Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St Elizabeth Nursing Home during CMS and state inspections, most recent first.
The facility failed to provide sufficient nursing staff, leading to prolonged call light response times and unmet care needs. Many residents required extensive assistance with ADLs, yet weekend schedules often had only one CNA on night shift and minimal coverage on day and evening shifts. Several residents reported waiting 30–45 minutes or longer for help with toileting, with one resident waiting over two hours and remaining incontinent in bed, and another experiencing leg numbness and a fall after extended time on the toilet. Call light logs documented multiple instances of lights remaining unanswered for 30–76 minutes. CNAs and the scheduler acknowledged that staffing was frequently inadequate, routine tasks such as toileting and repositioning every two hours were not consistently completed, and residents complained daily about long call light waits, while the DON conceded that such response times were unacceptable.
A resident with severe cognitive impairment, total dependence for toileting and transfers, and documented bowel/bladder incontinence was not assisted with toileting or incontinence care for an extended period, despite facility policy and care plan directives for toileting every 2–3 hours and before and after meals. The resident was observed in a wheelchair in common areas through the morning and early afternoon, including during meals, without toileting assistance. Staff interviews confirmed that one CNA provided incontinence care and got the resident up early in the morning, but no further toileting occurred until early afternoon, when two CNAs returned the resident to bed and provided incontinence care, at which time the brief was observed to be saturated with urine and feces.
PASRR screening was not completed appropriately for a resident admitted with neurocognitive disorder with Lewy Bodies, Parkinson's disease, and dementia. Surveyors found no PASRR Level II on file, and both the Admissions Director and NHA stated that a Level II would have been expected based on the Level I screen.
Indwelling catheter bags were left touching the floor for two residents with Foley catheters. Surveyors observed one resident with neurogenic bladder, recurrent UTIs, and a history of MRSA in urine, and another resident with urinary incontinence and bladder dysfunction, both with drainage bags hooked to wheelchairs or a recliner but resting in direct contact with the floor. Staff and the DON acknowledged catheter bags should not touch the floor.
A resident with multiple chronic conditions, including CHF, COPD, anemia, and low BMI, experienced a 9.94% weight loss in three weeks. The care plan called for weight monitoring, MD notification for significant weight changes, and supplements, but no new interventions were put in place when the loss triggered, and no documentation showed the MD was notified. The resident reported bland food and limited supplement options, while the RD, RN, and DON all acknowledged the loss was significant and should have been reported.
Oxygen care was not managed consistently for two residents. One resident with COPD, acute respiratory failure with hypoxia, and CHF had an O2 concentrator in the room without an oxygen-in-use sign on the door and tubing that was not dated, while another resident with cardiomyopathy, ESRD, and anemia also had undated O2 tubing. Staff stated tubing should be changed every 7 days and dated, but the required dating and signage were not in place when observed.
Hand hygiene and glove-use practices were not followed during perineal and catheter care for a resident. A CNA cleaned the resident’s perineal area and catheter tubing, then continued to assist the resident with getting up, dressing, and into a wheelchair, and also made the bed without removing gloves or performing hand hygiene. The CNA acknowledged the lapse, and the DON confirmed hand hygiene and a glove change should have occurred before moving on to those tasks.
Failure to Offer and Document Pneumococcal Immunization: A resident admitted with an activated HCPOA had no documentation that the pneumococcal vaccine was ever offered, received, or declined. The facility policy required immunizations to be reviewed on admission and documented in the EMR, but the DON stated the facility did not have vaccine consent or declination forms, and the CNC later confirmed the vaccine should have been offered or declined at admission.
The facility failed to maintain safe, clean, and sanitary resident bathrooms, resulting in multiple shared bathrooms with strong urine odors, dried urine on floors, urine and toilet paper left in toilets, and feces on toilet chairs, toilet rims, and toilet walls. A CNA confirmed the bathrooms were not clean and stated that housekeeping was responsible, while also noting there was only one housekeeper handling both housekeeping and laundry. The housekeeper reported being unable to complete all duties and indicated there was no checklist or schedule for room cleaning, despite an expectation that rooms be cleaned daily. Maintenance, which oversaw housekeeping, acknowledged there were no formal cleaning schedules and that resident rooms were cleaned only twice a week, and agreed the observed bathrooms were not clean. The DON stated that bathrooms and floors should be cleaned daily and that CNAs should tidy and pick up bathroom messes before housekeeping sanitizes, but acknowledged awareness that the bathrooms were not clean.
The facility failed to maintain an effective infection prevention and control program, affecting all residents. Key staff were unaware of their roles in the Water Management Plan, and control measures for Legionella were not documented. Immunization protocols were outdated, lacking the latest CDC guidance. Infection control rates were not calculated for the past year, indicating a lack of routine monitoring and analysis.
A facility failed to update a resident's advance directive in a timely manner. The resident's POA initially signed a DNR form, but after a hospital stay, the family revoked the DNR and requested full code status. Despite informing the staff, the necessary documentation was not completed immediately, leading to a delay in updating the resident's medical record.
The facility failed to conduct sleep assessments and monitoring for three residents receiving Melatonin for sleep, despite their medical and cognitive conditions. The Director of Nursing confirmed that the protocol requires such assessments and tracking, but it was not completed for these residents.
A resident's motorized wheelchair was improperly charged in her room, contrary to facility policy requiring charging in the Beauty Shop. The NHA, DON, and a CNA confirmed the policy, noting the resident was the only one with such a device. The DON initiated staff education to address the issue.
A resident experienced inadequate pain management due to the facility's failure to provide scheduled pain patches and assess pain goals. The resident's pain was not effectively managed, leading to missed physical therapy sessions. Facility staff did not adhere to policies for medication availability and documentation, and the resident's care plan lacked specific pain goals and non-pharmacological interventions.
A resident did not receive prescribed Lidocaine patches on multiple occasions due to unavailability, resulting in medication errors. Despite having a process for handling unavailable medications, staff interviews revealed inconsistencies in following procedures, such as accessing contingency stock and documenting missed doses. The resident's chronic pain condition was not adequately managed, as the facility failed to ensure the medication was administered as ordered.
Two residents in an LTC facility were found to be receiving psychotropic medications without proper monitoring. One resident was given a PRN anti-anxiety medication beyond the allowed 14-day period without physician follow-up, and another resident did not receive the required AIMS assessment for antipsychotic medication monitoring. Interviews with staff confirmed these deficiencies.
The facility did not update or implement its COVID-19 Vaccine policy for two residents, failing to offer the 2024-2025 vaccine as per CDC guidelines. One resident with dementia and a history of stroke, and another with chronic heart and lung conditions, were not offered the vaccine, despite the Director of Nursing acknowledging they should have been.
A resident with a UTI caused by Enterobacter cloacae complex and MRSA was prescribed Cefdinir, which is ineffective against MRSA. The facility failed to obtain the urinalysis culture and sensitivity results from the hospital, leading to inappropriate antibiotic treatment. The resident's condition worsened, resulting in hospitalization for sepsis and requiring intravenous antibiotics and fluids. The facility acknowledged the lack of follow-up as a deficiency in their antibiotic stewardship process.
A resident with chronic conditions experienced multiple instances of hypotension, but the facility failed to notify a physician as required by policy and discharge orders. Despite guidelines indicating immediate notification for blood pressure below 90, no documentation showed physician contact. Interviews confirmed that discharge orders should have been treated as physician orders, and a full RN assessment and notification should have occurred.
A resident with CHF was not weighed regularly due to the absence of a physician order, despite facility policy and discharge transfer orders indicating the need for weight monitoring. The facility lacked a standard practice for weighing residents, relying solely on physician orders. The DON and RN acknowledged the oversight, and the NP did not respond to inquiries about care expectations.
A facility failed to label a Humalog (Lispro) vial with a resident's name, as observed during insulin administration. The Medication Technician administered the insulin from an unlabeled vial, assuming it belonged to the resident. The facility's policy requires medications to be labeled and verified using the Five Rights principle, which was not followed. The resident had multiple diagnoses, including diabetes mellitus type 2 and dementia. Both the LPN and DON acknowledged the labeling requirement for medications pulled from contingency.
Two residents experienced harm due to the facility's failure to provide appropriate wound care and treatment. One resident with diabetes had a wound that was not properly assessed or treated, leading to infection and amputation. Another resident suffered a burn from undiluted Tea Tree Oil, resulting in infection and hospitalization. The facility did not adhere to professional standards, failing to conduct timely assessments and notify providers of changes in condition.
The facility did not ensure adequate nursing staff to meet resident needs, resulting in long call light wait times and incomplete care tasks. Two residents reported waiting over an hour for assistance, particularly during PM shifts. Staff confirmed frequent call-ins and inadequate staffing levels based on a grid that did not consider resident acuity. The new administration plans to address these issues.
The facility did not maintain an up-to-date facility-wide assessment to determine necessary resources for resident care during daily operations and emergencies. The existing assessment from December 2022 was outdated and did not reflect the current resident population or required resources. The NHA initially provided a PowerPoint presentation instead of a proper assessment, and later acknowledged the need for an accurate and updated assessment.
The facility did not perform daily diabetic foot checks for four residents as required by its diabetes care protocol. Despite having conditions like diabetes mellitus type 2 and neuropathy, there was no documentation to show these checks were completed. The Director of Nursing confirmed the lack of records, highlighting a failure to adhere to the facility's standards for diabetic foot care.
A facility failed to conduct a thorough investigation of an abuse allegation involving a CNA and a resident. Despite the ongoing investigation, the CNA was allowed to return to work before its completion, without obtaining a statement from the CNA or conducting additional interviews. The facility's actions were inconsistent with its policy, leading to a deficiency in handling abuse allegations.
The facility failed to provide appropriate catheter care and monitoring for three residents with indwelling catheters. Two residents had outdated physician orders for monthly catheter changes, contrary to CDC guidelines, and their urine output was not monitored as required. Another resident had conflicting orders for catheter sizes. Staff interviews revealed inconsistencies in urine output documentation, with only one resident having proper orders in the electronic medical record.
Three residents were found to be receiving psychotropic medications without appropriate diagnoses or indications. One resident was prescribed Quetiapine for agitation/anxiety, and another for dementing illness with behaviors, neither of which are appropriate indications for antipsychotics. A third resident was receiving Citalopram and had been on Haldol without specified diagnoses in the physician orders. The facility lacked documentation and consents for these medications, as acknowledged by the DON.
Three residents in an LTC facility experienced significant medication errors. A resident missed a dose of Apixaban due to unavailability, and the physician was not notified. Another resident missed two doses of Insulin Glargine without documented parameters or physician orders to hold the medication. A third resident had multiple missed doses of insulin and anticoagulant without valid physician orders or notification. The DON confirmed these were medication errors and acknowledged the lack of signed physician orders.
The facility did not ensure an RN was on duty for 8 consecutive hours daily, as required. On two specific days, the facility lacked RN coverage for the mandated duration, confirmed by the ADON. This deficiency potentially affects all 32 residents.
The facility failed to provide social service assistance for four residents, resulting in missed care conference meetings due to the absence of a social worker. This affected the facility's ability to ensure person-centered care and prioritize resident goals. Residents did not have their required care conferences, impacting their care planning and goal setting.
The facility did not ensure that two residents were assessed for the safe self-administration of medications. One resident was found with medication at her bedside without a completed assessment, and the DON confirmed she was not able to safely self-administer. Another resident reported that staff leave medications on her bedside table, but no assessment was documented. The facility's policy requires an assessment and prescriber's order for self-administration, which was not followed.
A facility failed to investigate an alleged verbal abuse incident between two residents, where one resident repeatedly yelled at another during meals due to a medical condition causing coughing. Despite staff awareness and acknowledgment of potential abuse, no formal investigation was conducted, and the situation was believed to have resolved itself by separating the residents. The facility's policy requires thorough investigation and intervention, which was not followed.
A resident with multiple diagnoses expressed a desire to return home, but the facility failed to develop a safe discharge plan. Despite staff awareness of the resident's intentions, the care plan lacked updates and interventions since 2022. The resident left without necessary medications or community supports, as the facility had been without a social worker for months, leading to an unsafe discharge.
A resident with multiple health conditions did not receive a shower for two weeks due to the facility's failure to provide necessary personal hygiene care. The resident's care plan lacked specific instructions for bathing assistance, and staff interviews revealed missed showers due to staffing issues and inadequate documentation. The facility did not follow procedures for documenting and communicating missed showers, resulting in a deficiency in care.
A resident with a C. diff infection was not placed on isolation precautions upon admission, contrary to CDC guidelines and facility policy. The oversight occurred due to an incomplete admission process during a shift change, and isolation was only implemented days later after staff reviewed the resident's medication and hospital notes. The DON confirmed the delay in initiating contact precautions.
A facility failed to notify a physician when a resident left against medical advice (AMA), as required by policy. The resident was discharged AMA with a family member, but the progress notes showed no evidence of physician notification. Interviews with the Executive Director and an LPN confirmed the oversight.
A resident reported that a family member was taking their money to buy drugs. The facility's policy requires immediate reporting of such allegations, but the Executive Director was not informed until two days later, and the state agency was notified even later. The Executive Director admitted to reporting outside the required period, leading to a deficiency in timely reporting.
A resident with a history of surgical amputation and osteomyelitis was discharged without arranged home health services, despite facility policy requiring such arrangements. The resident was not contacted by home health services post-discharge, and the ADON admitted that referrals were not made until the resident reached out. The ED and DON confirmed the nursing team's responsibility for discharge referrals, but it was unclear if this was fulfilled.
Failure to Provide Sufficient Nursing Staff Resulting in Prolonged Call Light Response Times
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ needs, as evidenced by prolonged call light response times and unmet care needs over a weekend period. The facility assessment shows that a high proportion of residents require assistance with activities of daily living (ADLs): for dressing, 42.5% require assistance of 1–2 staff and 45% are dependent; for bathing, 46.5% require assistance of 1–2 staff and 53.5% are dependent; for transfers, 45% require assistance of 1–2 staff and 40% are dependent; for eating, 40.7% require assistance of 1–2 staff and 18.6% are dependent; and for toileting, 52.5% require assistance of 1–2 staff and 32.5% are dependent. Despite this level of dependence, weekend staffing schedules show limited CNA coverage, including night shifts with only one CNA and one nurse when one CNA had called in, and day and evening shifts staffed at or below the facility’s stated minimum pattern. The DON stated there were no set goals for call light response times but believed no more than 15 minutes should elapse, and acknowledged that 20–60+ minute response times were not acceptable. Multiple residents reported long waits for assistance with toileting and other needs. One resident with osteoporosis, congestive heart failure, and major depressive disorder, who is cognitively intact, reported that call lights often took about 45 minutes to be answered and described waiting on the toilet so long that her legs fell asleep, making transfers difficult and resulting in at least one fall while attempting to get up. Another resident with anxiety disorder and overactive bladder, with moderate cognitive impairment, and her family member reported typical call light waits of about 45 minutes and difficulty obtaining timely assistance to the bathroom. On one observed occasion, they turned on the call light upon returning from church and waited from 10:15 a.m. until 11:10 a.m. before staff arrived to assist with toileting. An anonymous resident reported turning on her call light at 4:00 a.m. and not having it answered until 6:30 a.m., during which time she was incontinent of urine and remained in a wet bed; she stated a CNA told her she was the only CNA working and had four residents ahead of her and that she felt neglected and feared retaliation if she complained. Objective call light logs corroborated these reports of delayed responses. For one resident with difficulty walking, need for assistance with personal care, repeated falls, and urinary incontinence, the log showed a call light activated at 4:44 a.m. that was not answered for 1 hour and 16 minutes. For the resident with osteoporosis and heart failure, call light entries showed waits of 25 minutes, 26 minutes, 24 minutes, and 31 minutes on different occasions. For the resident with anxiety disorder and overactive bladder, the log showed waits of 50 minutes, 43 minutes, 38 minutes, and 34 minutes. Another cognitively intact resident with acute respiratory failure with hypoxia, venous thrombosis, and chronic diastolic heart failure reported waiting 30 minutes to as long as 2–3 hours for call lights to be answered and stated that when staff did not come to help with toileting and wiping, he attempted to manage by himself. Review of his call light data showed a wait time of 1 hour and 9 minutes on one morning. Staff interviews further supported that staffing was insufficient to meet residents’ needs. CNAs reported that there were not enough staff to care for residents, that daily assignments were sometimes not completed, and that tasks such as charting, passing water, and providing toileting and repositioning every two hours were often missed or delayed, with repositioning/toileting sometimes occurring only twice in a shift. CNAs stated that residents who preferred care at specific times were prioritized while others had to wait, and that residents complained daily about call light wait times. CNA interviewees indicated that acceptable call light response should be within 2–5 minutes and agreed that 20–60 minute waits were not timely. The nursing scheduler described a staffing pattern of at least 3 CNAs on day and evening shifts and 2 CNAs on nights, with slight increases when census exceeded 38, and acknowledged that call-ins on weekends were handled by the DON. Despite this, the actual weekend schedules reviewed showed shifts where only one CNA worked nights after a call-in, and the DON attributed the excessive call light response times to the staff working those dates while also acknowledging there was no reason for such delays. These combined resident reports, call light data, staffing schedules, and staff statements demonstrate that the facility did not provide sufficient nursing staff to meet residents’ needs and ensure timely response to call lights.
Failure to Provide Timely Toileting and Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary assistance with toileting and incontinence care for a resident who was unable to perform activities of daily living independently. The facility’s undated Standard ADL Protocol states that CNAs should provide toileting every 2 to 3 hours or per individual preference and provide incontinence care as needed. The resident, admitted with Alzheimer’s disease with late onset and vascular dementia, had a significant change MDS dated 2/20/26 showing a BIMS score of 00, indicating severe cognitive impairment. The comprehensive care plan identified an ADL self-care performance deficit related to dementia, with interventions specifying that the resident was totally dependent on two staff for toilet use and transfers with a Hoyer lift, and that toileting should be offered upon rising and after meals due to urge and functional bowel/bladder incontinence. On the survey date, the resident was assisted with incontinence care and transferred to a wheelchair for breakfast at 8:15 AM by a CNA who was not assigned to the unit, and then remained in the wheelchair from at least 9:32 AM until 12:10 PM, spending most of that time in the dining room and lounge. Observations at 12:10 PM, 12:45 PM, and 1:30 PM showed the resident still in the dining room, eating lunch and later yogurt, without documented toileting or incontinence care during this period. The CNA assigned to the resident stated she arrived around 8:30 AM, that the other CNA had done morning care, and she was unsure when the resident last received incontinence care; the CNA who got the resident up confirmed she had not assisted the resident after 8:15 AM and that toileting should occur every 2 to 3 hours. At 1:53 PM, two CNAs assisted the resident back to bed and provided incontinence care, at which time the surveyor observed the resident’s brief to be saturated with urine and feces. Multiple staff, including CNAs and an RN, stated that toileting or repositioning should occur every 2 to 3 hours, and the DON stated the resident should have been assisted with incontinence care before and after meals, acknowledging that this did not occur between 8:15 AM and 1:53 PM.
PASRR Level II Not Completed for Resident With Neurocognitive Disorder, Parkinson's Disease, and Dementia
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed appropriately for 1 of 5 residents reviewed, R13. The facility did not have a PASRR Level 2 completed for R13, despite the resident being admitted with diagnoses of neurocognitive disorder with Lewy Bodies, Parkinson's disease, and dementia. The facility policy stated that residents diagnosed with serious mental illness or developmental disabilities would be screened prior to admission using PASRR, and that PASRR Level 2 screening may be used to determine the facility's ability to manage the individual's needs. During surveyor review, the Admissions Director was unable to locate a PASRR II for R13 and stated that the person previously responsible had not turned it in. The Admissions Director also stated that, after reviewing R13's PASRR Level 1, a Level II would be expected. The Nursing Home Administrator likewise stated that R13 should have had the PASRR Level II completed and that the former Social Worker should have done one but did not.
Indwelling catheter bags were left touching the floor
Penalty
Summary
The facility did not ensure appropriate catheter care for two residents with indwelling urinary catheters, R5 and R8, when surveyors observed each resident’s catheter drainage bag resting in direct contact with the floor. Facility policy for indwelling catheter care states the drainage bag should be kept below the level of the bladder and off the floor, with tubing free of kinks, twists, or pressure. R5 had diagnoses including neuromuscular dysfunction of the bladder, benign prostatic hyperplasia with lower urinary tract symptoms, and urinary retention, and his care plan noted an indwelling Foley catheter due to neurogenic bladder, a history of MRSA in urine, recurrent UTIs, and enhanced barrier precautions. Surveyors observed R5 in the dining room with his catheter bag hooked to the bottom of his wheelchair and covered by a dignity flap, but the bag was touching the floor. Later, R5 was observed in his room with the catheter bag hooked to his recliner, with most of the bag still in direct contact with the floor. R8, who had diagnoses including functional urinary incontinence and neuromuscular dysfunction of the bladder and had an indwelling Foley catheter for urinary retention, was also observed in the dining room with her catheter bag hooked to the bottom of her wheelchair and touching the floor. Staff members acknowledged the bags should not be on the floor, and the DON stated urinary catheter bags should never be touching the floor.
Failure to Notify Physician and Address Severe Weight Loss
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status and failed to consult the resident’s physician regarding a severe weight loss for one resident, R3. R3 was admitted with diagnoses including muscle weakness, repeated falls, congestive heart failure, rheumatoid arthritis, low back pain, COPD, chronic respiratory failure, and anemia. The care plan identified R3 as nutritionally at risk related to low BMI and included monitoring weight, notifying the MD/responsible party of significant weight changes, and providing supplements such as Med Pass 2.0 and Mighty Shakes. R3’s weight record showed 100.6 pounds on 4/01/26, 102 pounds on 4/02/26, 93 pounds on 4/16/26, and 90.6 pounds on 4/23/26, reflecting a 9.94% weight loss in three weeks. The report states there were no new interventions put into place when the weight loss triggered on 4/23/26. The nutritional assessment listed the resident as at nutritional risk, with a goal to maintain or gain weight, and noted interventions including diet per MD order, supplements, monitoring meal intake, monitoring weights, and offering alternates to disliked meals. Surveyor interviews found no documentation that the physician was notified of the weight loss. The resident stated the food was bland, had no taste, and that she received Ensure only once in a while and did not like it; she also said no other flavors or supplemental choices had been offered. The RD stated the weight loss triggered severe weight loss and that the physician should have been updated as soon as it was identified, with interventions and care plan updates expected. The RN stated the nurse was responsible for notifying the MD when weights flagged at significant loss thresholds, and the DON agreed that the 9.94% loss was significant and that the physician should have been notified and interventions documented.
Oxygen Tubing Not Dated and Missing Oxygen Signage
Penalty
Summary
Safe and appropriate respiratory care was not provided for two residents who were receiving oxygen. Facility policy stated that oxygen-in-use signage should be posted in a prominent location, and staff told the surveyor that oxygen tubing should be changed every seven days and dated so the change date could be tracked. The facility did not provide any additional oxygen tubing or use policies. R34 had diagnoses including acute respiratory failure with hypoxia, COPD, and chronic diastolic heart failure, and had physician orders for oxygen and oxygen saturation monitoring. During observation, an oxygen concentrator was present in the room, but there was no oxygen-in-use sign on the door and the nasal cannula tubing was not dated. RN E confirmed the tubing was not dated and said she would change and date it. R34 stated he used oxygen overnight when short of breath and removed it in the morning. The surveyor later observed the tubing dated and a sign on the door. R15 had diagnoses including cardiomyopathy, dependence on renal dialysis, end stage renal disease, and anemia in chronic kidney disease. The surveyor observed nasal cannula tubing connected to the oxygen concentrator in the room without a date on it. RN E confirmed there was no date on the tubing and stated she would expect a date because otherwise she would not know when to change it. R15’s oxygen orders included continuous oxygen, oxygen saturation monitoring, and orders to change and date the tubing every seven days, but there had been no prior order specifying when the tubing should be changed.
Hand Hygiene Breach During Perineal and Catheter Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents reviewed for hand hygiene during perineal and catheter care. The resident, R5, was observed lying in bed while CNA H performed perineal care and catheter tubing cleansing. CNA H wore a gown and gloves while cleaning, rinsing, and drying the resident’s perineal area and catheter tubing. After completing the perineal and catheter care, CNA H did not remove her gloves or perform hand hygiene before assisting R5 to get up, get dressed, and transfer into a wheelchair. CNA H also made the resident’s bed while still wearing the same gloves. When asked later, CNA H stated her hands were dirty after the care and acknowledged she should have washed her hands and changed her gloves. The DON also stated that hand hygiene and a glove change should be done after completing perineal and catheter care before assisting a resident with dressing and making the bed.
Failure to Offer and Document Pneumococcal Immunization
Penalty
Summary
The facility did not ensure that each resident was offered a pneumococcal immunization unless medically contraindicated or already immunized, as shown for one resident reviewed for immunizations. The resident was admitted with an activated HCPOA, and the surveyor reviewed the resident’s immunization documentation in the facility chart. There was no indication that the resident had ever received or been offered the pneumococcal vaccine, and no vaccine consent or declination form was present in the chart at the time of review. The facility policy titled Individual Immunizations states that immunizations will be offered upon admission and documented in the electronic medical record. During the survey, the DON stated the facility did not have vaccine consent or declination forms for residents to complete, and later documented the refusal after speaking with the resident’s HCPOA. The Clinical Nurse Consultant reviewed the resident’s pneumococcal vaccine information and stated it should have been offered or declined when the resident was admitted, but could not find documentation that it had been offered prior to the surveyor’s request.
Unsanitary Resident Bathrooms and Lack of Housekeeping Policy
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment, specifically related to unsanitary resident bathrooms and the absence of housekeeping policies and procedures. Surveyor observations on 2/3/26 found that four of four inspected bathrooms serving seven residents had strong urine odors, dried urine on floors, urine and toilet paper left in toilets, and feces on toilet chairs, toilet rims, and toilet walls. In one shared bathroom, there was dried urine and feces on the toilet chair and rim, and dried urine on the floor. Another resident’s bathroom had feces on the toilet chair, toilet rim, and inside walls of the toilet. A third shared bathroom had a strong urine odor, dried urine on the floor, feces on the back of the toilet chair, and urine and toilet paper in the toilet. A fourth shared bathroom had a strong urine odor, urine and toilet paper in the toilet, dried urine on the floor, and toilet paper on the floor saturated with dried urine. The facility did not have a housekeeping policy or procedure in place, as confirmed by the Nursing Home Administrator. The CNA who accompanied the surveyor acknowledged that the bathrooms were not clean and stated that housekeeping was responsible for cleaning resident rooms, noting that there was only one housekeeper for both housekeeping and laundry. The housekeeper reported being unable to complete both housekeeping and laundry duties alone and stated there was no checklist or schedule for cleaning resident rooms, although each room was supposed to be cleaned daily. The maintenance staff member overseeing housekeeping confirmed there were no hard schedules, checklists, or calendars for room cleaning, stated that resident rooms were cleaned twice a week, and agreed that the observed bathrooms were not clean. The DON stated that bathrooms and floors should be cleaned daily and that CNAs were responsible for tidying and picking up bathroom messes before housekeeping sanitized, but acknowledged awareness that the bathrooms were not clean.
Inadequate Infection Control and Water Management
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, which could potentially affect all 33 residents. The Water Management Plan team members, including the Director of Nursing/Infection Preventionist (DON/IP) and the Facility Service Manager (FSM), were unaware of their roles and responsibilities. Control measures to prevent Legionella were not routinely completed or documented, and there was no monitoring of water heater temperatures or circulation pumps. Additionally, the facility's policies and procedures were not reviewed annually as required. The facility's immunization protocols were outdated and did not reflect the most recent CDC guidance for COVID-19 and pneumococcal vaccinations. The DON/IP was not familiar with the latest updates, and the facility's policies did not include the newest information. This lack of updated protocols could lead to residents not receiving the appropriate vaccinations as recommended by the CDC. Furthermore, the facility did not calculate infection control rates for the past year, which are essential for tracking and trending infections over time. The DON/IP only provided infection control documentation upon the surveyor's request, indicating a lack of routine monitoring and analysis of infection data. This deficiency in infection control practices highlights significant gaps in the facility's ability to prevent and manage infections effectively.
Failure to Update Resident's Advance Directive
Penalty
Summary
The facility failed to ensure that a resident's advance directive was properly updated and signed by the resident's representative. The resident, who was incapacitated prior to admission, had a Power of Attorney (POA) who initially signed a form indicating a Do Not Resuscitate (DNR) status. However, after a hospital stay, the family decided to revoke the DNR and requested a change to full code status, indicating the resident wanted cardiopulmonary resuscitation (CPR). The POA informed the facility staff of the change in code status shortly after the resident returned from the hospital. Despite the POA's communication and assurance from the staff that the update was made, the necessary documentation was not completed at that time. The Assistant Director of Nursing later provided a signed Resident CPR Preference Form, but it was dated after the initial request for the change, indicating a delay in updating the resident's medical record to reflect the new code status preference.
Failure to Conduct Sleep Assessments and Monitoring for Residents on Melatonin
Penalty
Summary
The facility failed to ensure that a comprehensive person-centered care plan was developed and implemented for three residents who were receiving Melatonin for sleep. Specifically, the facility did not conduct sleep assessments or implement sleep monitoring/tracking for these residents, which is necessary to meet their medical, nursing, and mental and psychosocial needs. The deficiency was identified during a survey where the surveyor requested documentation of sleep assessments and monitoring for the residents, but the facility was unable to provide it. Resident 8, who is cognitively intact, was admitted with diagnoses including depression, insomnia, anxiety disorders, and panic disorder. Resident 15, with severe cognitive impairment, was admitted with unspecified dementia and insomnia due to another mental disorder. Resident 30, with moderate cognitive impairment, was admitted with Alzheimer's Disease and dementia with behavioral disturbance. Despite these conditions and the administration of Melatonin, the facility did not complete the necessary sleep assessments or tracking. The Director of Nursing confirmed that the facility's protocol requires sleep assessments and tracking for residents on sleep medications, but acknowledged that this was not done for the residents in question.
Improper Charging of Motorized Wheelchair in Resident Room
Penalty
Summary
The facility failed to ensure that the resident environment was free from accident hazards, as evidenced by the improper charging of a motorized wheelchair in a resident's room. The facility's policy, reviewed on November 8, 2023, clearly states that batteries for motorized assistive devices must be charged in a non-resident approved area, specifically the Beauty Shop. However, on February 11, 2025, a surveyor observed the motorized wheelchair of a resident, identified as R8, being charged in her room next to her bed while she was sleeping. This was contrary to the facility's policy and posed a potential hazard. Interviews with the Nursing Home Administrator (NHA), Director of Nursing (DON), and a Certified Nursing Assistant (CNA) confirmed that the facility's protocol required all motorized wheelchairs to be charged in the Beauty Shop. The CNA noted that R8 was the only resident with a motorized wheelchair, indicating a lack of adherence to the established procedure. The DON acknowledged the deficiency and initiated staff education to reinforce the correct charging protocol, emphasizing that any deviation from this procedure should be immediately corrected.
Inadequate Pain Management for Resident
Penalty
Summary
The facility staff failed to adequately assess and manage the pain of a resident, identified as R6, who was reviewed for pain management. R6 did not receive his scheduled pain patch, which led to ineffective pain management and caused him to miss two physical therapy sessions. The facility also did not assess the resident's pain goal or complete a comprehensive care plan that included his pain goal and non-pharmacological interventions. R6, who was admitted with diagnoses including chronic pain, reported not receiving his pain medication as prescribed, which hindered his participation in therapy. The facility's Medication Administration Record indicated multiple instances where R6's lidocaine patches were not administered due to unavailability, and no progress notes were written for these missed doses. R6 expressed that his pain level was consistently high, affecting his ability to engage in therapy, which he needed to do in order to return home. Interviews with facility staff, including LPNs and the Director of Nursing, revealed a lack of adherence to the facility's policies regarding medication availability and documentation. The staff acknowledged that missed medications should be documented as medication errors and communicated to the medical provider, but this was not consistently done. Additionally, the care plan for R6 lacked a specific pain goal and non-pharmacological interventions, which were necessary for effective pain management.
Failure to Administer Prescribed Medication Due to Unavailability
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, identified as R6, by not ensuring the availability and administration of Lidocaine patches as prescribed. R6, who was admitted with conditions including chronic pain, did not receive the prescribed Lidocaine patches on multiple occasions due to the medication not being available. This resulted in medication errors on specific dates, as documented in the Medication Administration Record (MAR), where the medication was marked as unavailable. Interviews with staff, including LPNs and the Director of Nursing (DON), revealed that the process for handling unavailable medications was not consistently followed. Although there was a contingency stock accessible to licensed nurses, the medication was not obtained, and progress notes were not written for the missed doses. The staff acknowledged that a missed medication should be reported to the physician and documented as a medication error, but this protocol was not adhered to, leading to the deficiency.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that residents receiving psychotropic medications were free from unnecessary medications, as evidenced by deficiencies found in the care of two residents. Resident 16, who was admitted with diagnoses including anxiety disorder, depression, and insomnia, was receiving psychotropic medications without a care plan for targeted behaviors or behavior tracking. The resident was administered a PRN anti-anxiety medication beyond the 14-day period allowed without a physician follow-up, contrary to the facility's protocol which requires a 14-day stop date and a physician's face-to-face visit before reordering. Interviews with the LPN and DON confirmed the lack of behavior tracking and the inappropriate administration of the medication. Resident 22, admitted with diagnoses of depression and unspecified dementia with psychotic disturbance, was receiving an antipsychotic medication without an Abnormal Involuntary Movement Scale (AIMS) assessment, which is required to monitor for side effects such as Tardive Dyskinesia. The facility's policy mandates AIMS assessments at admission, with new orders or changes in orders, and quarterly. Interviews with the LPN and DON revealed that the required AIMS assessment was not conducted for this resident, indicating a failure to adhere to the facility's monitoring protocols.
Failure to Offer Updated COVID-19 Vaccine to Residents
Penalty
Summary
The facility failed to ensure that their COVID-19 Vaccine policy and procedure were up-to-date and properly implemented for two residents, identified as R22 and R11. The facility's policy, dated December 5, 2024, mandates that upon admission, the immunization status of individuals should be verified, updated with the Primary Care Provider (PCP) as needed, and immunizations administered as ordered. However, the facility's current recommendations were outdated, referencing the 2023-2024 formula instead of the 2024-2025 COVID-19 vaccine guidelines. According to the CDC's Interim Clinical Considerations, individuals aged [AGE] and older are recommended to receive two doses of the 2024-2025 COVID-19 vaccine, yet R22 and R11 were neither offered nor documented to have received the vaccine for the 2024-2025 season. R22, who is over the age of [AGE] and has a medical history including essential hypertension, dementia, and a history of stroke, had documented COVID-19 vaccinations in 2021 but none for the 2024-2025 season. Similarly, R11, also over the age of [AGE], with chronic conditions such as heart failure, COPD, and chronic kidney disease, had documented vaccinations up to 2022 but not for the current season. The Director of Nursing/Infection Preventionist (DON/IP) confirmed during an interview that neither resident was offered the 2024-2025 COVID-19 vaccine, acknowledging that they should have been offered the vaccine according to the updated guidelines.
Failure in Antibiotic Stewardship Leads to Resident Hospitalization
Penalty
Summary
The facility failed to ensure an effective antibiotic stewardship program, which resulted in a resident receiving inappropriate antibiotic treatment. The resident, who had a history of diabetes mellitus type 2, chronic respiratory failure with hypercapnia, heart failure, and dementia, was diagnosed with a urinary tract infection (UTI) in the emergency department. The UTI was caused by Enterobacter cloacae complex and Methicillin Resistant Staphylococcus aureus (MRSA), a multi-drug resistant organism. Despite this, the facility did not obtain the resident's urinalysis culture and sensitivity (UA C/S) results from the hospital to ensure the resident was receiving the correct antibiotic. The resident was prescribed Cefdinir, which is not effective against MRSA, and the facility did not administer the medication until the following morning due to its unavailability in contingency. The facility did not follow up on the urine culture and sensitivity results, which were available three days later, and failed to recognize that Cefdinir was not indicated for MRSA. Consequently, the resident's condition worsened, leading to hospitalization for sepsis due to the UTI. The resident required intravenous antibiotics and fluids, and the hospital adjusted the antibiotic treatment based on the culture susceptibilities. The facility's failure to follow up on the culture and sensitivity results and notify the physician about the inappropriate antibiotic treatment contributed to the resident's hospitalization. The Director of Nursing and Registered Nurse acknowledged the lack of follow-up and identified it as a deficiency in the facility's antibiotic stewardship process. The previous Director of Nursing, who was also the Infection Preventionist, was no longer employed at the facility due to this oversight.
Failure to Notify Physician of Resident's Hypotension
Penalty
Summary
The facility failed to immediately consult with a physician when needing to alter treatment for a resident who experienced four instances of hypotension over a period of time. Despite the facility's policy requiring immediate physician notification for blood pressure deviations from baseline, the staff did not contact the on-call physician to report the resident's low blood pressure, which could have allowed for an alteration of treatment if deemed necessary by the physician. The facility's policy and the INTERACT II guidelines both indicate that a blood pressure less than 90 requires immediate physician notification, yet this protocol was not followed. The resident involved had a history of chronic conditions, including Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, chronic kidney disease, Atrial fibrillation, and obstructive sleep apnea. The resident's vital signs on multiple occasions showed blood pressure readings below the threshold that necessitated physician notification, as per the discharge transfer orders and facility policy. However, there was no documentation or progress notes indicating that a physician was notified of these vital signs. Interviews with the Director of Nursing and a Registered Nurse confirmed that the discharge transfer orders should have been treated as physician orders and that a full RN assessment and physician notification should have occurred upon identifying the resident's hypotension.
Failure to Monitor Weight for Resident with CHF
Penalty
Summary
The facility failed to meet professional standards of quality for a resident with a history of Congestive Heart Failure (CHF) by not having a physician order for regular weight monitoring, which is crucial for managing CHF. The facility's policy on weighing individuals states that weights should be obtained and reviewed according to orders, including on admission, weekly for the first four weeks, and monthly thereafter. However, the resident in question was not weighed for months at a time, with recorded weights only on three occasions over a six-month period. This lack of regular weight monitoring is contrary to the recommendations of the American Heart Association, which advises daily weights for individuals with heart failure to detect early signs of fluid retention. The deficiency was further highlighted during an interview with the Director of Nursing (DON) and a Registered Nurse (RN), who acknowledged that discharge transfer orders, which included instructions to notify the physician of significant weight changes, should have been transcribed into the electronic medical record or reviewed by the facility physician. Despite the resident's medical history and the discharge transfer orders, there was no standard practice in place for weighing residents, and the facility relied solely on physician orders. The Nurse Practitioner (NP) involved in the resident's care did not respond to inquiries about their expectations for monitoring the resident's weight, leaving the deficiency unaddressed at the time of the survey.
Failure to Label Insulin Vial in Accordance with Professional Principles
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled in accordance with currently accepted professional principles, as observed during the administration of insulin to a resident. The surveyor noted that a Medication Technician administered Humalog (Lispro) to a resident from a vial that did not have the resident's name indicated. The vial was observed to be pulled from contingency, and the Medication Technician confirmed that it was not labeled with the resident's name, assuming it belonged to the resident as they were the only one receiving Humalog from that cart. The resident involved had multiple diagnoses, including diabetes mellitus type 2, chronic respiratory failure with hypercapnia, heart failure, and dementia. The facility's policy on medication administration requires that medications be labeled and verified against the medication administration record (MAR) using the Five Rights principle. However, the lack of labeling on the Humalog vial was a deviation from this policy. The Licensed Practical Nurse and the Director of Nursing both acknowledged that medications pulled from contingency should be labeled immediately with the resident's name and room number, which was not done in this instance.
Deficiencies in Wound Care and Treatment Lead to Resident Harm
Penalty
Summary
The facility failed to provide appropriate treatment and care for two residents, leading to significant health issues. One resident, who had diabetes mellitus type 2 and a history of amputations, experienced a change in condition with the development of a diabetic wound on the right second toe. The facility did not perform daily diabetic foot checks, assess or measure the wound, or update the resident's provider. This lack of care resulted in the wound becoming infected with multiple life-threatening multidrug-resistant organisms, leading to osteomyelitis and the eventual amputation of the toe. Another resident suffered a burn on the foot due to improper treatment with undiluted Tea Tree Oil. The facility failed to conduct weekly assessments as per professional standards, resulting in the wound becoming infected and requiring antibiotics. The resident's condition was further complicated by peripheral arterial disease, which increased the risk of complications and poor prognosis. The deficiencies in care for both residents were due to the facility's failure to adhere to professional standards of practice, including the lack of timely wound assessments, failure to notify providers of changes in condition, and incomplete administration of prescribed treatments. These actions and inactions led to immediate jeopardy for the residents, with one requiring hospitalization and surgery, and the other experiencing prolonged wound healing and hospitalization.
Removal Plan
- Skin sweep of entire facility completed
- Sweep of all active treatment orders completed for accuracy
- All residents with DM have daily foot checks added to TAR
- Education will be mandatory for all nurses and CNA including: DM foot care with completing daily diabetic foot checks; skin change observation expectations are that CNA report all skin changes immediately to the nurse; provider notification and change of conditions expectations are that nurses will report all diabetic foot ulcers, redness, purulence, drainage to physician; weekly wound assessments with measurements; and treatments completed as ordered
- DON or designee will ensure DM foot checks done daily, weekly and monthly bringing results to QAPI
- DON or designee will ensure weekly skin checks are completed daily, weekly and monthly bringing results to QAPI
- DON or designee will ensure weekly skin documentation completed during wound rounds; weekly and monthly bringing results to QAPI
- DON or designee will audit wound care treatments two residents weekly and monthly bringing results to QAPI
- Clinical Nurse Consultant will audit process of PCC documentation / 24 hour board follow up weekly and monthly to ensure changes of condition have needed follow up completed
Insufficient Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by interviews and record reviews. Two residents, R6 and R11, reported experiencing long wait times for their call lights to be answered, sometimes up to an hour or more. These delays were attributed to insufficient staffing, particularly during the PM shift, which left the staff overworked and unable to attend to residents promptly. The facility's staffing grid, used to determine staffing levels, was based on resident census rather than the acuity of the resident population, leading to inadequate staffing levels. Staff members, including CNAs and LPNs, expressed concerns about the impact of low staffing on their ability to complete tasks and provide necessary care. They reported frequent call-ins and a lack of accountability under previous management, which exacerbated staffing shortages. As a result, essential tasks such as showers, changing residents, and restorative care were not consistently completed, and residents were not always checked and changed as needed. The facility's scheduler, Scheduler K, confirmed that the staffing grid did not account for resident acuity and that previous administration directed her to follow this grid. The new Nursing Home Administrator acknowledged the issue and indicated plans to adjust scheduling to consider resident acuity. The Director of Nursing also noted staffing challenges during the transition from agency to in-house staff, which contributed to the staffing concerns.
Failure to Update Facility-Wide Resource Assessment
Penalty
Summary
The facility failed to conduct and document an up-to-date facility-wide assessment to determine the necessary resources for competent resident care during both day-to-day operations and emergencies. The assessment, which is required by nursing home participation requirements, was not updated annually or as needed. The existing Facility Wide Resource Assessment, dated December 2022, did not reflect the current resident population or the resources and education needed to appropriately care for them. During the survey, the Nursing Home Administrator (NHA) initially provided a PowerPoint presentation titled 'CMS minimum staffing mandate and facility assessment enhancements' instead of an actual assessment. Upon further inquiry, the Clinical Nurse Consultant (CNC) acknowledged the absence of a proper assessment and expressed embarrassment. The NHA, who was new to the facility and position, admitted that the PowerPoint was not a true assessment of the facility's resident population. Eventually, the outdated assessment from December 2022 was provided, and the NHA acknowledged the need for an accurate and up-to-date assessment.
Failure to Conduct Daily Diabetic Foot Checks
Penalty
Summary
The facility failed to ensure that four sampled residents received daily diabetic foot checks as required by professional standards of practice. The facility's policy, Standard Diabetes Mellitus Protocol, mandates daily foot checks for residents with diabetes to monitor potential complications. However, upon review, there was no documentation to support that these checks were completed for the residents in question. The residents involved had various medical conditions, including diabetes mellitus type 2, neuropathy, and other related health issues, which necessitated regular foot care to prevent complications. The surveyor's review of medical records and interviews with the Director of Nursing (DON) revealed a lack of evidence for the completion of daily diabetic foot checks for the residents. Despite the facility's policy and the DON's acknowledgment of the necessity for these checks, there was no documentation to demonstrate compliance. The absence of records for daily foot checks was confirmed for each resident, indicating a systemic failure in adhering to the established protocol for diabetic foot care.
Inadequate Investigation of Abuse Allegation
Penalty
Summary
The facility failed to ensure a thorough investigation of an alleged abuse incident involving a Certified Nursing Assistant (CNA) and a resident, identified as R2. The facility's policy mandates that upon receiving an abuse allegation, a comprehensive investigation should be conducted, including interviews with involved parties and protection of the resident from the alleged perpetrator. However, the facility did not adhere to this policy. On 8/2/24, the facility became aware of an abuse allegation against a CNA, but the investigation was not thorough. R2, who is cognitively intact with a BIMS score of 13, reported that a CNA verbally abused her on 8/1/24. The facility preliminarily identified CNA C as the potential perpetrator based on R2's description, yet failed to obtain a statement from CNA C regarding the allegations. Despite the ongoing investigation, the facility allowed CNA C to return to work on 8/3/24, before the investigation was completed on 8/6/24. This decision was made without gathering sufficient information or conducting additional interviews that could have revealed further concerns. The facility's documentation showed inconsistencies regarding CNA C's presence in the facility on the dates in question. The Director of Nursing (DON) and Clinical Nurse Consultant (CNC) acknowledged the possibility of additional concerns arising during the investigation period. The facility's failure to protect residents and thoroughly investigate the allegations resulted in a deficiency in handling abuse allegations.
Deficiencies in Catheter Care and Monitoring
Penalty
Summary
The facility failed to ensure appropriate treatment and services for residents with indwelling catheters, as evidenced by deficiencies in monitoring urine output and following current standards of practice for catheter changes. Three residents, identified as R1, R11, and R14, were affected by these deficiencies. R1 and R11 had physician orders for monthly catheter changes, which is not aligned with current CDC guidelines that recommend changes based on clinical indications. Additionally, urine output for R1 and R11 was not being monitored as required by facility policy. R1, who has a neurogenic bladder and a history of urinary tract infections, did not have his urine output documented, and his catheter care was not consistently performed as ordered. Similarly, R11, who is receiving palliative care and has moderate cognitive impairment, also did not have her urine output monitored, and she missed multiple catheter care treatments according to her physician's orders and facility policy. R14, with moderate cognitive impairment and a history of urinary tract infections, had active orders for two different sizes of Foley catheters, which could lead to confusion in care. Interviews with facility staff, including an LPN, a CNA, and the DON, revealed inconsistencies in the responsibility and documentation of urine output monitoring. The CNA reported that only one resident had orders for monitoring urine output, and despite notifying the nursing staff and DON, the necessary orders were not added to the electronic medical record. The DON confirmed that urine output should be monitored every shift and documented in the electronic medical record, but this was not being done for all residents with catheters.
Inappropriate Use of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that three residents receiving psychotropic medications were free from unnecessary drugs, as evidenced by the lack of appropriate diagnoses or indications for the use of these medications. Resident 11 was prescribed Quetiapine for agitation/anxiety, which is not an appropriate indication for an antipsychotic. The Director of Nursing (DON) acknowledged that Resident 11 did not have an appropriate diagnosis for the use of Quetiapine. Similarly, Resident 12 was prescribed Quetiapine for dementing illness with associated behaviors, which is also not an appropriate indication for an antipsychotic, as confirmed by the DON. Resident 10 was receiving Citalopram and had been receiving Haldol, but the physician orders did not specify the diagnoses associated with these medications. The facility lacked signed written consents indicating the associated diagnoses for Resident 10's medications. The DON admitted that the diagnoses should have been included in the physician orders and that they are typically added within 48 hours, but this was not done in this case. The absence of appropriate diagnoses and documentation for the use of psychotropic medications led to the deficiency identified by the surveyors.
Medication Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting three of the seven sampled residents. Resident R9 did not receive a scheduled dose of Apixaban, a blood thinner, due to the medication being unavailable, and the physician was not notified of this error. The Director of Nursing (DON) confirmed that the medication was not given and acknowledged that it should have been administered, with the physician being contacted in such cases. Resident R13 missed two doses of Insulin Glargine, a long-acting insulin, on separate occasions. The medication administration record indicated that the doses were held, but there were no documented parameters or physician orders to justify holding the insulin. The Licensed Practical Nurse (LPN) involved could not find any orders for holding the insulin and admitted that the physician should have been contacted for guidance. The DON also confirmed the absence of hold orders and expected the nurse to seek physician advice before making such decisions. Resident R1 experienced multiple missed doses of insulin and anticoagulant medication without valid physician orders or notification. The resident's medical record lacked signed hold orders for Enoxaparin, an anticoagulant, and the DON admitted that missed doses were considered medication errors. The DON also acknowledged that physician orders were not signed since June, and there was an assumption that all orders were electronically signed, which was not the case. The surveyor confirmed that the physician should have been contacted for missed medications or errors.
Failure to Ensure RN Coverage for 8 Consecutive Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for 8 consecutive hours a day, 7 days a week, as required. This deficiency was identified during a review of the facility's schedules and an interview with the Assistant Director of Nursing (ADON C). On Saturday, July 6, 2024, and Sunday, July 7, 2024, the facility did not have an RN present for the required 8 consecutive hours. The ADON confirmed that there is not always an RN in the facility on weekends for the mandated duration. This oversight has the potential to affect all 32 residents residing within the facility.
Failure to Conduct Care Conferences Due to Lack of Social Worker
Penalty
Summary
The facility failed to provide necessary social service assistance for four residents, resulting in a lack of care conference meetings. The absence of a social worker for several months contributed to this deficiency, as the facility was unable to conduct care conferences consistently. Residents R2, R5, R3, and R4 did not have their required care conference meetings, which are essential for ensuring person-centered care and prioritizing resident goals. Specifically, R2 did not have any care conference meetings in 2024, and R5 had not had a care conference since admission. R3 and R4 also missed their quarterly care conferences, with their last meetings occurring in early 2024. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged the lapse in care conference meetings, attributing it to the absence of a social worker. The facility's policy on Individual Advance Care Planning emphasizes the importance of discussing and verifying advance care planning upon admission, re-admission, change in condition, and during care conferences. However, due to the lack of a social worker, these meetings were not held consistently, impacting the facility's ability to support residents in achieving their care goals.
Failure to Assess Residents for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that the self-administration of medications was clinically appropriate for two residents, R5 and R4, as observed by the surveyor. R5 was found with medication at her bedside without a completed self-administration assessment. Despite R5's indication that she is dependable and the medication being a vitamin, the Director of Nursing (DON) confirmed that R5 did not have an assessment and was not able to safely self-administer medications. The facility's policy requires an interdisciplinary team assessment and a prescriber's order for residents to self-administer medications, which was not followed in R5's case. Similarly, R4 reported that staff generally leave medications on her bedside table, which she takes within an hour. R4 did not recall any assessment being performed to determine her ability to self-administer medications safely. The surveyor's review of R4's care plan and records confirmed the absence of any documentation supporting her ability to self-administer medications. The DON acknowledged that R4 did not have a self-administration assessment and that medications should not be left at her bedside, indicating a failure to adhere to the facility's policy.
Failure to Investigate Alleged Verbal Abuse Between Residents
Penalty
Summary
The facility failed to ensure a thorough investigation and appropriate response to an alleged incident of verbal abuse between two residents, R4 and R6. On June 23, 2024, R4, who is cognitively intact with a BIMS score of 13, was reported to have yelled at R6 during a meal, telling him to 'knock it off and shut up' due to R6's medical condition causing him to aspirate and cough. This behavior was noted in R4's progress behavior note and was a repeated occurrence, as indicated by the psychiatric follow-up note on July 10, 2024, which documented R4's irritability and use of foul language. Despite the incident being reported by a CNA to an LPN, and the LPN acknowledging the potential for the incident to be considered abuse, no formal investigation was conducted. The LPN reported the situation to an agency nurse, but no further action was taken. The Director of Nursing (DON) was aware of the incident but did not pursue further investigation, believing the situation had resolved itself by separating the residents. The DON later acknowledged that further intervention would have been warranted had the repeated nature of the incidents been known. The facility's policy on abuse, neglect, and mistreatment requires thorough investigation and intervention in such cases, but this was not adhered to. The lack of investigation and follow-up on the repeated verbal altercations between R4 and R6 represents a failure to protect residents from potential abuse, as required by the facility's own policies and procedures.
Failure to Develop Safe Discharge Plan for Resident
Penalty
Summary
The facility failed to develop and implement a discharge planning process for a resident, identified as R2, who had expressed a desire to return home. Despite being aware of R2's intention to discharge home, the facility did not engage in discussions with R2 to create a safe discharge plan. R2 was admitted with multiple diagnoses, including alcohol polyneuropathy, hypertension, and depression, and had a care plan that initially indicated a wish to remain in the facility for a long stay. However, the care plan lacked updates and new interventions since 2022 to ensure a safe discharge, and it was unclear what R2's discharge goals were. On the evening of R2's discharge, staff, including an LPN and CNAs, were aware of R2's plan to return home and had observed R2 packing to leave. The LPN attempted to educate R2 on the importance of a safe discharge and the need for medications, but R2 insisted on leaving without them. The facility had been without a social worker for several months, and the Director of Nursing acknowledged that R2's discharge care plan should have been current and reflective of R2's desires. The lack of a robust discussion and planning led to R2 leaving without appropriate community supports, notifications, orders, and medications in place, resulting in an unsafe discharge.
Failure to Provide Necessary Personal Hygiene Care
Penalty
Summary
The facility failed to ensure that a resident, who was unable to carry out activities of daily living, received the necessary services to maintain good personal hygiene. The resident, who was admitted with conditions such as morbid obesity, anemia, depression, urinary incontinence, muscle weakness, and difficulty in walking, did not receive a shower between July 5 and July 17, 2024. The resident's care plan indicated a need for assistance with personal care, but the bathing/showering section did not specify the amount of assistance required. During an interview, the resident reported not having had a shower in two weeks and expressed frustration that staff did not respond to her requests. The surveyor's investigation revealed that the facility lacked documentation of the resident's showers during the specified period. Interviews with staff, including a CNA and the DON, indicated that showers were sometimes missed due to staffing issues, and there was no record of the resident's shower schedule or any refusals. The facility's procedure for documenting and communicating missed showers was not followed, as evidenced by the absence of shower sheets and lack of information on the 24-hour report sheet. This deficiency highlights a failure in the facility's processes to ensure residents receive necessary personal hygiene care.
Failure to Implement Isolation Precautions for C. diff Infection
Penalty
Summary
The facility failed to establish an effective infection prevention and control program, as evidenced by the mishandling of a resident's admission with a Clostridium difficile (C. diff) infection. Upon admission, the resident, who had a diagnosis of enterocolitis due to C. diff, was not placed on isolation precautions as required by CDC guidelines. The facility's policy on outbreak and isolation procedures, which aligns with CDC guidelines, mandates immediate isolation for suspected or confirmed C. diff infections. However, this protocol was not followed, resulting in a lapse in infection control measures. The deficiency was further highlighted during interviews with facility staff. RN D, who began the admission process for the resident, acknowledged that isolation precautions were not implemented due to an incomplete admission process during a shift change. It was only after RN D returned from a weekend off that the resident was placed on isolation, following a review of the resident's medication and hospital notes indicating a C. diff diagnosis. The Director of Nursing (DON B) confirmed that the resident was not put on contact precautions until several days after admission, despite the presence of a C. diff diagnosis, which should have prompted immediate isolation measures.
Failure to Notify Physician of AMA Discharge
Penalty
Summary
The facility failed to notify the physician when a resident left the facility against medical advice (AMA). According to the facility's policy on discharges against medical advice, staff are required to notify the physician, Adult Protective Services, and the activated Power of Attorney for Health Care agent or Guardian, as indicated. The resident was admitted to the facility and discharged AMA with a family member. A review of the resident's progress notes from the time of admission to discharge showed no evidence that the physician was notified of the AMA discharge. Interviews with the Executive Director and an LPN confirmed that the physician was not notified, despite the requirement to do so.
Failure to Timely Report Misappropriation Allegation
Penalty
Summary
The facility failed to timely report an allegation of misappropriation of resident property for one of the sampled residents. According to the facility's policy, any allegations involving abuse, neglect, exploitation, or misappropriation of resident property must be reported immediately, or within 24 hours if the events do not involve abuse or result in serious bodily injury. In this case, a resident with a medical history of a right femur fracture, chronic pain, and opioid use reported to a licensed practical nurse that a family member was taking their money to buy drugs. This allegation was made on May 10, 2024, but the Executive Director was not notified until May 12, 2024, and the local police department and adult protective services were informed on May 13, 2024. The facility further delayed notifying the state agency, which was not done until May 21, 2024. During interviews, the Executive Director acknowledged being aware of the allegation on May 11, 2024, and admitted to reporting it to the state agency on May 13, 2024, outside the required reporting period. The Executive Director also mentioned that she believed she had submitted all necessary documentation but realized it was not done timely. This series of actions and inactions led to the deficiency in reporting the misappropriation allegation as per the facility's policy and federal and state laws.
Failure to Arrange Home Health Services for Discharged Resident
Penalty
Summary
The facility failed to arrange home health services for a resident who was discharged home. The resident, who had a medical history including orthopedic aftercare following surgical amputation, acute right ankle and foot osteomyelitis, and peripheral vascular disease, was admitted to the facility and expressed a desire to return home after completing therapy. The care plan directed staff to arrange necessary community resources to support the resident's independence post-discharge. However, upon discharge, the resident was not contacted or seen by the home health services that were supposed to be in place. The Assistant Director of Nursing (ADON) acknowledged that the home health referrals were not made until the resident called the facility after discharge, indicating a lapse in the discharge process. The Executive Director (ED) and the Director of Nursing both stated that the nursing team was responsible for ensuring discharge referrals were sent to the home health agency, but it was unclear if this was done for the resident. This oversight resulted in the resident being advised to seek emergency department care for wound care needs until home health services could be arranged.
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 184 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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 Janesville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mercy Manor Transition Center | 0.8 mi | ★★★★★ | 0 | 0 |
| Rock Haven | 1.6 mi | ★★★★★ | 8 | 0 |
| Oak Park Place Of Janesville | 1.7 mi | ★★★★★ | 1 | 0 |
| Cedar Crest Health Center | 2.7 mi | ★★★★★ | 4 | 0 |
| Beloit Health And Rehabilitation Center | 9.4 mi | ★★★★★ | 19 | 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.