASRR 2 and that it would be corrected that day.
Failure to complete RN assessment and monitor significant weight gain
Penalty
Summary
The facility did not ensure that residents received treatment and care in accordance with professional standards of practice for two sampled residents. For one resident with multiple sclerosis, paraplegia, generalized weakness, and dependence on staff for mobility, a wheelchair transport incident occurred when the resident’s foot came off the footrest and was struck by the wheelchair wheel or hit the ground during movement. The resident reported pain afterward, and nursing notes documented ongoing pain with no swelling or redness initially, later noting tenderness and yellowish discoloration. The record did not show that an RN completed an assessment after the incident, and an RN interviewed by surveyors stated she had no knowledge of the event and had not assessed the resident’s foot. For the same resident, the incident was first documented by an LPN, who noted the resident’s foot had come off the footrest and that the resident had pain. The LPN stated she checked the foot and saw no redness or swelling, but also stated she did not notify the physician at the time. Another LPN later documented continued pain and then contacted the physician after physical therapy reported increased pain and recommended an x-ray. Surveyor interviews with the PT, RN, and DON confirmed that the RN assessment was not completed at the time of the incident and that the DON was not notified until several days later. A second resident with chronic systolic CHF had a recorded weight increase from 178 pounds to 201 pounds within one week, with subsequent weights remaining around 200 pounds. The facility did not document an RN assessment in response to the significant weight gain, and the chart lacked evidence of monitoring for CHF exacerbation such as edema checks or lung sound assessments. The resident’s medical record also did not show timely notification of the MD or RD regarding the weight gain. The RD stated she would expect staff to alert her and investigate significant weight changes, especially with CHF, and the DON stated the facility should notify the MD and RD of significant weight changes and complete RN assessments, but acknowledged that this did not occur.
Failure to Address Severe Weight Loss
Penalty
Summary
The facility failed to recognize, evaluate, and address the nutritional and hydration needs of a resident with multiple diagnoses including normal pressure hydrocephalus, type 2 diabetes mellitus, unspecified protein-calorie malnutrition, dysphagia, muscle wasting and weakness, GERD, depression, Alzheimer's disease, and abnormal weight loss. The resident's MDS showed moderate cognitive impairment, food pocketing, coughing or choking during meals or with medications, and a weight loss of 5% or more in the last month and 10% or more in the last 6 months. The care plan identified nutritional risk and included interventions such as ordered diet, fortified cereal, meal monitoring, encouragement during meals, and weight monitoring. The resident's documented weights showed a decline from 170.8 pounds to 162.8 pounds, then to 140 pounds, reflecting a 22.6-pound loss in 1 month and a 32-pound loss over 6 months. The report states that after the 9.2-pound loss in the prior month and the severe loss that followed, there was no indication the resident was reweighed for accuracy, no new MD orders were received, no new RD recommendations were made, and no update was made to the care plan. A Mini Nutritional Assessment later documented no decrease in food intake and no weight loss, despite the recorded severe loss. Survey interviews showed that staff and leadership were aware that a large weight change should trigger a reweigh and notification of the MD and dietitian, but this did not occur for the resident's severe loss. The MD note referenced a 5% weight loss and ordered weekly weights, but the report states there was no order in the chart for weekly weights and weekly weights were not obtained. The RD later documented that the resident triggered for significant weight changes and recommended a reweight and fortified pudding, while the DON acknowledged the resident's loss was significant and should have been reweighed for accuracy and the dietitian or doctor notified. The facility concluded that it failed to obtain reweights, failed to evaluate the care plan, and failed to implement interventions to prevent further decline.
Failure to Assess and Monitor Hypnotic Medications
Penalty
Summary
The facility did not ensure that residents’ drug regimens were free from unnecessary medications for 3 of 5 residents reviewed for unnecessary medications. The deficiency involved residents receiving hypnotic medications for sleep without the facility completing and documenting sleep assessments before the medications were started, and without routine monitoring of sleep patterns and medication effects as required by the facility policy. The policy stated that hypnotic medications should be used only when clinically necessary and after non-drug interventions had been attempted and documented, with assessment and documentation of sleep pattern, contributing factors, non-drug interventions tried, reason for medication, measurable goals, informed consent, and nursing monitoring for effectiveness, side effects, fall risk, and morning sedation. R7 was admitted with diagnoses including major depressive disorder, altered mental status, mild cognitive impairment, dementia, and insomnia, and had orders for amitriptyline 100 mg at bedtime and trazodone 2 tablets at bedtime for insomnia. R1 was admitted with diagnoses including atrial fibrillation, acute kidney failure, anxiety, and insomnia, and had an order for zolpidem tartrate 5 mg at bedtime for insomnia. R3 had an order for Ambien 10 mg at bedtime for sleep disorder. For R1 and R3, the surveyor requested sleep assessment documentation and none was provided. On interview, the DON stated that residents on hypnotic medication should have a sleep assessment completed and routine monitoring, and the facility failed to complete sleep assessments prior to residents starting hypnotic medications as well as provide routine monitoring.
Failure to Recognize and Respond to Change of Condition and Inadequate Wound Care
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for two residents who experienced changes in condition. For one resident with a history of Alzheimer’s disease, kidney disease, and an indwelling Foley catheter, multiple CNAs observed and reported significant changes including increased lethargy, decreased intake, and changes in urine color and output. Despite these reports, nursing staff did not complete a nursing assessment, did not monitor the resident’s condition, and did not notify the provider of the changes. Documentation of intake and output was inconsistent and incomplete, with staff using non-quantitative symbols instead of actual measurements, making it impossible to determine the resident’s fluid status. The resident’s condition deteriorated over several days, culminating in hospitalization for severe sepsis, bacteremia, and UTI, and ultimately resulted in death. Another resident was subjected to a straight catheterization by an LPN to obtain a urine sample without a physician’s order, which is not permitted by professional standards or facility policy. The resident reported pain and discomfort from the procedure, which was attempted multiple times, including one attempt that resulted in a contaminated sample. Additionally, this resident had multiple wounds that were not consistently assessed or measured, and there was no documentation of an admission skin assessment or classification of the wounds. Physician orders for wound care were not consistently followed, and wound documentation was incomplete and lacked necessary details such as tunneling and depth. Interviews with staff and review of facility documentation revealed a lack of clear responsibility for monitoring intake and output, inconsistent documentation practices, and failures to notify providers of significant changes in residents’ conditions. The facility’s own policies required immediate notification of changes in condition and adherence to the nursing process, but these were not followed. These failures resulted in immediate jeopardy for one resident and demonstrated a pattern of deficient practice in the recognition, assessment, and management of changes in condition and wound care.
Removal Plan
- Educate all nursing staff, including agency, on recognition of change of condition and immediate reporting to the nurse. The nurse will perform a head to toe assessment and notify the PCP of findings.
- Educate staff on recognizing a change of condition, including changes in mental status, intake or output, urine color, communication, pain, swelling, weakness, and skin color. Use the stop and watch warning tool.
- Educate staff to report possible change of condition to the nurse immediately. The nurse will do a full assessment, call the MD, follow MD directions, document the change, notify the POA/MCO, continue monitoring, and ensure documentation in the resident’s chart, 24-hour board binder, and report to next shift.
- Educate nurses on completing a head to toe assessment, including vitals, pain, GI, respiratory, cardiac, GU symptoms, and immediate MD notification. Continue monitoring and ensure documentation in the resident’s chart, 24-hour board binder, and report to next shift.
- Train staff on properly recording fluid intake and food percentage for each resident on each shift. CNA assigned to the dining room will record all intakes and ensure residents eating in rooms are recorded. CNA is responsible for charting this information in the resident’s chart.
- Educate staff on recording intakes using the spreadsheet for each meal, properly documenting in the resident’s chart, noting if the amount is off baseline, and immediately reporting to the nurse.
- Educate staff to report immediately to the nurse if the resident’s intake or output has decreased.
- Educate staff on the 24-hour board binder and proper recording of change of condition to be reviewed during report off.
- Sweep the building for any changes in condition.
- Review policy related to changes of condition and notification of changes.
- Implement 24-hour board binder for monitoring and review during stand up.
- Implement process for monitoring fluid intake and output and when to notify MD/NP.
- Review head to toe and system-specific assessment for intake and output.
- Implement system to report off resident change of condition to next shift.
- The DON or designee will conduct audits of charting for change of condition and documentation.
- The DON or designee will conduct audits of the 24-hour report for properly completed and documented assessments and MD notification.
- The DON or designee will conduct audits to ensure changes of condition are recognized, assessments completed, and MD notification.
- The DON or designee will conduct audits of intake sheets and proper documentation in charts.
- The DON or designee will conduct audits of output documentation and proper reporting of inadequate output.
- The DON or designee will conduct audits of the intake sheet and proper documentation and reporting of decreased intake.
- The DON or designee will conduct audits on proper reporting of change of condition to the next shift.
- Review all facility actions, education, and audits at QAPI.
Failure to Report Alleged Mental Abuse Involving Resident Recording
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately to the administrator and the State Survey Agency as required. Multiple staff members, including CNAs and LPNs, witnessed a CNA taking videos and pictures of a resident with Parkinson's disease at the nurse's station. Staff statements indicated that the CNA was encouraging the resident to dance while recording, which was perceived by some staff as inappropriate and demeaning. Despite these observations and staff concerns, the administrator did not report the allegation to the State Survey Agency. The administrator acknowledged that recording a resident could be considered potential abuse but chose not to submit an initial abuse report after conducting an internal investigation and determining the allegation could not be substantiated. The facility's own abuse policy requires reporting all alleged violations to the appropriate authorities within specified timeframes, but this procedure was not followed. The resident involved has a guardian and was admitted with a diagnosis of Parkinson's disease. The failure to report the allegation was identified through staff interviews, record review, and an anonymous complaint received by the state agency.
Failure to Thoroughly Investigate Alleged Abuse and Neglect
Penalty
Summary
The facility failed to ensure that all alleged violations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated for two of four residents reviewed. In the first instance, a certified nursing assistant (CNA) reported allegations of verbal and sexual abuse involving another CNA and a resident. The report included claims of inappropriate conduct, such as flirting and the exchange of food, as well as verbal mistreatment. The facility's investigation did not include interviews with all potentially involved staff or other residents who may have had relevant information. Specifically, the second CNA on duty during the alleged incident was not interviewed, and no other residents were questioned about the allegations. The nursing home administrator acknowledged that additional interviews should have been conducted to fully understand the scope of the allegations. In the second instance, a resident with multiple diagnoses, including severe cognitive impairment, experienced a change in condition that led to hospitalization and subsequent death from sepsis. The facility initiated a self-report investigation after learning of the resident's death and diagnosis of sepsis. However, the investigation did not include interviews with staff or audits of resident care, nor was any education provided regarding the incident. The nursing home administrator confirmed that no staff interviews or house audits were completed, and there was an expectation that nursing staff would report changes in condition and complete assessments. Surveyors found, through their own interviews and record review, concerns related to the resident's change of condition, assessments, and physician notification that were not addressed in the facility's investigation. Both cases demonstrate that the facility did not follow its own policy requiring immediate and thorough investigations of alleged abuse, neglect, or mistreatment. The investigations lacked comprehensive documentation, failed to identify and interview all involved persons, and did not fully determine the extent or cause of the alleged incidents. These deficiencies were identified through observation, interview, and record review by surveyors.
Failure to Ensure Two-Person Assistance During Hoyer Lift Transfer
Penalty
Summary
A deficiency occurred when a resident who requires total assistance for transfers, as documented in their care plan and Minimum Data Set (MDS), was transferred using a Hoyer lift by only one Certified Nursing Assistant (CNA) instead of the required two staff members. The facility's policy and the resident's care plan both specify that all mechanical lift transfers must be performed with two staff to ensure safety. The resident, who has multiple diagnoses including spina bifida, diabetes mellitus, asthma, chronic heart failure, and a history of falls, reported to the surveyor that sometimes only one CNA assists with Hoyer lift transfers, particularly during the PM shift. During interviews, a CNA confirmed that due to staffing shortages, he sometimes performs Hoyer lift transfers alone, including with this resident, despite knowing the policy requires two staff. Both the Director of Nursing (DON) and the Nursing Home Administrator (NHA) stated that they expect staff to follow the facility's policy and resident care plans, which mandate two staff for Hoyer lift transfers. The failure to consistently provide adequate supervision and follow established transfer protocols led to the deficiency.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
A medication error rate of 5 percent or greater was identified during the survey. This indicates that the facility failed to ensure that the administration of medications was performed with an acceptable level of accuracy, resulting in a higher than permitted rate of medication errors. The deficiency was based on direct findings by surveyors regarding the facility's medication administration practices, as evidenced by the calculated error rate exceeding the regulatory threshold.
Crushing and Administering Extended-Release Medication Without Order
Penalty
Summary
A significant medication error occurred when a registered nurse crushed and administered an extended-release Divalproex (Depakote) tablet to a resident, despite the medication being prescribed in its extended-release form for seizure management. Facility policy specifies that medications should be administered as ordered and in accordance with manufacturer specifications, which includes not crushing medications labeled as 'do not crush.' The resident's physician orders did not include instructions to crush the Divalproex extended-release tablet, and the Director of Nursing confirmed that there was no such order and that it is not acceptable to crush this medication. The error was directly observed by the surveyor during medication administration.
Failure to Provide Required Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident experienced a significant medication error, indicating a failure in the medication administration process. Specific details regarding the actions or inactions that led to the error, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Insufficient Nursing Staff and Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified based on observations and findings that indicated staffing levels and licensed nurse coverage were insufficient to comply with regulatory requirements. No additional details about specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Notify Law Enforcement of Medication Misappropriation
Penalty
Summary
The facility failed to ensure that all alleged violations involving misappropriation of resident medications were reported to all required authorities. Specifically, when the facility became aware of an allegation that a nurse had signed out a resident's narcotic medication and placed the pill in her pocket, the facility initiated an investigation and submitted a Facility Reported Incident to the State Agency as required. However, the facility did not notify law enforcement about the incident, despite this being a requirement outlined in their own policy and acknowledged by the Nursing Home Administrator (NHA) during interview. The facility's policy mandates immediate reporting of all alleged violations, including misappropriation of resident property, to the administrator, state agency, adult protective services, and law enforcement when applicable. The surveyor's review of the investigation confirmed that while staff were educated and an internal investigation was conducted, the police were not contacted regarding the misappropriation of medication. The NHA confirmed during interview that law enforcement should have been notified in this case.
Failure to Provide Required Discharge Documentation for Multiple Residents
Penalty
Summary
The facility failed to provide proper discharge documentation for three out of four residents reviewed for discharge. In the case of one resident who was transferred to an assisted living facility, the discharge process was delayed by one to two weeks due to incomplete and unclear documentation, lack of coordination, and missing information in the discharge summary. The required sections of the discharge summary, such as care during stay, recapitulation of illness and treatment, functional status, and pre-discharge preparation, were not completed. The social services director, who was responsible for the discharge, did not document key aspects of the process and was reportedly unsure about the necessary procedures and the receiving facility. Another resident, who was discharged home, also did not receive a complete discharge summary. The documentation provided at discharge consisted only of an order summary with an active medication list, lacking details such as the date and time of last medication administration and a comprehensive recap of the resident's stay. The care plan did not address discharge planning, and the interdisciplinary discharge summary was left incomplete. The social worker, who was primarily responsible for discharge planning, was not available, and the director of nursing confirmed that the documentation was insufficient and incomplete. A third resident was transferred to a hospital, but the facility failed to document the transfer appropriately or communicate necessary information to the receiving provider. There was no completed discharge summary, no documentation of the reason for transfer, and no bed-hold notice or explanation regarding the resident's potential return. The progress notes did not address the discharge, and the interdisciplinary discharge summary remained unfinished. The director of nursing acknowledged the lack of documentation and information regarding the resident's transfer.
Failure to Follow Proper Catheter Care and Infection Prevention Protocols
Penalty
Summary
Staff failed to provide appropriate catheter care and infection prevention for two residents with indwelling urinary catheters. In one instance, a CNA performed suprapubic catheter care without following proper hand hygiene protocols, such as not changing gloves or performing hand hygiene when moving from dirty to clean tasks, and failed to use a barrier under the wash basin. The CNA also contaminated the wash basin by reaching into it with soiled gloves and admitted to not following correct procedures during an interview. The DON confirmed that hand hygiene should be performed before and after care and when moving from dirty to clean, and that a barrier should be used under the wash basin. In another case, an LPN provided catheter care to a resident with a history of chronic kidney disease, pyelitis cystica, and obstructive uropathy. The LPN did not don a gown, failed to change gloves or perform hand hygiene after picking up a cleansing wipe that had fallen into the toilet, and continued care without following standard precautions. The resident was found with urine-soaked clothing due to the catheter not being attached to the leg bag, and the stat lock and extension tubing were missing. The LPN admitted to not knowing the facility's catheter care policy and acknowledged that gloves should have been changed after handling the contaminated wipe. Facility policy and CDC guidelines require hand hygiene and standard precautions, including glove changes and the use of barriers, during catheter care to prevent infection. Both staff members failed to adhere to these protocols, as evidenced by their actions and their own admissions during interviews. The DON also stated that she teaches staff to triple glove and remove layers as they become soiled, but was unsure if this practice aligns with CDC recommendations.
Failure to Ensure Accurate and Timely Medication Administration and Documentation
Penalty
Summary
The facility failed to ensure accurate and timely administration of medications for one resident, resulting in multiple missed doses, late administrations, and incomplete documentation. The resident, who had diagnoses including type 2 diabetes, neoplasm-related pain, acute kidney failure, secondary breast cancer, bone cancer, depression, and anxiety disorder, did not receive her scheduled morning medications on several days, including when she left the facility for a pre-scheduled appointment. There was no documentation in the Medication Administration Record (MAR) for numerous medications on specific dates, and no progress notes explaining the omissions or the resident's absence from the facility. Further review of the MAR revealed that on one occasion, the resident received both her morning and afternoon medications at the same time, and several medications were administered outside the recommended time window, with some doses given four to seven hours late. The facility's medication administration policy requires medications to be given within one hour before or after the scheduled time, with immediate documentation and notation of any delays or omissions, but these procedures were not followed. Interviews with the DON and a Medication Technician confirmed that staff should check appointment logs and communication boards to ensure residents receive medications before leaving for appointments, but this process was not consistently implemented. The Director of Nursing acknowledged the missed medications and lack of documentation, agreeing that progress notes should have been made to explain the omissions. The DON also confirmed that medication administration times should reflect the actual time of administration, and that the facility's practices did not align with policy requirements. No additional documentation was provided to account for the missed or late medications, and the facility did not document any medication errors during the period in question.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident experienced a significant medication error, indicating a failure in the administration or management of medications as required by regulations. Specific details regarding the actions or omissions that led to the error, as well as the resident's medical history or condition at the time, are not provided in the report.
Failure to Implement Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program as required, specifically in the implementation of Enhanced Barrier Precautions (EBP) for a resident with an indwelling urinary catheter. The facility's policy and physician orders required the use of gloves and gowns during high-contact care activities, such as changing briefs, toileting, and catheter care, for residents under EBP. Despite these requirements, a staff member was observed entering the resident's room and performing these high-contact care activities without donning a gown, as mandated by both facility policy and CDC guidelines. The resident involved had a medical history that included chronic kidney disease, pyelitis cystica, and obstructive and reflux uropathy, and was at increased risk for infection due to the presence of an indwelling Foley catheter. The resident's care plan and physician orders specifically called for EBP, including the use of appropriate PPE during high-contact care activities. A sign was posted on the resident's door indicating the need for gloves and gowns for such activities, yet this protocol was not followed during the observed care. Interviews with the LPN who provided care confirmed awareness of the EBP requirements but revealed non-compliance, as the LPN admitted to not wearing a gown during catheter care. The Director of Nursing also confirmed that staff had been educated on EBP protocols and that it was her expectation for staff to follow these precautions for residents with catheters or wounds. Despite this, the required infection control measures were not implemented during the observed incident.
Inaccurate Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to ensure that daily nurse staffing information postings were accurate, as required. Surveyors reviewed staffing schedules and posted staff information over a two-week period and found multiple discrepancies between the posted information and the actual schedules. For several days, the number and type of staff listed on the postings did not match the staff who actually worked, as indicated by the schedules. For example, postings often included staff such as RNs or Med Techs who were not present according to the schedule, or omitted staff who did work. Additionally, the Director of Nursing (DON) was included in the postings even when not providing direct patient care, contrary to requirements that only direct care staff be listed. During interviews, the staff member responsible for preparing the postings stated that she completed them based on the printed schedule and included the DON's hours regardless of whether direct care was provided. Both the staff member and the Nursing Home Administrator acknowledged that the postings and schedules were not accurate and did not match. These inaccuracies affected the reported total number and hours of licensed and non-licensed staff responsible for resident care on each shift, potentially impacting all 43 residents in the facility.
Failure to Provide Care Consistent with Standards of Practice Resulting in Immediate Jeopardy
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for three residents, resulting in significant adverse outcomes. In one case, a resident with a history of dysphagia, respiratory failure, and psychological disorder reported swallowing a stress ball. Staff did not contact poison control to determine the toxicity of the ball's contents, did not complete a Registered Nurse (RN) assessment including respiratory, abdominal, or pain assessments, and inaccurately reported to the Nurse Practitioner (NP) that the ball was retrieved without having it in possession. The resident requested to go to the hospital but was not sent until the following day, despite expressing distress and pain. Orders from the NP for close monitoring were not followed, and the resident's care plan was not updated to prevent recurrence. The resident ultimately developed a high-grade small bowel obstruction requiring surgical intervention and a six-day hospitalization. Another resident with diabetes and a history of serious ankle fracture developed cellulitis in the right third toe, which progressed to gangrene and possible osteomyelitis. The facility did not initiate the prescribed antibiotic in a timely manner, failed to monitor, assess, or document the wound, and did not complete or document required diabetic foot checks. Wound care orders from podiatry were not carried out, and the wound was not measured or assessed as required. The resident's care plan was not updated to reflect the infection, wound, or subsequent amputation of all five toes on the right foot. A third resident developed a vascular ulcer on the right leg. Staff failed to transcribe wound and antibiotic orders to the Treatment Administration Record (TAR), resulting in missed treatments and a four-day delay in antibiotic administration. Weekly wound assessments and measurements were not completed, and a person-centered care plan for the vascular ulcer was not developed. The ulcer deteriorated and became infected, leading to hospitalization for cellulitis and intravenous antibiotics. Across these cases, the facility did not complete RN assessments with changes in condition, did not follow provider orders, and failed to document and implement required care and monitoring, resulting in immediate jeopardy.
Failure to Provide Adequate Supervision and Safe Environment for Residents
Penalty
Summary
The facility failed to ensure that two residents were provided with adequate supervision and a safe environment, resulting in accident hazards and actual harm to one resident. One resident with multiple complex diagnoses, including Parkinson's disease, traumatic brain injury, epilepsy, and mobility impairment, was identified as being at high risk for falls and required staff assistance for transfers and toileting. Despite a physical therapist's documented recommendation for 1:1 supervision due to repeated falls and a history of seizures, the facility did not implement this intervention or increase supervision. The resident experienced multiple unwitnessed falls, including one that resulted in a hip fracture while self-transferring from a wheelchair to bed. Documentation showed that the care plan was reviewed after each fall, but no new or enhanced interventions were put in place, and there was no evidence of staff education following the injury. Interviews with staff and administration confirmed that 1:1 supervision was not provided, and there was no documentation explaining why the recommended intervention was not implemented. Another deficiency was observed regarding the charging of a power wheelchair. A resident with multiple medical conditions, including diabetes, muscle weakness, and mild cognitive impairment, was found charging their motorized wheelchair in their room, rather than in a designated charging area behind a fire-safe door. The facility administrator acknowledged that the wheelchair should not have been charged in the resident's room and that there was no policy or procedure in place for power wheelchair charging. The lack of a policy and the improper charging location created a potential accident hazard within the resident's environment. The facility's own policies and clinical guidelines require the assessment of fall risk, implementation of appropriate interventions, and maintenance of a safe environment free from hazards. In both cases, the facility did not follow through with necessary actions to prevent accidents, either by failing to implement recommended supervision for a high-risk resident or by not having procedures in place to ensure safe charging of power wheelchairs. These failures resulted in actual harm to one resident and the presence of accident hazards for another.
Failure to Date Mark Opened and Thawed Food Items in Dietary Services
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe and sanitary environment for food storage, preparation, and distribution, as required by professional standards and facility policy. Specifically, food items such as milk, mandarin oranges, barbecue sauce, and magic cups were found to be opened or removed from their original packaging without being labeled with open or thaw dates. The facility's policy requires all opened or prepared food to be clearly marked with the date by which it should be consumed or discarded, and for the head cook or designee to check the refrigerator daily for expiring items. During interviews, the Dietary Manager acknowledged that magic cups should be labeled with thaw dates and all opened food or drink should have open dates, but was unable to confirm when the observed items had been opened or thawed. The Nursing Home Administrator and Director of Nursing also confirmed that food removed from manufacturer packaging and opened milk should be labeled with use by or open dates, and that magic cups require thaw dates. These lapses in date marking and labeling were observed to have the potential to affect all 41 residents in the facility.
Failure to Maintain Clean, Safe, and Homelike Environment for Residents
Penalty
Summary
Surveyors identified that the facility failed to provide a safe, clean, comfortable, and homelike environment for multiple residents. Observations included soiled linens, dirty towels, food, clothing, and various items scattered on the floors of several resident rooms. In one instance, a resident's bed had yellowish/brown stains on the sheets and pillowcase, and the floor was cluttered with food, personal items, and trash. Residents and their representatives voiced concerns about the cleanliness of their rooms and personal equipment, such as wheelchairs, which were observed to be dirty with dried food particles and stains. Interviews with staff revealed a lack of clarity regarding responsibility for cleaning certain items, particularly wheelchairs. Housekeeping staff, CNAs, and other personnel were unsure about who was responsible for cleaning wheelchairs or how often this should occur. Some staff recalled that there was previously a schedule for wheelchair cleaning, but it was no longer in use, and no one could confirm the current process. This lack of a defined cleaning protocol contributed to the ongoing issues with unclean equipment and resident environments. Additional environmental deficiencies were noted, such as water stains and a cut-out section in a resident's ceiling due to a leaking roof, cobwebs above beds, and various debris including straw wrappers, crumbs, and personal items on the floors of multiple rooms. Maintenance issues, such as unresolved roof leaks and water damage, were acknowledged by facility leadership but remained unaddressed at the time of the survey. Residents with varying levels of cognitive impairment and complex medical conditions were affected by these deficiencies, with several expressing dissatisfaction with the cleanliness and upkeep of their living spaces.
Failure to Assess and Document Bed Rail Safety and Alternatives
Penalty
Summary
The facility failed to ensure that alternatives were attempted prior to the installation and use of bed rails for multiple residents. For six residents reviewed, there was no documentation that alternative interventions were tried before bed rails were installed. Additionally, the facility did not complete or document required assessments for the risk of entrapment, particularly when bed rails were used in combination with air mattresses, which is known to increase entrapment risk. There was also a lack of evidence that the risks and benefits of bed rail use were reviewed with residents or their representatives, and informed consent was not obtained or documented. For several residents, including those with significant medical conditions such as Parkinson's Disease, Multiple Sclerosis, morbid obesity, and cancer, the facility did not perform or document safety/gap tests between the mattress and bed rails. Comprehensive care plans and physician orders indicated the use of bed rails and air mattresses, but there was no evidence of updated bed rail assessments, ongoing monitoring, or audits of bed rails. Residents and family members reported not receiving education or information about the risks and benefits of bed rail use, and there was no written proof of consent in the medical records. Interviews with facility staff revealed confusion and lack of clarity regarding responsibilities for assessing entrapment risk, performing gap measurements, and maintaining documentation. The maintenance director and DON each believed the other was responsible for certain aspects of bed rail safety and assessment. There was no documentation of routine maintenance or audits of bed rails, and staff could not provide evidence of completed assessments or education provided to residents or families. The facility's own policy and FDA recommendations regarding bed rail safety and assessment were not followed, resulting in multiple deficiencies related to the safe use of bed rails.
Failure to Serve Food and Drink at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to ensure that food and drink served to residents were palatable and maintained at safe, appetizing temperatures, as required by facility policy and professional food safety standards. During surveyor observations, two test trays were served with milk at temperatures above the recommended maximum of 41°F, specifically at 53.2°F and 48°F, which placed the milk in the temperature danger zone. The milk was also noted to taste warm. The food items were served after all other trays had been distributed, and while plates were covered, no plate warmers or ice were used to maintain appropriate temperatures for hot or cold items. Interviews with the Dietary Manager revealed a misunderstanding of the correct temperature range for cold foods, as she stated that cold foods should be served between 40°F and 55°F, rather than the required 41°F or less. The facility's own policies referenced the need to keep refrigerated, ready-to-eat, time/temperature control for safety (TCS) foods at 41°F or less, and to distribute and serve foods in a manner that maintains proper temperatures and prevents contamination. Despite these policies, the observed practices did not align with the stated requirements, resulting in the deficiency.
Failure to Document and Resolve Resident Grievance Regarding Missing Personal Item
Penalty
Summary
A resident with multiple complex medical conditions, including muscle wasting, neoplasm-related pain, diabetes, morbid obesity, immunodeficiency, chronic respiratory failure, cancer, and acute kidney failure, reported a missing gray scrub top to laundry staff. The resident, who was cognitively intact, expressed frustration about the missing item and stated she had reported it to a laundry aide approximately two months prior. The laundry aide confirmed receiving the complaint but did not document the grievance, report it to a supervisor, or escalate it to the Grievance Official as required by facility policy. The aide also indicated there was no log for lost or missing items and was unsure of the process for unresolved missing items. Further interviews revealed that the Housekeeping/Laundry Manager only became aware of the missing item after being informed by the laundry aide a week prior to the survey. The manager described an informal process of searching for the item and, if not found, eventually notifying medical records to replace it, but did not mention any documentation or formal grievance filing. The Nursing Home Administrator stated that staff are expected to report missing items to the Social Worker, search for the item, complete a grievance form, and replace the item if not found. However, in this case, the facility failed to document, investigate, or resolve the grievance in accordance with its own grievance policy.
Failure to Complete Required Skin Assessments After Hospital Readmission
Penalty
Summary
The facility failed to ensure that a resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice. Specifically, after two separate hospitalizations, there was no documentation that a full body skin assessment was completed upon the resident's return, as required by the facility's own policy. The policy mandates that a licensed or registered nurse perform a full body skin assessment upon admission or readmission, daily for three days, and weekly thereafter. Despite this, there were no skin or wound assessments documented for the dates the resident returned from the hospital. The resident involved had multiple risk factors, including type 2 diabetes with polyneuropathy, chronic venous hypertension with ulcer, and a history of pressure ulcers. The resident's Braden Scale scores fluctuated between high and mild risk for pressure ulcers. Progress notes and wound visit reports confirm that wound assessments were not performed or documented on the days the resident returned from the hospital, and staff interviews confirmed that assessments were expected but not completed. Direct observation of the resident's wound revealed significant changes in the wound's size and appearance, further underscoring the lack of timely assessment.
Failure to Provide Routine Diabetic Foot Checks
Penalty
Summary
The facility failed to provide routine diabetic foot checks as required by physician orders and facility policy for two residents with diabetes. For one resident with type 2 diabetes, diabetic polyneuropathy, and a history of pressure ulcers, the care plan and physician orders specified daily foot checks at bedtime. However, documentation showed that foot checks were not completed or signed off on several dates, and there was no documentation of foot checks prior to the initiation of the order. Interviews with nursing staff and the interim director of nursing confirmed that if the checks were not documented, they were not done, and that nightly foot checks were expected. For another resident with diabetes and a recent ankle fracture, physician orders and the treatment administration record also required nightly diabetic foot checks. Review of the records revealed multiple dates across several months where foot checks were not completed. An LPN interviewed could not recall specific details about the resident's foot checks and admitted that checks were sometimes rushed due to the resident's agitation. Additionally, a dressing placed by podiatry remained unchanged for several days, despite documentation indicating that foot checks had been completed. The interim director of nursing confirmed that foot checks should be completed and documented as ordered, and that any abnormalities should be recorded in a progress note.
Delay in Initiation of Prescribed Antibiotic for Cellulitis
Penalty
Summary
A deficiency occurred when the facility failed to ensure a resident was free from significant medication errors. The resident, who had a history of diabetes, a serious right ankle fracture, and dementia, was admitted to the facility and later sent to the emergency room with complaints of abdominal pain and right third toe redness and swelling. The ER diagnosed early cellulitis of the right third toe and prescribed an antibiotic (Keflex 500 mg four times daily for 7 days). The ER instructions included prompt initiation of the antibiotic. Despite these instructions, the facility delayed entering the antibiotic order into the Medication Administration Record (MAR) until the day after the ER visit, and the first dose was not administered until two days after the ER visit. Interviews with facility staff confirmed that new orders are not always processed immediately, and the facility's own policy requires timely documentation and transcription of new medication orders. This delay resulted in the resident not receiving the prescribed antibiotic as promptly as required.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care Activities
Penalty
Summary
The facility failed to implement and maintain its infection prevention and control program as required, specifically regarding Enhanced Barrier Precautions (EBP) for two residents. For one resident with an indwelling urinary catheter, two CNAs transferred the resident from a wheelchair to the bathroom using a sit-to-stand machine and assisted with personal care activities, including moving the catheter bag and removing clothing, without wearing gloves or gowns. Both CNAs acknowledged after the fact that they were aware of the EBP requirements and should have worn appropriate PPE during these high-contact care activities, as indicated by the signage and care plan. In a separate incident, a resident with multiple wounds, including a pressure ulcer and venous ulcers, was observed during a wound dressing change. The Interim DON removed the resident's bandage and border dressing without wearing a gown, only donning gloves after handling the resident's leg. The Interim DON initially stated that a gown was not required unless there was a positive wound culture or excessive drainage, which contradicted the facility's policy and the expectations confirmed by the Vice President of Clinical and the Nursing Home Administrator, both of whom stated that both gown and gloves are required for wound care under EBP.
Failure to Document and Resolve Grievances per Facility Policy
Penalty
Summary
The facility failed to document a thorough investigation and resolve grievances in accordance with its own grievance policy for a resident with severe cognitive impairment and multiple medical diagnoses, including Parkinson's Disease, dementia, dysphagia, and moderate protein-calorie malnutrition. The resident's activated power of attorney (POA) voiced ongoing concerns about the resident's care, specifically regarding hydration, via email. Despite these concerns being communicated, the facility did not document the grievance, conduct a thorough investigation, or provide a written response as required by their policy. During the survey, facility leadership, including the current Nursing Home Administrator (NHA) and Director of Nursing (DON), were unable to produce documentation of grievances for the relevant period and indicated that the grievance binder was empty. The facility only provided grievances for the current month and could not account for previous months, despite the POA's documented concerns. The NHA acknowledged that the facility should have followed its grievance policy and that the POA's concerns should have been documented and addressed as a grievance.
Failure to Complete Thorough Abuse Investigations and Timely Reporting
Penalty
Summary
The facility failed to conduct thorough investigations and timely reporting in response to allegations of abuse involving multiple residents. In one instance, a resident with moderate cognitive impairment reported being verbally abused by another resident, who used derogatory language in the dining room. Although the facility separated the residents and obtained statements, there was no documentation that other residents were interviewed to determine if they were also affected, as required by facility policy. Additionally, the final investigation report was not submitted to the State Agency within the required five working days. In another case, a cognitively intact resident reported being verbally abused by a CNA, who called the resident a derogatory name. While psychosocial support was reportedly offered, there was no documentation that the resident was assessed for psychosocial harm, such as a trauma assessment or PHQ2-9, as described by the Social Services Director. The final investigation report for this incident was also not submitted within the required timeframe. A third incident involved a staff member allegedly making an inappropriate statement to a resident. The final report for this event was also not submitted within the five-day requirement. Interviews with facility leadership confirmed that assessments and timely reporting were expected but not completed as per policy and regulatory requirements. The lack of documentation and delayed reporting were consistent across the reviewed cases.
Failure to Ensure Resident Is Free from Significant Medication Errors
Penalty
Summary
A deficiency occurred when a resident with multiple complex diagnoses, including cancer, diabetes, morbid obesity, immunodeficiency, pathological fracture, secondary malignant neoplasms, acute kidney failure, depression, anxiety disorder, and muscle wasting, did not receive all prescribed medications as ordered by the physician during February and March. Specifically, the resident missed several doses of Anastrozole, a cancer medication, and Methadone, a pain medication, as evidenced by blank entries and unexplained codes on the Medication Administration Record (MAR). Interviews with nursing staff, including LPNs, an RN, and the Director of Nursing, revealed inconsistent documentation practices. Staff confirmed that blank boxes on the MAR typically indicate that a medication was not given, and a code of '7' should be accompanied by a nurse's note explaining the reason for non-administration. However, in multiple instances, there were no corresponding nurse's notes, and staff could not confirm whether the medications were administered or the reasons for omission. Staff also acknowledged that there had been issues with prior authorization for Methadone, which contributed to missed doses, and that PRN pain medications were offered as substitutes. The facility's policy requires immediate documentation of medication administration on the MAR, but this was not consistently followed. The lack of proper documentation and unexplained missed doses resulted in the resident not receiving all prescribed medications as ordered, constituting a significant medication error.
Resident's Right to Choose Physician Not Honored
Penalty
Summary
The facility failed to honor a resident's right to choose their attending physician, as evidenced by the case of a resident who was unable to switch to a new primary care physician (PCP) due to the facility's extensive requirements. The resident, who was cognitively intact and had a history of secondary malignant neoplasm of bone, neoplasm-related pain, and type two diabetes mellitus, expressed dissatisfaction with the current facility physician and wished to change to a physician at an external clinic. Despite the resident's and family member's efforts to facilitate this change, the process was hindered by the facility's demands for extensive documentation from the new physician. The facility's policy supports residents' rights to choose their attending physician, provided the physician meets state and federal requirements. However, the facility's process for changing PCPs involved sending a lengthy form to the new physician, MD I, which included requests for personal and professional information that MD I found excessive and unnecessary. This form was not retained by the facility, and there was a lack of follow-up communication with MD I, who ultimately decided not to proceed with becoming the resident's PCP due to the prohibitive nature of the facility's requirements. Interviews with facility staff revealed a lack of clarity and documentation regarding the process for changing PCPs. The Social Service Director was unaware of the procedure, and the Director of Nursing, who was out sick, had not communicated with the new physician. The Scheduler attempted to follow up but did not document these efforts. As a result, the resident's request to change physicians was not fulfilled, and the facility's medical director continued as the resident's PCP, contrary to the resident's expressed wishes.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 62 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Muscoda
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Schmitt Woodland Hills | 9.9 mi | ★★★★★ | 10 | 0 |
| Care And Rehab - Boscobel | 14 mi | ★★★★★ | 0 | 0 |
| Pine Valley Community Village | 17.8 mi | ★★★★★ | 1 | 0 |
| Dove Healthcare - Fennimore | 18.4 mi | ★★★★★ | 33 | 0 |
| Greenway Manor | 19.2 mi | ★★★★★ | 9 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.