Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Watertown Health Care Center during CMS and state inspections, most recent first.
A facility failed to maintain a clean, comfortable, homelike environment for 3 residents. One resident’s room had stained walls, a stained privacy curtain, and a discolored bedspread; another resident with an intestinal fistula was observed with a saturated gown, strong odor, and flies on the bedding after reporting delayed ostomy care and leakage; and a third resident’s bathroom had standing water next to the toilet on repeated observations, with staff unsure of the cause.
A resident was transferred to the hospital, but the facility did not complete or keep the required written bed-hold notice for the resident and/or resident representative. The facility policy required written notice at transfer explaining bed-hold duration, reserve bed payment policy, return-to-bed conditions, and a signed copy in the chart. The ADON confirmed the facility did not have a bed hold for the hospital admission but should have had one.
A resident with DM2, morbid obesity, right leg pain, and weakness had a care plan calling for 2-person assistance for bed mobility, dressing, oral care, hygiene, toileting, and transfers with a full body lift. Interviews and record review showed staff often provided only 1-person assistance, and multiple CNAs and an RN described the resident as a 1-assist for cares, despite the documented care plan.
Failure to provide timely incontinence care and repositioning for a dependent resident. The resident, who had TBI, quadriplegia, aphasia, and a feeding tube, was observed moaning in a Broda chair with a large puddle of clear liquid underneath. Staff confirmed the resident had last been changed and repositioned hours earlier, and when care was later provided, the brief, sling, and shorts were wet; peri care and barrier cream were not performed.
Failure to care plan and document frequent colostomy care. A resident with an open abdominal wound and leaking bowel contents had orders for frequent fistula and ostomy-related care, but the care plan and Kardex did not include colostomy goals, interventions, or monitoring. Staff said they relied on the Kardex for care instructions, and the resident was observed with a strong odor, flies on the blankets, and a gown saturated with drainage. The resident reported being left soiled for long periods, while the UM and CNO confirmed the colostomy care needs were not documented.
A resident with a hx of protein-calorie malnutrition and intact cognition did not receive a physician-ordered 2 PM snack, despite a documented preference for yogurt. Surveyor review found the resident was not on the kitchen snack list, and a CNA delivered labeled snacks to the unit without a snack for the resident’s hallway; the DM stated the resident should have been on the list and had been missed.
Incomplete and inaccurate resident medical records were found for two residents. One resident’s chart lacked documentation of the events leading up to a hospital transfer after staff noted the resident was sleepy, lethargic, and not acting like usual, while the record also failed to show what occurred before the ER transfer. Another resident’s MAR documented that a 2:00 PM snack was given and fully consumed, but the resident said she did not receive it, surveyors did not observe a labeled snack for her, and an RN said she assumed the snack had been given without checking.
Failure to Follow EBP and Hand Hygiene During Tracheostomy Care: An LPN provided tracheostomy care to a resident with tracheostomy status without wearing a gown despite an EBP sign outside the room. During the care, the LPN changed gloves several times without performing hand hygiene between glove changes, including after handling the garbage can, removing the old dressing, and adjusting suction equipment. The DON and CNO confirmed a gown should have been worn and hand hygiene should have been completed when changing gloves.
A resident with COPD, acute respiratory failure, dementia, seizures, and quadriplegia was found unresponsive, pulseless, and not breathing despite being full code. Staff checked for a pulse, left to verify code status, and delayed starting CPR and calling 911; the AED was not used during resuscitation. EMS later arrived and assumed care.
A resident admitted with an existing sacral PI and inability to reposition independently did not receive timely turning and repositioning, and a new left buttock PI developed and worsened to an unstageable wound. Physician orders and the care plan called for pressure relief measures, including a wheelchair/Broda cushion, but staff confirmed the resident did not have the cushion and that repositioning was not started on admission. The DON stated the root cause involved friction, shear, moisture, and the Guardian wanting the resident up in the chair for long periods, and staff were not educated on the root cause analysis or prevention of worsening/new PIs.
Food Served at Improper Temperatures: Surveyors observed both cold and hot meal items served at unsafe temperatures, including cold foods above the required cold-holding range and hot foods below the required hot-holding range. A cognitively intact resident reported that meals were often cold, food quality was poor, breakfast lacked protein, and milk and coffee frequently ran out; the resident’s record also noted a complaint to the NHA about food services.
Privacy and confidentiality were not maintained for a resident with severely impaired cognitive skills when a family-installed camera remained active in the room and recorded video and voice footage of cares such as pericare, tube feedings, transfers, trach care, dressing, and bathing. The facility had no policy or procedure for electronic monitoring and recording devices, no care plan for the device, no signage notifying others of surveillance, and the NHA stated no assessment was completed because the camera was not installed by the resident.
Grievances were not promptly documented or resolved for two cognitively intact residents. One resident reported finding a paperclip in cereal and said CNA O saw it and told kitchen staff, but the issue was not entered in the grievance log and the DON was unaware of it. Another resident voiced concerns about being transferred closer to family and about poor food quality, but social services had not timely sent referrals or documented follow-up, despite leadership stating referrals are usually sent immediately.
Unnecessary Psychotropic Medication Use: A resident with vascular dementia, agitation, anxiety, and repeated falls was prescribed multiple psychotropic medications, including scheduled and PRN quetiapine, PRN lorazepam, PRN haloperidol, Cymbalta, and Remeron. The resident’s care plan did not address antipsychotic use, the facility did not provide a requested psychotropic medication policy, and staff interviews described wandering, exit seeking, and an elopement event. The MAR showed repeated PRN psychotropic administration, while the EHR lacked documentation supporting delirium despite staff and hospice references to it.
Inadequate supervision of an elopement-risk resident. A resident with severe dementia, wandering, and repeated exit-seeking attempted to leave through a common area door while the alarm sounded. Staff redirected him and entered the alarm code, but during the delay before the alarm reset, staff resumed other duties and the resident doubled back, exited the building, and was found in the ER waiting room next door. Records and staff interviews showed ongoing wandering and repeated attempts to elope.
A resident with an intracranial hemorrhage, chronic respiratory failure, DM2, tracheostomy, and G-tube had no nutrition care plan and experienced significant weight loss while receiving enteral feeds. The resident lost 13.5 lbs in one week, with additional weight loss documented later, but there was no documentation that the provider was notified. Interviews showed the LPN, RD, and DON recognized significant weight loss as a change of condition and stated the MD should be notified.
Failure to Send Requested Transfer Referrals: A resident with MDD, GAD, and chronic pain, who was cognitively intact, repeatedly asked to be transferred to a facility closer to her daughter. Social services notes showed the resident wanted referrals sent closer to home, but the requested referrals were not made for about 6 weeks. Staff interviews confirmed referrals were expected to be sent immediately or the same day if possible, and the delay was not considered acceptable.
A resident with a post-CABG sternal wound had delayed RN assessments, missing wound documentation, and no timely physician notification as the wound enlarged and became infected. Two residents had repeated missing BM documentation, no documented physician notification, and no evidence that PRN bowel meds were offered when constipation persisted. Another resident with severe cognitive impairment had multiple missed or undocumented meds, treatments, and monitoring tasks on several shifts, including stoma care, oxygen checks, pain monitoring, and output recording.
Two residents were not treated with dignity and respect in common areas. One resident with MS was observed in a gown with the back and side exposed while being assisted to activities, and staff said the resident preferred a gown and needed help staying covered. Another resident with debility and dementia was observed sitting in the common area wearing only a t-shirt and incontinence brief with the bottom half exposed while staff walked by; a CNA later covered the resident with a blanket, and the NHA acknowledged residents should be dressed appropriately for dignity.
Failure to provide timely ADL assistance: Two residents did not receive needed help with grooming and toileting. One resident with dementia and other diagnoses had whiskers on the chin despite wanting to be clean-shaven, and an RN stated staff should assist with shaving on shower days and as needed. Another resident with heart failure, bipolar disorder, IBS, and a sacral pressure ulcer was left in bed with a bowel movement while the call light remained unanswered for 35 minutes; CNA staff later confirmed the resident needed assistance and stated call lights should be answered within 5 to 10 minutes or as soon as possible.
A resident with paraplegia, morbid obesity, and total dependence for bed mobility developed an unstageable DTI on the sacrum and bilateral buttocks. Staff said the resident needed frequent repositioning and used an air mattress, but nursing did not document repositioning and the TAR lacked multiple shift checks for the mattress setting and function. The DON acknowledged the missing documentation, and the ADON stated repositioning was treated as standard care rather than documented.
A resident with cerebral palsy, quadriplegia, chronic respiratory failure, and severe cognitive impairment had a physician order for Cough Assist BID and PRN, but the order was not entered into the TAR and the treatment was not consistently provided in the facility. Staff interviews showed confusion about whether the order existed, and the DON could not find evidence it was provided. The resident was hospitalized multiple times for respiratory distress, aspiration, pneumonia, and sepsis, and hospital records noted use of Cough Assist during those stays.
A resident missed a dental appointment because transportation was not arranged correctly, and the appointment had to be rescheduled. The resident said multiple appointments had been missed in the past. Staff reported confusion over whether the MCO or the facility was responsible for scheduling transportation, and noted prior issues with appointment and transportation coordination.
Failure to provide ordered Speech Therapy services for a resident with paraplegia, morbid obesity, a trach, and other complex diagnoses. The resident had an order for ST evaluation and treatment, but was never seen by ST during the stay. The ST reported not being informed of the order, and the Therapy Director confirmed the resident was not evaluated due to a communication error and that the resident was not added to the daily schedule.
RN coverage was not documented for at least 8 consecutive hours per day on multiple reviewed days. Staffing schedules and nurse postings did not show an RN on duty for the required time, and handwritten entries for the RN/IP did not identify hours worked or the capacity in which the employee worked. The DON and NHA confirmed the RN manager was on-call and stated there was no time-stamped documentation to verify the salaried RN’s presence or duties.
Unsafe food storage, cooling, holding, and labeling practices were observed in the kitchen. Surveyors found dirty vents, a dusty fan blowing onto clean dishes, buildup on cooking equipment, and debris on prep surfaces. Cooked foods were stored without proper cooling methods, staff could not locate current cooling logs, and breakfast items such as eggs, yogurt, shakes, and juice were left at unsafe temperatures. Several dry goods and refrigerated items were also missing required open/use-by dates, and staff were unsure of the correct date-marking and temperature requirements.
The facility did not ensure its QAA committee met with the required members at least quarterly. Review of QAPI/QAA sign-in sheets showed that the full required group, including the DON, MD, NHA, IP, and other staff, was documented only twice over the review period, with many monthly meetings missing one or more required members. The NHA acknowledged the requirement and stated the MD sometimes attended by phone, and the sign-in sheets should reflect who attended.
The facility failed to thoroughly investigate and resolve grievances related to missing personal property and laundry items. Several residents reported that clothing, socks, and a nightgown were missing, and that staff were aware but did not provide updates or document these concerns in the grievance log, despite ongoing discussion of missing items in Resident Council meetings. Laundry staff described an inconsistent admission inventory and labeling process, reliance on an informal bulletin board to track missing items, and frequent loss of unlabeled clothing. In a separate case, a cognitively intact resident’s borrowed wheelchair went missing shortly after admission; although a grievance was filed and a replacement wheelchair provided, the investigation did not include broader staff or resident interviews, and no admission inventory of the resident’s belongings was found in the medical record.
The facility failed to follow its abuse/neglect/exploitation policy requiring timely caregiver background checks for multiple CNAs, an activity aide, and a maintenance staff member. For several staff, BID forms and DOJ/GF reports were either missing, completed after the hire date, or not updated within the required four-year interval, yet these individuals were allowed to work with residents or in resident care areas. Leadership acknowledged that background checks are required prior to staff working with residents and that responsibility for this process had been assigned to a former business office manager.
The facility failed to develop and implement individualized comprehensive care plans for three residents with clearly identified needs. One resident who reported theft of money did not receive a care plan for safe keeping of valuables despite the facility’s investigation indicating one would be implemented. Another resident with end stage renal disease, documented on the MDS as receiving dialysis, had no dialysis care plan in the medical record. A third resident with Alzheimer’s disease and moderate cognitive impairment, known by CNAs to exhibit dementia-related behaviors such as refusing to get out of bed, had no Alzheimer’s/dementia care plan or related interventions documented. Facility leadership, including the DON and CNO, confirmed these omissions.
Surveyors found that the facility failed to administer and document medications accurately and on time for multiple residents. One resident with multiple severe pressure ulcers had an acetic acid order lacking specific application instructions, with numerous missed doses coded as “other” and no explanatory notes; staff, including an LPN and the DON, did not know where or why it was to be applied, and a staff member admitted documenting doses as given that they had not administered. Another resident’s methenamine for recurrent UTIs was not restarted when specified in hospital discharge instructions after a sepsis hospitalization. Several residents received routine morning medications, including antipsychotics, antidepressants, antihypertensives, antidiabetics, and anticoagulants, significantly later than their ordered times, and one resident’s cardiac and rheumatologic medications were repeatedly not given because they were unavailable. A resident with epilepsy reported small seizures when seizure medications were given late, and MAR review showed multiple late or irregularly timed doses of lacosamide and levetiracetam, with some entries coded as “other” and lacking corresponding nursing notes.
Surveyors found that staff did not consistently follow the facility’s infection control and hand hygiene policies. A CNA providing peri and catheter care to a resident on enhanced barrier precautions failed to change gloves and perform hand hygiene when moving from soiled to clean tasks and touched the resident and supplies with contaminated gloves. An assistant administrator entered the room of a resident on contact precautions for CRAB without performing hand hygiene or donning required PPE, then went to another room without hand hygiene. An RN prepared and administered medications to several residents without performing hand hygiene as required by policy. During multiple meal services, residents were not offered hand hygiene, meal trays lacked wipes, and dining tables had no wipes or hand sanitizer, despite staff acknowledging that residents should be offered hand hygiene before meals.
Failure to Provide Bed Hold, Transfer, and Ombudsman Notifications: The facility did not complete written bed hold or transfer notices for several residents who were sent to the hospital, and it did not notify the Ombudsman for some transfers and discharges. Affected residents included people with CVA, respiratory failure, dysphagia, paraplegia, sepsis, cancer, diabetes, encephalopathy, malnutrition, and tracheostomy, with cognition ranging from intact to severe impairment. Staff interviews showed confusion about who was responsible for the notices, and the NHA confirmed the missing documentation and notifications.
The facility inaccurately coded MDS assessments for multiple residents. One resident with a tracheostomy was incorrectly coded as comatose and the trach was omitted; another resident was also incorrectly coded as comatose. A resident receiving Hospice was not coded as such, a resident on levetiracetam was not coded for anticonvulsant use, a resident was incorrectly coded as receiving insulin despite no insulin order, and a resident with a Foley catheter was not coded as having a catheter. MDSC-N confirmed several of the coding errors, and the DON and NHA confirmed the Hospice coding error.
Two residents with serious infections did not receive multiple ordered IV antibiotic doses due to issues such as delayed PICC placement and pharmacy non-availability, and staff did not document timely physician notification of these missed doses. One resident with osteomyelitis and multiple pressure ulcers missed doses of ceftriaxone and vancomycin when the PICC line was not yet placed and medications were not available, with MAR codes indicating held or other but no record of provider contact. Another resident admitted with sepsis, cellulitis, and a history of MRSA missed several scheduled doses of IV cefazolin attributed to pharmacy issues, later sought ED care after expressing concern about going without antibiotics, and the DON acknowledged that the provider was not contacted until after multiple doses were missed, with no clear documentation of the notification in the record.
A resident with paraplegia and a baclofen pump experienced multiple missed and delayed pre‑op and surgical appointments due to unreliable transportation coordination. The facility failed to schedule a ride and complete required blood work for one pre‑op visit, did not hold the resident’s Eliquis in time for another attempt, and a transportation company arrived with an inappropriate vehicle instead of a wheelchair van on a subsequent occasion. Progress notes and an APNP note documented that the pre‑procedure physical and baclofen pump replacement surgery were delayed multiple times because of transportation issues. Transportation staff, the RN, DON, and NHA acknowledged missed appointments and transportation problems, and the surveyor was not provided with staff education for the updated transportation process when requested.
Incomplete Informed Consent for Psychotropic Medications: The facility did not ensure informed consent documentation was fully completed for psychotropic medications for three residents. One resident with intact cognition had incomplete consent forms for buspirone and Seroquel, while two residents with moderate cognitive impairment and activated POAHCs had no completed consent forms on file for risperidone, trazodone, and sertraline. The LPN and DON verified the missing or incomplete documentation.
Failure to Hold Regular Care Conferences: A resident with vascular dementia and moderately impaired cognition did not receive regular care conferences, and the activated POAHC reported not being invited for more than a year. The SSD and CNO confirmed the facility had not been holding quarterly care conferences, despite a policy requiring conferences per the MDS schedule and with significant changes in condition.
The facility did not ensure POAHC paperwork was completed or documented as offered for two residents. Both residents had intact cognition, and social services notes showed each was asked about advance directive paperwork, but the records did not contain a completed POAHC or documentation that the offer and resident decision were fully documented.
Failure to Provide Medicare Non-Coverage Notice: The facility did not provide a resident with the required NOMNC or ABN when the resident’s Medicare Part A stay was ending. The resident had intact cognition and diagnoses including PVD, respiratory failure, anxiety, and depression, and the SSD confirmed the forms were not provided.
A resident with critical illness myopathy, hemiplegia/hemiparesis after cerebral infarction, seizures, a tracheostomy, and tongue cancer started Hospice services, but the facility did not complete a Comprehensive Significant Change MDS assessment within the required timeframe. A Hospice CNA said the resident had been on Hospice for months, while the MDSC said she did not initiate the assessment because she believed the resident was not receiving Hospice; the RMDSC, NHA, and DON confirmed the resident was on Hospice and that the assessment should have been completed.
Two residents had delayed RAI/MDS transmission after assessments were completed but not electronically sent to CMS within the required timeframe. A Regional MDS Coordinator reported an EMR glitch caused assessments to remain in Complete status instead of Export Ready status, and said the system could incorrectly code the facility as not Medicare/Medicaid certified, preventing transmission.
PASRR screening was not completed appropriately for two residents. One resident with schizoaffective disorder, anxiety, and depression had an inaccurately completed Level I screen and no Level II screen was done. Another resident with epilepsy, major depressive disorder, and anxiety had an inaccurate Level I screen, was non-verbal and unresponsive, and also did not receive the required Level II screen.
A resident with dementia and recurrent falls had a care plan that included a fall mat and anti-rollback device, but surveyors observed those interventions were not in place. Required neuro checks and root cause analysis documentation were missing after unwitnessed falls with head injury while the resident was on Eliquis. In addition, another resident who smoked independently did not have a completed smoking assessment or smoking care plan, and staff observed the resident extinguish a cigarette without following the supervised smoking process.
Failure to Monitor and Report Significant Weight Changes: The facility did not ensure ordered weight monitoring was completed for two residents. One resident with severe protein calorie malnutrition, multiple pressure ulcers, and G-tube feeding had missed daily, weekly, and monthly weights and a significant weight loss was not re-weighed the next day. Another resident with CHF had multiple weight gains that met the physician-notification threshold, but the record did not show the physician was notified. Staff interviews confirmed the weights should have been obtained, rechecked, and reported.
Lack of Monitoring for High-Risk Medications: The facility did not ensure monitoring for adverse reactions or side effects was in place for three residents prescribed high-risk medications. A resident with epilepsy was prescribed levetiracetam, and two residents with pain diagnoses were prescribed opioid medications, including PRN oxycodone and morphine, but their records did not contain monitoring interventions. An LPN and the DON confirmed the missing monitoring.
A resident with moderately impaired cognition and an activated POAHC was not offered the influenza vaccine, and no consent, declination, or vaccine education was documented. The IP confirmed the resident's vaccination status was not reviewed or addressed as required by the facility's immunization policy.
Failure to Offer COVID-19 Vaccine and Provide Education: Two residents were not offered the COVID-19 vaccine, and consent or declination was not obtained. The IP also did not provide vaccine education for either resident. One resident had severe cognitive impairment with an activated POAHC, and the other had moderately impaired cognition with an activated POAHC. The IP confirmed the vaccine was not offered and stated it was the IP's responsibility to review vaccines, obtain consent, provide education, and administer vaccines at admission.
The facility failed to submit the final results of an abuse investigation to the State Agency within the required five working days. After a family visit, a resident with intact cognition exhibited a significant escalation in behavior, and a family member reported that another family member may have previously provided the resident with illicit substances. The facility submitted the initial abuse allegation as a facility-reported incident, but the final misconduct investigation report was not completed and submitted by the CNO until several days past the required deadline, despite leadership acknowledging awareness of the five-day reporting requirement.
A resident who required staff assistance for toileting and hygiene reported that the facility repeatedly ran out of the correct size briefs and wipes, leading staff to improvise with multiple briefs and sometimes skip cleansing during changes. Staff interviews, including an LPN and CNA, confirmed ongoing shortages of briefs, wipes, and wash cloths, with supplies often depleted by week's end and residents voicing complaints. The central supply clerk and administrator acknowledged supply issues, and no supply policy was provided during the survey.
Unclean Resident Rooms and Unsafe Conditions
Penalty
Summary
The facility did not provide a clean, comfortable, homelike environment for 3 of 19 sampled residents. R14’s room had visible dark brown marks on the wall beside the bed, discoloration on the bedspread, and dark stains on the privacy curtain. R14 was admitted with multiple wounds related to peripheral vascular disease, including wounds to the fingers and hands that required daily dressing changes, and was known to remove dressings independently. R10, who was admitted with a fistula of the intestine and had a BIMS score of 15 out of 15, was observed resting in bed with a blanket over the head. R10 stated that staff left the resident soiled for long periods, did not like to empty the ostomy bag, and that when it was not emptied frequently it leaked and overflowed. The next day, R10 was observed lying in bed with a strong odor and flies on top of the blankets, and the gown was saturated with colostomy drainage. R10 stated the blankets were kept over the head to keep the flies off and described the situation as cold, cruel, and callous treatment. R13’s room and bathroom were observed with standing water on the bathroom floor next to the toilet on two consecutive days. The resident stated the water was not healthy or clean and did not like it. Staff who observed the area did not know whether the toilet was leaking or what was causing the water, and housekeeping identified it as a maintenance issue. The standing water remained in the same location during repeated observations.
Missing Written Bed-Hold Notice After Hospital Transfer
Penalty
Summary
The facility did not ensure that a written bed-hold notice was completed for one resident who was transferred to the hospital. The facility’s policy required that, at the time of transfer for hospitalization or therapeutic leave, the resident and/or resident representative receive written notice explaining the duration of the bed-hold policy, reserve bed payment policy if applicable, facility bed-hold procedures, and the conditions for return to the facility, and that a signed and dated copy be kept in the resident’s file. The resident’s medical record showed the resident was sent to the hospital, but the record did not contain a written bed-hold notice. During interview, the ADON stated the facility did not have a bed hold for the resident’s hospital admission but should have had one. The surveyor also notified the Interim Nursing Home Administrator and the CNO about the missing bed-hold form.
Care Plan Not Followed for Two-Person Assistance
Penalty
Summary
The facility did not ensure that R9’s comprehensive care plan was being followed for staff assistance of two for all care needs. R9 was admitted with diagnoses including Type 2 diabetes mellitus, morbid obesity, pain in the right leg, and weakness. R9’s most recent MDS assessment showed a BIMS score of 15 out of 15, indicating cognitive intactness. The comprehensive care plan, initiated on 5/22/26, included interventions for bed mobility, dressing, oral care, personal hygiene, toileting, and transfer assistance of 2, including a full body lift for transfers. Record review and interviews showed that staff were not consistently providing the two-person assistance documented in the care plan. R9 stated that sometimes two staff assisted with dressing, toileting, and hygiene, but most of the time only one staff member did. A CNA described an incident in which R9 became combative during care and the CNA had to get a nurse to assist. Other CNAs and an RN stated that R9 was a one-assist for cares, with some staff saying two people were used only sometimes or that they were unsure of the required level of assistance. The Interim Nursing Home Administrator stated that if two-person assistance was in the care plan, he would expect it to be followed.
Failure to Provide Timely Incontinence Care and Repositioning
Penalty
Summary
The facility failed to provide elimination care and repositioning for a dependent resident who was unable to perform ADLs independently. The resident had diagnoses including traumatic brain injury, quadriplegia, and aphasia, was dependent on staff for all ADLs including incontinence care, personal hygiene, and repositioning, and had a feeding tube for nutrition and hydration. The resident’s care plan directed staff to reposition every 2 to 3 hours and to provide thorough skin care after incontinent episodes with barrier cream application. During observation, the resident was heard moaning and grunting while sitting in a Broda chair, and a large puddle of clear liquid was observed under the chair with a rolled-up blanket lying in it. The RN verified the puddle, and the CNA stated the resident had last been changed and repositioned at 11:50 AM. Incontinence care and repositioning had not been provided for 3 hours and 40 minutes. When care was later observed, a wet brief was removed, and the RN stated the sling under the resident and the resident’s shorts were wet. The CNA placed a clean brief and shorts on the resident without performing peri care or applying barrier cream.
Failure to Care Plan and Document Frequent Colostomy Care
Penalty
Summary
Appropriate colostomy care was not provided for one resident with an open abdominal wound leaking bowel contents after intestinal fistula repair. The resident was admitted for rehabilitation following a recent intestinal fistula and laceration of the sigmoid colon, which required colostomy placement and drainage of the abdominal incision. Medical orders directed frequent fistula and wound care, including changing the wound immediately after a leaking colostomy appliance change and using skin barrier, ostomy rings, and a wound manager to help maintain a seal. However, the resident’s care plan and Kardex did not document goals, interventions, or monitoring related to the leaking colostomy, and staff reported they relied on the Kardex for resident cares. During observation, the resident was found with a strong odor, flies on the blankets, and a gown saturated with colostomy drainage, while the resident stated staff left them soiled for long periods and that the ostomy bag was not emptied frequently, causing it to leak more and overflow. The resident also stated they had been kept under blankets for hours to keep flies off and described the situation as cold, cruel, and callous treatment. Staff interviews confirmed the colostomy leaked frequently, that staff followed the Kardex for care instructions, and that the Kardex was not updated with colostomy care needs. The unit manager reviewed the care plan and Kardex and verified that colostomy cares were not documented there, and the chief nursing officer stated the colostomy should have been care planned and that clinical management was responsible for updating the care plan and Kardex.
Missed Ordered Afternoon Snack
Penalty
Summary
The facility did not ensure that a resident with a physician-ordered 2:00 PM snack received that snack in accordance with the resident’s plan of care and preferences. The resident was admitted with a diagnosis of unspecified protein-calorie malnutrition and had a BIMS score of 15 out of 15, indicating cognitive intactness. The resident stated that she was supposed to receive a 2:00 PM snack and preferred yogurt, but did not remember the last time she received one. The physician order directed staff to offer a 2:00 PM snack, with yogurt noted as the resident’s preference, and to record afternoon supplement intake. Surveyor observations and record review showed the resident was not on the kitchen’s snack list, and the dietary manager confirmed the resident should have been on the list if an order existed. On observation, a CNA delivered labeled snacks to the wing, but the resident did not have a labeled snack on the tray for her hallway. When asked about the missing snack order, the dietary manager stated this was the first time she had heard the resident was not receiving the snack and indicated the resident may have been missed when she took over the position.
Incomplete and inaccurate resident medical records
Penalty
Summary
The facility did not maintain complete and accurate medical records for residents, as shown by two examples involving R6 and R12. The facility policy required resident records to contain an accurate, complete picture of the resident’s progress, with documentation completed at the time of service or no later than the shift in which the care occurred. During record review and interviews, surveyors found that R6’s record did not include documentation of the events leading up to the resident’s transfer to the hospital, even though staff later described a change in condition that progressed over the day. For R6, the record showed a progress note stating the resident appeared more tired than usual, was easy to arouse, had vital signs obtained, received Tylenol, and had the NP notified with orders for a UA and labs. The record also contained an ER report showing the resident was transferred by ambulance for altered mental status, shortness of breath, and fever, with staff reporting the resident was normally alert and oriented x4 but was x1 that day and had been that way all day. However, there was no other documentation in the medical record showing the transfer to the hospital or what occurred in the hours before the transfer. Interviews with LPNs and the DON described the resident as sleepy, lethargic, not acting like their normal self, and eventually being sent out after provider contact, but those events were not documented in the record. For R12, who had diagnoses including unspecified protein-calorie malnutrition and a BIMS score of 15 indicating cognitive intactness, the record did not accurately reflect snack administration. R12 stated she was supposed to receive a 2:00 PM snack and did not remember the last time she received one, and she preferred yogurt. The physician order required offering a 2:00 PM snack and recording the amount consumed. The MAR showed RN G documented that R12 received the snack and consumed 100%, but the resident told surveyors she did not receive it, surveyors observed the snack tray and did not find a labeled snack for R12, and RN G stated she assumed the resident had received the snack and should have checked before documenting it.
Failure to Follow EBP and Hand Hygiene During Tracheostomy Care
Penalty
Summary
An infection prevention and control deficiency was identified when an LPN did not follow Enhanced Barrier Precautions or complete hand hygiene between glove changes while providing tracheostomy care to a resident with tracheostomy status. The resident was admitted with diagnoses including tracheostomy status, and the quarterly MDS indicated tracheostomy care was required. Facility policy stated that EBP includes gown and glove use during high-contact care for residents with medical devices, including tracheostomy care, and that hand hygiene must be performed after gloves are removed. During observation, the resident had a sign outside the room indicating Enhanced Barrier Precautions. The LPN washed hands and put on gloves but did not don a gown. While performing tracheostomy care, the LPN changed gloves multiple times without completing hand hygiene between glove changes, including after moving a garbage can with gloved hands, after removing the resident's old dressing, and after handling the suctioning machine and opening a new trach kit after a piece fell on the floor. The LPN acknowledged the EBP sign, and the DON and CNO later confirmed that a gown should have been worn and hand hygiene should have been completed when changing gloves.
Delayed CPR, 911 Call, and AED Use for a Full-Code Resident
Penalty
Summary
Facility personnel failed to provide basic life support to a resident who was a full code and was found pulseless and nonbreathing. The resident had diagnoses including COPD, acute respiratory failure with hypoxia, tracheostomy, dementia, seizures, and quadriplegia. The resident’s CPR form and physician orders both indicated full code status, and the care plan stated that CPR would be performed as ordered. When the resident was found unresponsive, staff attempted to obtain vital signs and check for a pulse. RN E was unable to obtain vital signs and went to get LPN F. LPN F checked the resident’s carotid pulse, found no pulse, and then left the room to verify the resident’s code status in the electronic record. LPN F returned and instructed staff to start CPR. Staff interviews and other records indicated there was a delay between the resident being found without vital signs and the start of CPR, and 911 was not called immediately. The report also states that the facility did not use the AED while CPR was being performed. LPN F stated the AED was not used. RN J stated the AED was located near the nurses’ station on another unit and was not removed until after EMS arrived. EMS documentation noted that nurses were actively performing CPR when EMS arrived and that the AED was first applied by EMS. The police report and body camera footage reflected that CPR began several minutes after the resident was found pulseless and nonbreathing, and that 911 was called after CPR had already started.
Failure to Prevent and Treat Pressure Injuries
Penalty
Summary
The facility did not ensure appropriate pressure injury care and prevention for one resident, R7, who was admitted with a Stage 3 pressure injury to the sacrum and was unable to turn and reposition independently. Although R7’s admission MDS identified him as at risk for pressure injuries and noted an existing Stage 2 pressure injury, the facility did not implement a turning and repositioning schedule until 8 days after admission. R7’s care plan also did not include turning and repositioning until that same date, despite his immobility and existing skin breakdown. On 5/5/26, R7 was found with a new Stage 2 pressure injury to the left buttock. Physician T documented the wound and ordered pressure relief measures, including a pressure redistribution mattress and wheelchair pressure redistribution cushion, and the care plan included a pressure reducing wheelchair cushion. The wound worsened by 5/12/26 to an Unstageable pressure injury, with Physician T documenting slough and granulation tissue and noting, “Bed rest please.” The wound measurements increased further on subsequent assessments, with continued documentation of an Unstageable pressure injury to the left buttock. Surveyor interviews and record review showed the facility did not provide R7 with a cushion for his Broda chair despite the physician order and care plan. LPN U stated turning and repositioning had not been in place on admission and was started later, and also stated R7 did not have a cushion in his Broda chair. ADON Q confirmed the facility did not normally place cushions in Broda chairs and stated R7 still did not have one. DON B stated the root cause of the left buttock pressure injury was friction, shear, and some moisture, along with R7’s Guardian wanting him up in the chair for long periods, and also stated the facility did not educate staff about the root cause analysis and prevention of worsening or new pressure injuries.
Food Served at Improper Temperatures
Penalty
Summary
The facility did not ensure that food and drinks were maintained at safe and appetizing temperatures for residents. Surveyors observed a lunch test tray with cold items that were not cold enough, including chicken salad at 57.2 degrees F, potato salad at 42.3 degrees F, and chocolate milk at 48.4 degrees F. Surveyors also observed a lunch test tray with hot items that were not hot enough, including sloppy joe meat at 125.6 degrees F, tater tots at 121.6 degrees F, and peas at 122.5 degrees F. The facility policy stated food must be stored, prepared, handled, and served to minimize the risk of foodborne illness, including proper cooking and holding temperatures, and the FDA Food Code requires cold food at 41 degrees F or less and hot food at 135 degrees F or above. A cognitively intact resident who ate most meals in her room voiced concerns that the food quality was awful and very bad, that meals were often cold, and that milk and coffee had frequently run out. She also stated that breakfast often lacked protein and showed a dietary form indicating no breakfast alternatives were offered. The resident’s electronic record included a note that the NHA had received a complaint from the Regional Ombudsman regarding food services and planned to coordinate a care conference with the resident to discuss the concerns.
Privacy and Confidentiality Not Maintained With Room Camera
Penalty
Summary
Keep residents' personal and medical records private and confidential was not maintained for one resident. A camera was observed in the resident's room and was pointed toward the resident's bed while the resident was sleeping. The resident's most recent MDS indicated severely impaired cognitive skills for daily decision making, and the care conference documentation noted that the family wanted to put a camera in the room. The resident did not have a care plan for electronic monitoring and recording devices. The surveyor observed that two family members had installed the camera in the room and had saved recordings with video and voice footage that included cares performed in the room, such as pericare, tube feedings, transfers, trach care, dressing, and bathing. The facility did not turn off or cover the camera at any time to respect the resident's privacy, and there was no signage or notification to residents, family, or staff entering the room that the room was under surveillance. The NHA stated the facility did not have a policy and procedure for electronic monitoring and recording devices and said no assessment was completed because the device was not installed by the resident.
Grievances Not Promptly Documented or Resolved
Penalty
Summary
The facility did not make prompt efforts to document, investigate, and resolve resident grievances for 2 of 3 residents reviewed. The grievance policy stated that residents have the right to voice grievances without discrimination or reprisal, that grievances should be promptly investigated and resolved, and that written resolutions should summarize the grievance, investigation, findings, actions taken, and completion date. The policy also stated grievances should generally be resolved within five working days, with the resident or representative notified if more time was needed. One resident, who was cognitively intact with a BIMS score of 15, reported finding a paperclip in a bowl of cereal and stated she told CNA O right away. CNA O confirmed the resident told her about the paperclip and that she observed it, then reported it to kitchen staff, but could not recall who she told or what staff said they would do. The resident stated she never heard anything back and had previously found a piece of wax paper and plastic wrap in her food as well. The grievance log for the month did not include this food issue, and the DON stated she was not aware of any resident issues regarding items found in food. Another cognitively intact resident, also with a BIMS score of 15, voiced concerns about wanting to be transferred closer to her daughter and about food quality, including lack of protein at breakfast, cold food, and shortages of milk and coffee. EHR notes showed the resident had requested referrals closer to home and that a complaint from the Regional Ombudsman had been received regarding the resident’s transfer requests and food service concerns. When interviewed, social services staff stated referrals had not yet been sent and that she was just beginning to talk with the resident, while leadership stated referrals are usually sent immediately and that a six-week delay would not be acceptable. A later social service note documented that four referrals were faxed and were pending response, with no other follow-up information provided.
Unnecessary Psychotropic Medication Use
Penalty
Summary
The facility did not ensure that one resident’s drug regimen was free from unnecessary psychotropic medications. The resident, admitted with diagnoses including vascular dementia with severe agitation, repeated falls, generalized anxiety disorder, and restlessness, was prescribed multiple psychotropic medications, including scheduled quetiapine, Cymbalta, and Remeron, along with PRN lorazepam and PRN haloperidol. The resident’s care plan addressed antidepressant-related complications and general mood concerns, but it did not address the use of antipsychotic medications. The resident’s physician orders showed quetiapine initially ordered at bedtime for dementia, then changed to twice daily for dementia-related agitation and restlessness, with an additional PRN quetiapine order for agitation. Haloperidol was ordered PRN for agitation, delirium, and nausea, and lorazepam was ordered PRN for anxiety, nausea, and restlessness. The resident’s MAR showed repeated administration of PRN haloperidol and lorazepam over several days. Surveyor review also noted that the facility did not provide a psychotropic medication policy when requested. Staff interviews described the resident as wandering, exit seeking, anxious, and agitated at times, with a reported elopement event in which the resident attempted to leave the facility and entered an ER before being returned. Staff stated that 15-minute checks were initiated and that the resident was being redirected with preferred activities. The ADON and DON stated that hospice had added lorazepam, morphine, haloperidol, and quetiapine, and that the psych NP had adjusted quetiapine dosing. The DON also stated she was unaware of delirium documentation, and the surveyor noted there was no documentation in the EHR indicating the resident had symptoms of delirium.
Inadequate supervision of an elopement-risk resident
Penalty
Summary
The facility failed to ensure adequate supervision for a resident with a history of wandering and elopement risk. R5 was admitted with diagnoses including severe vascular dementia with agitation, repeated falls, generalized anxiety disorder, and restlessness and agitation. His MDS showed a BIMS score of 9, indicating moderate cognitive impairment. His care plan identified him as at risk for elopement due to attempts to leave the living center and wandering, and included interventions such as 15-minute checks, redirection from doors, and providing reassurance and diversion activities. On 5/18/26, R5 attempted to exit through a common area door and the alarm sounded. Staff redirected him away from the door and entered the code to shut off the alarm, but there was an approximate 3-minute delay before the alarm system reactivated. During that delay, staff did not maintain adequate supervision of R5. According to the facility’s self-report and staff interviews, while one staff member went to get supplies and another returned to other duties, R5 doubled back and exited the facility without the alarm immediately sounding. He was later found in the emergency room waiting area next door to the facility. The record also showed ongoing exit-seeking behavior after the incident, including progress notes documenting wandering, attempts to exit, and continued 15-minute checks. Surveyor observation on 5/26/26 found R5 actively attempting to exit the building, requiring a CNA to retrieve and redirect him. Staff interviews confirmed that R5 continued to wander and attempt to elope, and that he had been left alone briefly during a later attempt as well. The maintenance director and administrator stated that the door alarm reactivation delay had been adjusted to 15 seconds.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status and failed to consult the resident’s physician regarding significant weight loss for one resident. The resident was admitted with diagnoses including non-traumatic intracranial hemorrhage, chronic respiratory failure, type II diabetes mellitus, tracheostomy, and gastrostomy tube placement. The resident’s admission nutritional assessment documented a weight of 321.6 pounds and a goal of no significant weight changes, with gradual weight loss desired due to high BMI. However, the resident did not have a nutrition care plan with specific interventions and goals for weight loss or gain. The resident experienced a significant weight loss of 13.5 pounds, or 4.29%, in one week, with weights documented as 335.1 pounds on 5/12/26 and 321.6 pounds on 5/19/26. The physician order included enteral feeding with Jevity 1.5 at 70 mL/hr and 150 mL free water flushes every 4 hours, along with weekly weights for 4 weeks. The record also showed an additional weight loss to 316.4 pounds on 5/27/26, a further loss of 5.2 pounds, or 5.58%, in 15 days. No documentation was provided showing that a provider was updated about the resident’s weight loss. During interviews, an LPN stated that a significant weight loss would be identified by a red banner in the chart and that she would assess the resident, check trends, and call the MD, as well as notify the DON and immediate floor manager. The RD stated that weight loss was discussed at resident-at-risk meetings and that the physician was not notified until a 5% weight loss occurred. The DON stated that a significant weight loss in one week would be considered a change of condition and that staff should notify the physician. Despite these statements, the resident had no documented physician notification related to the weight loss.
Failure to Send Requested Transfer Referrals
Penalty
Summary
The facility did not provide medically related social services to help a resident achieve the highest practicable physical, mental, and psychosocial well-being when it failed to make requested transfer referrals. The resident was admitted with diagnoses including Major Depressive Disorder, Recurrent, Unspecified, Generalized Anxiety Disorder, and Chronic Pain Syndrome, and her MDS indicated a BIMS score of 15 out of 15, showing she was cognitively intact. She repeatedly requested to be transferred to a facility closer to her daughter, her only living relative, and stated she had asked facility management over and over, spoken with social work, and written a letter asking to move closer to family. Record review showed a Social Services note at baseline care plan meeting stating the resident wanted referrals sent closer to home, and another note indicating she requested referrals be sent out and would consider other options. The resident continued to report that her request had not been followed up on for about 6 weeks. Interviews with the SSA, NHA, DON, and CNO showed the facility expected social services to send referrals immediately or the same day if possible, and staff acknowledged that a 6-week delay was not acceptable. A later Social Services note documented that 4 referrals were faxed to skilled nursing facilities and that the facility was waiting to hear back.
Missed wound care, bowel monitoring, and ordered treatments
Penalty
Summary
Care and treatment were not provided in accordance with professional standards for four residents, involving wound care, bowel monitoring, and completion of ordered treatments and medications. The facility’s own wound care policy required documentation of wound type, date and time of care, position, staff performing the care, changes in condition, assessment data, tolerance, and resident complaints, but the record showed gaps in assessment and documentation for a resident admitted after CABG surgery with a sternal wound that was already draining and later became larger, tunneling, purulent, and odorous with slough. RN assessments were not completed timely, changes in the wound were not documented, and staff did not notify the physician of the changes. Provider notes documented ongoing drainage, dressing problems, debridement, and later MRSA infection, while facility wound assessments initially failed to address the sternal wound at all. Two residents had bowel monitoring and constipation management concerns. One resident with Parkinson’s disease and a recent bowel obstruction/colostomy went 4 days without a documented BM, the physician was not notified, and prescribed PRN medication was not given. The record also showed missing bowel documentation on multiple shifts, and weekly skin checks were not consistently completed. Another resident with schizophrenia and secondary Parkinsonism had missing bowel documentation on multiple shifts across March, April, and May, with no recorded bowel output for multiple consecutive days on two separate occasions; the facility could not provide physician notification or evidence that PRN bowel medication was offered. The DON confirmed bowel movements should be documented every shift, PRN medication should be provided after 3 days if available, and the physician should be notified. A fourth resident with severe cognitive impairment and multiple complex diagnoses had multiple ordered medications, treatments, and monitoring tasks not completed or not documented on several shifts. The MAR showed missed topical medications, enteral medications, pain monitoring, stoma care, oxygen-related monitoring, air mattress checks, oral care, behavior monitoring, and output recording. When interviewed, the DON stated documentation should be complete so nurses can take credit for what they administer, and that missing documentation does not necessarily mean the order was not implemented because staff can be forgetful.
Residents Left Exposed in Common Areas
Penalty
Summary
The facility did not ensure two residents were treated with dignity and respect that promoted maintenance or enhancement of quality of life. R9 was admitted with diagnoses including heart failure, muscle weakness, obesity, anxiety, major depressive disorder, and multiple sclerosis. R9’s care plan stated R9 needed extensive assistance with bed mobility and dressing. During observation, R9 was being assisted down the hallway and to activities while wearing a gown with the entire back and side exposed. Staff interviews confirmed R9 preferred to wear a gown and needed assistance to remain covered while in common areas, and staff stated R9’s back and side should have been covered. R13 was admitted with diagnoses including age-related physical debility, major depressive disorder, restlessness and agitation, anxiety disorder, mild cognitive impairment, and dementia. R13’s care plan stated R13 needed maximal assistance of one person. During observation, R13 was sitting in the common area talking with a peer while wearing only a t-shirt and an incontinence brief, with the brief and entire bottom half exposed as multiple staff walked past. A CNA covered R13 with a blanket after the observation. The NHA stated residents should be dressed appropriately in common areas for dignity and acknowledged R13 sometimes declined to wear pants and that this should be care planned.
Failure to Provide Timely ADL Assistance
Penalty
Summary
The facility did not ensure two residents who needed assistance with activities of daily living received the necessary care and services. The facility’s ADLs supporting policy stated that residents unable to carry out ADLs independently are to receive services necessary to maintain good nutrition, grooming, and personal and oral hygiene, including assistance with hygiene and elimination. One resident, who had diagnoses including kidney disease, history of falling, muscle wasting, dementia, cognitive communication deficit, and anxiety disorder, was care planned for maximal assist of one with dressing and personal hygiene. On observation, the resident had whiskers on the chin and chin area, and the resident stated a preference to be shaved and not have whiskers. An RN stated the resident should not have whiskers and that staff should assist with shaving on shower days and as needed, and also stated the resident had never refused care. A second resident, who had diagnoses including heart failure, depression, bipolar disorder, irritable bowel syndrome, and a pressure ulcer of the sacral region, was care planned for one-person assistance with personal hygiene and toileting. The resident was observed in bed with a bowel movement and stated the call light had been on for an hour, that staff had previously turned it off and said they would return, and that no one had come back to assist. The resident stated the bowel movement had been present for hours. The surveyor observed the call light on for 35 minutes, and when staff finally responded, CNA-H confirmed the resident had a bowel movement and needed assistance. CNA-H and CNA-I stated staff should answer call lights within 5 to 10 minutes and/or as soon as they can.
Failure to Document Repositioning and Air Mattress Checks for a Resident With Pressure Injuries
Penalty
Summary
The facility did not ensure necessary care and services were provided to prevent pressure injuries from developing and to support healing for one resident with paraplegia, morbid obesity, and dependence on staff for bed mobility. The resident was admitted with intact cognition, was totally dependent with physical assist of 2 for bed mobility, and had a care plan identifying risk for altered skin integrity related to paraplegia, obesity, and the need for staff assistance with positioning. The care plan called for hourly side-to-side repositioning and a pressure-reducing mattress set at 350, and the resident had an order for staff to check the setting and function of the air mattress each shift. The resident developed an unstageable deep tissue injury on the sacrum and bilateral buttocks, with a skin assessment documenting a deep tissue injury on the sacrum and a later provider note stating the wound physician debrided the sacral and bilateral buttock wound at the bedside. The resident’s MDS assessment indicated the resident was not on a turning/repositioning program. Staff interviews showed nursing staff did not document repositioning, despite acknowledging the resident needed assistance to reposition because of paraplegia, obesity, a cervical neck collar, and the need for the head of bed to remain at least 30 degrees. The resident’s TAR also lacked documentation that the air mattress setting and function were checked on multiple shifts between 4/10/26 and 4/19/26, even though staff stated this was expected each shift. The DON acknowledged the missing documentation and stated the facility did not have a documentation policy, while the ADON stated staff do not document repositioning because it is considered standard of care. The report also notes the resident had a skin tear on the right buttock and later wound care orders for the bilateral buttocks and posterior inner left thigh.
Failure to Provide Ordered Cough Assist Respiratory Care
Penalty
Summary
The facility did not provide ordered respiratory care for one resident with severe neurologic and respiratory conditions. The resident had diagnoses including cerebral palsy, acute and chronic respiratory failure with hypoxia, quadriplegia, pneumonia, sepsis, seizures, and severe protein-calorie malnutrition, and had a BIMS score of 0 with a healthcare guardian. A hospital discharge/transfer document signed by the physician ordered bronchial hygiene with Cough Assist treatments twice daily and as needed, with specific settings and oral suctioning as needed after treatments. The Cough Assist order was not transcribed into the resident’s TAR, and the resident did not receive Cough Assist treatments in the facility from admission until discharge. Staff interviews showed the LPN who entered admission orders did not recall entering the Cough Assist order and was unsure who double-checked the admission orders, while another LPN stated the resident did not have an order for Cough Assist. The DON reviewed the record and did not find evidence that the Cough Assist machine was ordered or provided, and the ADON stated she entered settings into the machine in the resident’s room and completed one treatment, but did not recall documenting it and confirmed the order was not in the TAR. During the stay, the resident was hospitalized three times for respiratory-related problems, including respiratory difficulty with recurrent aspiration, hypoxia with acute respiratory failure and left-sided pneumonia with sepsis, and later respiratory distress with fever and aspiration pneumonia. Hospital documentation noted use of a Cough Assist machine during the hospitalizations. The primary care provider stated it was extremely unlikely that not using Cough Assist as ordered caused the hospitalizations, while the hospital discharge physician stated Cough Assist would have been useful to help clear secretion buildup but did not think it would have prevented hospitalization given the resident’s comorbidities.
Missed Dental Appointment Due to Transportation Issues
Penalty
Summary
The facility did not assist a resident with arranging transportation to and from an outside dental appointment, resulting in the resident missing the appointment on 4/16/26 and needing to reschedule because of transportation issues. The resident stated that multiple appointments had been missed in the past. The resident was admitted with diagnoses including chronic pain syndrome, anxiety disorder, post-traumatic stress disorder, and contusion of the left upper arm. Surveyor review of records showed a progress note from the Director of Social Services documenting that the resident missed the dental appointment due to transportation issues. The Director of Social Services stated there had been a conversation with the resident about the dental appointment and that transportation problems caused the rescheduling. The Director also stated there had been confusion in the past about whether the resident's Managed Care Organization or the facility was responsible for scheduling transportation. The Receptionist stated there had been previous issues with transportation and scheduling the correct transportation services, and the Nursing Home Administrator stated there had been past issues with scheduling appointments and transportation.
Failure to Provide Ordered Speech Therapy
Penalty
Summary
The facility did not ensure specialized rehabilitative services were provided for a resident with an order for Speech Therapy evaluation and treatment. R10 was admitted with diagnoses including complete paraplegia, morbid obesity, neuromuscular dysfunction of the bladder, tracheostomy, anxiety, and an unspecified T7-T10 spinal cord injury. R10’s MDS assessment showed a BIMS score of 15 out of 15, indicating intact cognition. R10 had a Speech Therapy order, along with orders for a Shiley uncuffed size 4 trach, head of bed elevation, trach care every shift, and for the trach to remain capped with removal if needed. R10 was not seen by Speech Therapy during the stay from the time the order was written until discharge. A progress note documented that R10 refused to use a trach inner cannula because of the capped trach and stated it was not needed. A provider note indicated R10 should continue Physical, Occupational, and Speech Therapy to optimize functional recovery. During interview, the Speech Therapist stated R10 was not evaluated, was not informed of the order, and that the communication issue prevented services from being provided. The Therapy Director confirmed the resident was not seen for Speech Therapy and stated it was the Therapy Director’s responsibility to ensure new therapy orders were followed and residents were added to the daily schedule. The DON stated R10 should have been seen by Speech Therapy within days of the order.
RN Coverage Not Documented for Required Daily Hours
Penalty
Summary
The facility did not ensure a Registered Nurse (RN) was on duty for at least 8 consecutive hours per day, 7 days per week. Survey review of the facility assessment and staffing records showed that the facility’s schedules and nurse staff postings did not include an RN on duty for at least 8 consecutive hours on 5 of 10 days reviewed. The dates identified were 11/27/25, 11/29/25, 11/30/25, 12/26/25, and 12/27/25, affecting the facility’s 77 residents. The staffing records for 11/27/25, 11/29/25, and 11/30/25 included the RN and Infection Preventionist (IP)-I’s name handwritten at the bottom, but the schedules did not show the hours worked or the capacity in which IP-I worked. The DON and NHA stated the facility had an RN manager on-call expected to work on the floor if called in, and confirmed IP-I was the RN manager on duty for the November dates. The NHA also stated payroll time clock punches should have been submitted to corporate, but because IP-I was salaried there was no time-stamp to confirm presence in the building, and the facility did not have documentation showing an RN worked 8 consecutive hours on the identified dates. Login data from the electronic medical record system did not show how many hours IP-I was in the facility or what tasks were completed while working as the RN on duty.
Unsafe food storage, cooling, holding, and labeling practices
Penalty
Summary
Food was not stored, prepared, cooled, held, labeled, or served in a sanitary manner in the kitchen and food service areas. During an initial kitchen tour, surveyors observed black debris on ceiling vents above food preparation and cooking areas, a dusty oscillating fan blowing directly onto clean dishes, residue inside the food steamer, food and grease buildup on the stove top and flat top grill, and food debris and unidentified residue on shelves, tabletops, and steamtable surfaces. A container of Thick It also had white and black residue on the outside and lid while stored beneath the soiled ventilation area. The Dietary Manager acknowledged the debris, stated the fan contained dust and debris, and noted the grill and stove top needed daily wiping, while maintenance later confirmed the ceiling vents had not been on a cleaning rotation and that debris could contaminate the counters where meal trays were prepared. Safe cooling practices were not followed for cooked foods. In the walk-in cooler, surveyors observed multiple previously cooked foods, including taco casserole, baked ham, apple crisp, oatmeal, cream of wheat, pureed eggs, shredded pork, bacon, turkey sausage, and approximately 12 warm pork loins stacked in a deep pan. The pork loins were not placed in a shallow pan, spread out, sliced, or set on ice to cool more quickly. The Dietary Manager stated the facility used leftovers and should have a cooling log, but staff were unsure where to find it, and the most recent cooling log located was dated November 2024. The log indicated cooked food should be checked every two hours and reach 41 degrees Fahrenheit within six hours. Food was also not maintained at safe temperatures during breakfast service, and time/temperature control foods were not labeled appropriately. Surveyors observed fried eggs on the stove that were not being kept warm, yogurt and Mighty Shakes sitting out on the counter instead of being kept cold, and resident trays with pre-poured juice waiting for service. A fried egg was later temped at 115 F and would have been served to a resident if the surveyor had not intervened. At the end of breakfast, juice measured 66.5 F, yogurt 56.3 F, and hard boiled eggs 51.4 F. Surveyors also found bulk flour with no open or use-by date, bulk sugar with an open date but no use-by date, open linguini pasta with two dates but no clear use-by date, and an unlabeled container of Thick It powder with two dates that staff could not explain. The Dietary Manager and kitchen staff were unsure of the correct holding temperatures and date-marking information, and the NHA and DON stated kitchen management and staff should be aware of and follow facility protocols for safe food storage, handling, preparation, and serving.
QAA Committee Did Not Meet Required Membership Quarterly
Penalty
Summary
The facility did not ensure that the minimum required members of its Quality Assessment and Assurance (QAA) committee met at least quarterly. The facility's QAPI plan, effective 10/1/25, required the QAA committee to be interdisciplinary and to include, at a minimum, the DON, the Medical Director or designee, at least 3 other staff members with at least one in a leadership role, and the Infection Preventionist. Survey review of the QAA committee meeting sign-in sheets for the prior year showed monthly meetings from February 2025 through February 2026, but the required membership was documented only in August 2025 and February 2026. The sign-in sheets showed that the required members were not present at most meetings: the MD and NHA were absent in February 2025; the NHA and IP were absent in March 2025; the NHA was absent in April 2025; the DON and IP were absent in May 2025; the NHA and IP were absent in June 2025; the NHA, IP, and MD were absent in July 2025; the MD and IP were absent in September 2025; and the MD was absent in October, November, December 2025, and January 2026. In February 2026, the required members attended, with the MD participating by phone. During interview, the NHA acknowledged the requirement and stated the MD sometimes attended by phone, and confirmed the sign-in sheets should reflect who attended the meetings.
Failure to Thoroughly Investigate and Resolve Grievances About Missing Personal Property
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and resolve resident grievances related to missing personal items and laundry, and to consistently follow its grievance and personal property policies. Multiple residents reported that laundry items such as clothing and socks frequently went missing. One resident, who was also the Resident Council president, stated that missing laundry was a recurring issue discussed at Resident Council meetings and wanted staff to resume bringing unclaimed personal items from laundry for residents to sort through. Another resident reported missing pajama pants and a sweater, stating the Nursing Home Administrator was aware and had said the items would be replaced, but this had not occurred. A further resident reported a missing nightgown with cardinals, and both that resident and the roommate indicated staff were aware but had not located the item or provided an update. Review of Resident Council minutes showed that missing clothing and lost-and-found items had been discussed in prior meetings, and staff had acknowledged working on an improved process to decrease missing items. Despite this, the grievance log contained no entries for the residents’ missing items. In the laundry area, the surveyor observed a bin of unlabeled clothing and a bulletin board listing residents’ names and missing items, which laundry staff used informally to track lost belongings. Laundry staff reported that residents’ belongings were supposed to be inventoried on admission and sent to laundry for labeling, but this process was inconsistent, and items were often laundered before being labeled. Laundry staff also stated that they were not always informed when items were missing, and that missing items occurred almost daily. Another component of the deficiency involved a resident whose borrowed brown wheelchair went missing shortly after admission. The resident, who had intact cognition and used a wheelchair, reported telling multiple staff about the missing wheelchair and expressed a desire to have the friend’s wheelchair returned. A grievance documented that the care team reported the missing wheelchair, that staff searched the facility and interviewed the receptionist, and that a new wheelchair was provided, with the grievance noting the resident was reportedly satisfied and had no further complaints. However, the grievance did not include interviews with other staff or residents to determine if anyone else had seen the wheelchair or knew its whereabouts. Additionally, the resident’s medical record lacked an admission inventory of belongings, and the Assistant DON confirmed that while belongings should be inventoried and documented, no such inventory was found for this resident.
Failure to Complete Required Caregiver Background Checks Before Staff Worked With Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement its written Abuse/Neglect/Exploitation policy requiring screening of potential employees for a history of abuse, neglect, exploitation, or misappropriation of resident property through background, reference, and credential checks. Surveyor review of 10 staff files on 3/11/26 showed that 6 staff members did not have timely or properly completed caregiver background checks. One CNA hired on 6/24/16 had a Background Information Disclosure (BID) form dated 6/23/16, but the Department of Justice (DOJ) and Government Findings (GF) reports were not completed until 3/11/26, after the surveyor requested them, and not within the required four-year interval. Another CNA hired on 1/29/26 had a BID form dated 1/30/26, completed after the hire date, and there was no evidence that DOJ or GF reports were requested. A third CNA hired on 11/2/04 had a BID form completed on 8/26/16, but the DOJ and GF reports were not completed until 12/29/20, which was not within the last four years. An activity aide hired on 1/24/26 had a BID form dated 1/26/26 and DOJ/GF reports dated 1/27/26, all completed after the hire date, meaning the aide worked with residents before completion of the background check. A maintenance staff member hired on 12/8/25 had DOJ and GF reports dated 12/9/25, after the hire date, and worked in resident care areas before the background check was completed. Another CNA hired on 1/6/26 had DOJ and GF reports dated 1/8/26, also after the hire date. In an interview, the NHA and DON confirmed that the previous business office manager had been responsible for background checks, that this person had left employment a few weeks earlier, and that background checks are required every four years and must be completed before staff work with residents or in resident care areas.
Failure to Develop and Implement Comprehensive Care Plans for Identified Resident Needs
Penalty
Summary
The deficiency involves the facility’s failure to develop and/or implement individualized comprehensive care plans addressing specific identified needs for three residents. For one resident with intact cognition and multiple diagnoses including muscle wasting, diabetes, encephalopathy, schizoaffective disorder, and seizures, the facility investigated a facility-reported incident involving an allegation of misappropriation of money. The investigation indicated that a safe keeping of valuables care plan would be implemented, but review of the medical record showed that no such care plan was added. During interviews, facility leadership confirmed that the resident’s care plan did not address safe keeping of valuables and acknowledged that it should have been included. A second resident with end stage renal disease and intact cognition was identified on the MDS as receiving dialysis, yet the medical record contained no dialysis care plan, which was confirmed by the DON. A third resident with Alzheimer’s disease, anxiety, depression, and moderate cognitive impairment, and who had an activated POA for healthcare, was known by staff to have dementia-related behaviors such as sometimes refusing to get out of bed, requiring staff to reapproach later. However, review of this resident’s care plan showed no interventions for Alzheimer’s disease/dementia care. The DON verified that this resident did not have an Alzheimer’s disease/dementia care plan, despite facility policies requiring resident-centered care plans for individuals with dementia and comprehensive care plans describing services to maintain residents’ highest practicable well-being.
Widespread Failures in Timely and Accurate Medication Administration and Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate and timely medication administration in accordance with physician orders and facility policy for multiple residents. The facility’s Medication Administration policy required medications to be administered as prescribed, within 60 minutes of scheduled times, with clear documentation and clarification of unclear orders. For one resident with multiple severe pressure ulcers and osteomyelitis, an order for 5% acetic acid stated only to apply externally every day and evening shift, without specifying the location, method of application, or treatment parameters. Review of the MAR showed that 11 of 44 scheduled doses were not documented as administered, with 10 doses coded as “other” and one as “refused,” and no corresponding progress notes explaining the “other” codes. Nursing staff, including an LPN and the DON, stated they did not know where the acetic acid should be applied or the indication for its use and acknowledged the order was unclear and should have been clarified. Another staff member reported never applying the acetic acid despite documenting it as given and stated they had been pressured by the wound nurse to sign out medications and treatments they did not administer. A second resident with paraplegia, sepsis, anxiety, and depression had been on methenamine hippurate twice daily for frequent UTIs. After a hospitalization for sepsis with possible UTI, the hospital discharge summary instructed that methenamine be held during a 7‑day course of Bactrim and then resumed three days after completion, specifying a resume date. The facility did not restart methenamine hippurate until 11 days after the date indicated in the discharge instructions. The ADON, who also served as Infection Preventionist, confirmed that the methenamine should have been resumed per the hospital instructions and stated the order had been missed. Additional residents experienced late or unavailable medications and administration not in accordance with orders. One cognitively intact resident reported that morning medications, including olanzapine, glipizide ER, and fluoxetine, were sometimes late; an audit showed these 8:00 AM medications were administered around midday. Another resident admitted with atrial fibrillation, hypertension, and rheumatoid arthritis had multiple essential medications, including amiodarone, hydroxychloroquine, metoprolol, and sulfasalazine, not administered on several days because they were unavailable, as documented on the MAR. Several other residents had scheduled morning medications (including metformin, methenamine, acetaminophen, antihypertensives, anticoagulants, psychotropics, and other chronic medications) ordered for 7:00 or 8:00 AM but observed being administered after 9:00 AM; the RN administering these medications acknowledged they were late and stated that morning medications were given between 7:00 and 11:00 AM. The DON stated medications should be administered within one hour before or after the prescribed time. Another cognitively intact resident with epilepsy, diabetes, asthma, and anxiety reported needing seizure medications on time and stated that seizure medications were given two hours late, leading to small seizures, which the resident described to nursing staff and the DON. The MAR showed multiple doses of lacosamide and levetiracetam scheduled for 8:00 AM and 4:00 PM were administered late, coded as “other,” or documented as given significantly outside the scheduled times, with some doses of levetiracetam administered several hours after the scheduled time. Nurses’ notes for the dates with “other” codes were not available for review, and there were no progress notes documenting seizure activity. A pharmacist later explained that twice‑daily medications are recommended to be given at least eight hours apart and preferably closer to 12 hours, and confirmed that certain doses of levetiracetam were supplied in limited quantities due to insurance refill timing, with the possibility that the resident had home supply, but the MAR still reflected late administrations and code entries.
Failure to Follow Hand Hygiene, PPE, and Meal-Time Infection Control Practices
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain its infection prevention and control and hand hygiene policies, including during enhanced barrier precautions, contact precautions, medication administration, and meal service. The facility’s policies required hand hygiene before and after resident contact, after glove removal, when moving from soiled to clean body sites, and before medication preparation and administration. Policies also required appropriate use of PPE for residents on contact precautions and mandated that all residents be offered hand hygiene prior to meals. Surveyors found multiple instances where these requirements were not followed. One resident on enhanced barrier precautions due to a catheter and a wound was observed receiving peri care and catheter care from a CNA who did not change gloves or perform hand hygiene when moving from dirty to clean tasks. The CNA washed the resident’s upper body, anterior peri area, and completed catheter care without removing soiled gloves, cleansing hands, and donning clean gloves before touching the resident’s gown. The CNA then removed soiled gloves, retrieved a bottle of hand sanitizer from under the gown and reached into the scrub top without performing hand hygiene, and later washed the resident’s peri rectal area without changing gloves or cleansing hands. The CNA also touched the resident and a bottle of lotion before finally removing gloves, cleansing hands, and donning clean gloves. The DON, present for most of the observation, confirmed that staff should remove soiled gloves, cleanse hands, and don clean gloves when going from dirty to clean, and the CNA did not understand the breach in hand hygiene. Another resident with a history of carbapenem-resistant Acinetobacter baumannii (CRAB) and open wounds had an active order for contact isolation and a contact precautions sign posted at the room. Despite the sign instructing everyone to clean their hands before entering and when leaving, and for staff to don and discard gloves and gowns upon room entry and exit, the assistant administrator entered the room without performing hand hygiene or donning PPE, then exited and entered another room without hand hygiene. When questioned, the assistant administrator stated that if the sign was not on the resident’s door it was not active, and only after the RN checked the electronic record and confirmed the resident was on precautions for CRAB did the assistant administrator acknowledge that appropriate precautions should have been followed. Surveyors also observed a RN preparing and administering medications to multiple residents without performing hand hygiene at the start of medication preparation or before administering medications, contrary to the facility’s medication administration policy. The RN later stated that hand hygiene was usually completed between every several residents unless there were visible bodily fluids, while the DON indicated staff should complete hand hygiene prior to medication preparation and after medication administration. In addition, during multiple meal services on different units and in the main dining room, residents were not offered hand hygiene before eating. Trays did not include hand hygiene wipes, tables lacked wipes or hand sanitizer, and staff did not offer hand hygiene prior to meals. A CNA acknowledged not offering hand hygiene before breakfast and described only using a wet paper towel if hands were dirty after meals. Two residents reported they were not offered hand hygiene before or after meals but stated they would like or thought it would be a good idea to be offered hand hygiene. The dietary manager and nursing leadership confirmed that residents should be offered hand hygiene prior to meals and that hand wipes should be on room trays for all meals.
Failure to Provide Bed Hold, Transfer, and Ombudsman Notifications
Penalty
Summary
The facility did not ensure written bed hold and transfer notices were completed for multiple residents who were sent to the hospital, and it did not notify the Ombudsman of several transfers and discharges. The residents identified included R6, R13, R79, R56, R11, R9, and R21. The record review showed that these residents had hospital transfers on multiple dates, and their charts did not contain written bed hold or transfer notices. The facility also failed to include several of these residents in the Ombudsman notification list that was sent by email on 3/10/26. The affected residents had varied medical conditions and levels of cognition. R6 had a history of CVA, respiratory failure, and dysphagia, with a BIMS score of 0 and an activated POAHC. R13 had paraplegia, sepsis, and anxiety, with intact cognition. R79 had esophageal cancer and intact cognition, R56 had muscle wasting and atrophy and chronic pain syndrome with moderate cognitive impairment, R11 had muscle wasting and atrophy and diabetes with intact cognition, and R9 was non-verbal and unresponsive with an assigned guardian. R21 had encephalopathy, malnutrition, and a tracheostomy and was non-verbal with an activated POAHC. Interviews showed staff uncertainty about who was responsible for completing the notices and sending Ombudsman notifications. An LPN stated they did not complete bed hold or transfer notices and was not sure who did. The SSD stated nursing staff were required to complete the notices, while the AD stated they did not do anything with bed hold and transfer notices and sometimes called families without documenting it. The NHA confirmed the facility did not have written bed hold and transfer notices for the residents identified and did not notify the Ombudsman of the transfers and discharges.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility did not accurately code MDS 3.0 assessments for 6 residents, resulting in assessments that did not match the residents’ actual conditions or treatments. The record review and staff interviews showed that R21’s MDS assessments incorrectly identified the resident as comatose and failed to indicate the resident had a tracheostomy, even though R21 was alert, responded to staff with head nods and facial expressions, and had a tracheostomy. MDSC-N confirmed the coding errors for R21. R62’s MDS assessment also incorrectly indicated the resident was comatose, although CNA-U described R62 as alert but non-verbal and able to respond to pain. R22’s MDS assessment did not indicate Hospice services, even though the resident had signed onto Hospice services and a Hospice CNA stated the resident had been receiving Hospice care for months. The facility’s MDSC-N initially stated R22 did not receive Hospice services, but the NHA and DON later confirmed the assessment should have reflected Hospice services. Additional coding errors were identified for R29, whose MDS did not indicate anticonvulsant medication despite a physician order for levetiracetam; R7, whose MDS indicated insulin use despite no insulin order and a care plan stating the resident was non-insulin dependent; and R36, whose MDS did not indicate a catheter despite the resident having a Foley catheter. In each of these cases, MDSC-N confirmed the assessment was coded inaccurately or that the relevant condition or treatment had been missed.
Missed IV Antibiotic Doses and Lack of Timely Physician Notification
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were free from significant medication errors, specifically missed doses of IV antibiotics for two residents with serious infections. For one resident with acute osteomyelitis, multiple stage 3 and 4 pressure ulcers, hemiplegia, and severe protein-calorie malnutrition, physician orders were in place for IV ceftriaxone once daily for two weeks and IV vancomycin for osteomyelitis. Review of the MARs showed that ceftriaxone and vancomycin were not administered on specified dates, with MAR codes indicating "other" and "hold" and references to nurse’s notes. Documentation showed that on one date the PICC line had not yet been placed and that the facility was awaiting vancomycin from the pharmacy, and on another date ceftriaxone was not available. The resident’s record did not contain evidence that the physician was notified of the missed antibiotic doses. For the second resident, who had sepsis from a soft tissue infection, right calf cellulitis and abscess, type 2 diabetes, a history of MRSA infection, and chronic lower extremity wounds, the care plan identified IV antibiotics for sepsis and cellulitis and the risk of infection related to IV/PICC use. A physician order directed IV cefazolin three times daily for infection. The MAR indicated that the order was started the day after admission, but the scheduled morning and afternoon doses were not administered. A health note later documented that the resident had missed antibiotics due to pharmacy issues. Emergency Department documentation recorded that the resident had missed three doses of IV antibiotics, and the resident expressed concern about going without antibiotics and chose to go to the ED for evaluation. Interviews with staff confirmed that delays in medication administration occurred due to pharmacy delivery and PICC line placement issues. An LPN stated that residents miss doses when medications are not delivered timely from the out-of-state pharmacy, which typically delivers nightly and can send stat medications taking approximately two hours if requested. The DON stated that medications should be administered as ordered, that non-initialed or coded MAR entries are considered not administered, and that IV medications should be started right away if available, with physician notification and documentation if there is a delay. The DON also indicated that the process is to notify the provider if a medication has not arrived so the provider can hold or change the order, but in the case of the second resident, the provider was not contacted until after multiple doses had already been missed, and the record did not show when or if the physician was notified of the missed doses. These actions and inactions resulted in multiple missed doses of ordered IV antibiotics for both residents without documented, timely physician notification.
Failure to Ensure Reliable Transportation for Baclofen Pump Services
Penalty
Summary
The deficiency involves the facility’s failure to provide reliable transportation for a resident requiring outside laboratory and surgical services for a baclofen pump change. The resident, who had paraplegia, a T1 spinal cord injury, anxiety, and depression, was cognitively intact with a BIMS score of 15/15. According to the resident’s interview, there were multiple missed or unsuccessful attempts to complete the necessary pre‑operative and surgical appointments, and the resident only reached the appointment on the fourth attempt. The resident reported that the first appointment was missed because the facility did not schedule a ride for the pre‑op visit and did not complete the required blood work, the second attempt failed because the facility did not hold the resident’s Eliquis in time, and the third attempt failed when the transportation company arrived with a car instead of a wheelchair van. Progress notes documented that a pre‑procedure physical appointment was missed due to transportation issues, and an APNP note stated that the baclofen pump replacement surgery had been delayed multiple times due to transportation problems. Staff interviews further confirmed issues with transportation coordination and reliability. Transportation staff reported using several different transportation companies and were unaware of the specific transportation failures for this resident, and could not explain what happened with at least one missed appointment, noting that another former transportation staff member might have kept notes elsewhere. A RN acknowledged there had been a few missed appointments recently and confirmed that at least one of this resident’s appointments was missed when the ride did not show up, despite the resident being ready. The DON confirmed there were issues with a transportation company, and the NHA stated that transportation scheduling and approval processes were in place, including a binder and electronic dashboard for appointments, but staff education for the updated transportation process was not provided to the surveyor when requested.
Incomplete Informed Consent for Psychotropic Medications
Penalty
Summary
The facility did not ensure that residents or their legal representatives were thoroughly informed in advance of the risks and benefits of prescribed psychotropic medications, and the related informed consent forms were not fully completed for three sampled residents. R20, who had diagnoses including anxiety, major depression, and mood disorder and had a BIMS score of 15/15 indicating intact cognition, was prescribed buspirone and Seroquel for anxiety, depression, and mood disorder. Although informed consent forms were present for Seroquel and buspirone, they were not thoroughly completed, including missing initials and dates on each page and a signature and date on the last page. The LPN/unit manager and the DON both verified the forms were not thoroughly completed. R3, who had dementia, anxiety, insomnia, and PTSD and had a BIMS score of 9/15 with moderate cognitive impairment, had an activated POAHC and was prescribed risperidone, trazodone, and sertraline. The medical record did not contain informed consent forms for these medications, and the LPN believed nursing staff were waiting for the POAHC to sign the forms. R72, who had Alzheimer’s disease, schizophrenia, anxiety, insomnia, and depression and had a BIMS score of 11/15 with moderate cognitive impairment, also had an activated POAHC and was prescribed risperidone for schizophrenia. The medical record did not contain an informed consent form for risperidone, and both the LPN and DON verified that the form had not been completed.
Failure to Hold Regular Care Conferences
Penalty
Summary
The facility did not ensure care conferences were held regularly for one resident with vascular dementia with psychotic disturbance and moderately impaired cognition, as shown by a BIMS score of 9 out of 15. The resident had an activated POAHC. The facility’s policy stated interdisciplinary care conferences were to be conducted according to the MDS assessment schedule and whenever there was a significant change in condition, with residents or legal representatives invited to participate. The resident’s POAHC stated they had previously been invited to care conferences but had not been invited for more than a year. The SSD verified the resident had not had a care conference since the SSD began working at the facility and confirmed the facility had not been doing regular quarterly care conferences. The SSD stated care conferences were scheduled for new admissions and as needed, and the facility planned to coordinate care conferences and POAHC invites with quarterly MDS assessments. The CNO also confirmed the facility had not been doing care conferences and had a training set up to educate staff.
Advance Directive Documentation Not Completed or Offered
Penalty
Summary
The facility did not ensure a Power of Attorney for Healthcare (POAHC) document was completed or offered for 2 residents, R7 and R74, and neither resident’s medical record contained a POAHC document or documentation showing the facility offered assistance with one. The facility’s Advanced Directives policy states that prior to or upon admission, Social Services or designee inquires about any written advance directives, and if none exist, staff will offer assistance in establishing them and document the offer and the resident’s decision in the medical record. R7 was admitted with diagnoses including diabetes and coronary artery disease and had a BIMS score of 15 out of 15, indicating intact cognition. A social services progress note documented that R7 was asked about completing POAHC paperwork and stated interest, wanted family members listed, and would complete the paperwork when family visited. R74 was admitted with end stage renal disease and also had a BIMS score of 15 out of 15. A social services progress note documented that R74 said family had been designated and that R74 would try to find the paperwork; the writer could not locate hospital paperwork. Another note showed the NHA contacted R74’s family and emailed them to set up a time to complete the paperwork. The SSD stated both residents were admitted shortly before or after the SSD started employment and their POAHC paperwork may have been missed.
Failure to Provide Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to provide written notice of Medicare coverage ending and the resident’s potential financial liability for continued services for one resident, R77, whose Medicare Part A stay was scheduled to end on 1/30/26. The report states that the facility did not provide R77 with a Notice of Medicare Non-Coverage (NOMNC), which includes appeal rights, or an Advanced Beneficiary Notice (ABN) for the Part A stay ending on that date. Survey review of R77’s record between 3/9/26 and 3/11/26 showed that R77 was admitted to the facility with diagnoses including peripheral vascular disease, respiratory failure, anxiety, and depression. The 2/27/26 MDS documented a BIMS score of 15 out of 15, indicating intact cognition. On 3/11/26, the surveyor requested NOMNC and ABN forms for the Medicare Part A stay, and on 3/12/26 the Social Services Director stated that these forms were not provided for R77’s stay ending on 1/30/26.
Missing Significant Change MDS After Hospice Enrollment
Penalty
Summary
A Comprehensive Significant Change MDS assessment was not completed for one resident after the resident started Hospice services. The resident was admitted with diagnoses including critical illness myopathy, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, seizures, tracheostomy, and malignant neoplasm of the tongue. The resident’s record contained a Hospice Election Statement dated 1/13/26 indicating Hospice services began on 1/14/26, but the record did not contain a Comprehensive Significant Change MDS assessment within 14 days of the Hospice start date. During the survey, a Hospice CNA stated the resident had received Hospice services for a couple of months. The MDS Coordinator stated the assessment was not initiated because she believed the resident did not receive Hospice services and referenced a progress note indicating the resident refused Hospice on 2/19/26. After being informed of the CNA interview, the MDS Coordinator stated she was not aware the resident received Hospice services. The Regional MDS Coordinator was also not aware the resident received Hospice services and stated that when a resident signs onto Hospice, staff should complete a Comprehensive Significant Change MDS assessment. The NHA and DON confirmed the resident received Hospice services and that a Comprehensive Significant Change MDS assessment should have been completed.
Delayed MDS Transmission for Two Residents
Penalty
Summary
The facility did not ensure timely transmittal of Resident Assessment Instrument/Minimum Data Set (RAI/MDS) assessments for 2 residents, R55 and R64, out of 37 sampled and supplemental sampled residents. The report states that required MDS records must be electronically transmitted and accepted into the CMS system within 14 days of the assessment reference date, but the facility failed to transmit the assessments for these residents within that timeframe. R55 was admitted to the facility and had a Quarterly MDS completed on 12/17/25, but the assessment was not transmitted until 3/11/26. R64 was admitted to the facility and later discharged on 10/24/25; a Discharge - Return Not Anticipated MDS was completed on 10/27/25, but it was also not transmitted until 3/11/26. During interview, the Regional MDS Coordinator stated there was a glitch in the EMR system, explaining that assessments could remain in Complete status instead of Export Ready status and therefore not transmit. The coordinator also stated the EMR pre-populated Section A incorrectly as not Medicare/Medicaid certified, and that the missing MDS report had last been run in early January.
PASRR Screening Not Completed Appropriately for Two Residents
Penalty
Summary
PASRR screening for mental disorders or intellectual disabilities was not completed appropriately for 2 residents. One resident had diagnoses of schizoaffective disorder, anxiety disorder, and depression, along with long- and short-term memory impairment, but the facility did not complete a PASRR Level II screen. The resident’s medical record contained a PASRR Level I screen indicating the resident did not have a diagnosis of a major mental disorder, and the Admissions Director later confirmed the Level I screen had been marked incorrectly and that a Level II screen was not completed. A second resident had diagnoses including epilepsy, major depressive disorder, and anxiety disorder, was non-verbal and unresponsive, and had a guardian responsible for healthcare decisions. The resident’s PASRR Level I screen indicated there was no diagnosis of a major mental illness or intellectual/developmental disability, so a PASRR Level II screen was not completed. The Admissions Director later confirmed the Level I screen had been completed inaccurately and that a Level II screen should have been completed for this resident.
Failure to maintain safe environment and complete required fall and smoking assessments
Penalty
Summary
The facility did not ensure the environment remained as free of accident hazards as possible for a resident with a history of falls and cognitive impairment. R3 had vascular dementia with psychotic disturbance, a BIMS score of 9 out of 15 indicating mild cognitive impairment, and an activated POAHC. R3’s care plan identified fall risk related to a recent fall with fracture, decreased mobility, and poor safety awareness, and included interventions for an anti-rollback device on the wheelchair and a fall mat beside the bed. However, survey observation found the fall mat was not in place and the wheelchair did not have an anti-rollback device, and the POAHC reported repeatedly requesting the fall mat because of multiple falls. R3 had unwitnessed falls on 11/1/25 and 1/1/26, with documentation showing R3 was found face down in the room with a hematoma on the back of the head after the first fall and later fell while going to the bathroom, hitting the head and developing a hematoma on the forehead and a headache after the second fall. R3 was on Eliquis and was sent to the hospital after both events. Surveyors requested fall reports, neuro checks, and root cause analysis documentation, but did not receive neuro checks or a root cause analysis for the 11/1/25 fall and did not receive a risk management report, neuro checks, or a root cause analysis for the 1/1/26 fall. The DON verified the missing interventions should have been in place. The facility also did not complete a smoking assessment for R20 to determine whether R20 could smoke independently, and R20’s care plan did not address smoking. R20 had diagnoses including muscle wasting and atrophy, asthma, diabetes, affective mood disorder, anxiety, and polyneuropathy, and had intact cognition with a BIMS score of 15 out of 15. Although a smoking assessment was dated 3/9/26 and did not identify safety concerns, R20 was observed smoking independently on the patio without a smoking apron, and surveyors observed R20 extinguish a cigarette without placing the butt in the receptacle or giving it to staff. CNA-R and the DON/CNO confirmed R20 should have given the cigarette to staff to extinguish, and the DON verified R20 did not have a smoking assessment or smoking care plan prior to the survey date.
Failure to Monitor and Report Significant Weight Changes
Penalty
Summary
The facility did not ensure that two residents received the ordered monitoring needed to track weight changes. The facility’s policy required resident weights to be monitored, recorded, and rechecked when a weight change of 5% or more was identified, and it also required notification of the dietitian and physician for significant changes. The facility also had a policy requiring notification of the physician for significant changes in a resident’s condition. For one resident, who had diagnoses including severe protein calorie malnutrition, multiple pressure ulcers, hemiplegia and hemiparesis following cerebral infarction, and a G-tube with enteral feeding, the record showed ordered daily, weekly, and monthly weights were not documented as scheduled. The resident was weighed at 103.1 lbs and then at 97.0 lbs seven days later, reflecting a 6.1 lb loss and 5.9% body weight loss. A re-weigh was not obtained the next day after the significant weight loss, and no other weights were documented through the end of the survey review period. For the other resident, who had congestive heart failure and intact cognition, the record showed repeated weight gains that met the physician-notification threshold, including gains of 3 lbs in one day, 4 lbs in one day, 10 lbs in one week, 3.6 lbs in one day, 11 lbs in one day, and 5.2 lbs in one day. The medical record did not indicate the physician was notified of these weight changes. Staff interviews confirmed that weights should have been obtained as ordered, re-weighed when significant changes occurred, and that the physician should have been notified of the increased weights.
Lack of Monitoring for High-Risk Medications
Penalty
Summary
The facility did not ensure monitoring for adverse reactions or side effects was in place for three residents who were prescribed high-risk medications. R3, who was admitted with a diagnosis of epilepsy and had moderate cognitive impairment with an activated POAHC, was prescribed levetiracetam, but the medical record did not contain monitoring interventions for adverse reactions or side effects of the medication. On interview, an LPN and the DON confirmed that staff should have been monitoring R3 for adverse reactions or side effects of levetiracetam, and the DON confirmed that this monitoring was not in place. R7, who was admitted with a diagnosis of rheumatoid arthritis and had intact cognition with a BIMS score of 15, was prescribed oxycodone and oxycodone hydrochloride PRN for pain, but the record did not contain monitoring interventions for adverse reactions or side effects of the opioid medications. R29, who was admitted with a diagnosis of osteoarthritis and had severe cognitive impairment with an activated POAHC, was prescribed morphine sulfate PRN for pain, but the record also lacked monitoring interventions for adverse reactions or side effects of the opioid medication. An LPN verified that staff should monitor R7 and R29 for adverse reactions or side effects, and the DON confirmed that R29 was not monitored for adverse reactions or side effects of morphine.
Influenza Vaccine Not Offered or Documented
Penalty
Summary
The facility did not ensure that one resident, R72, was offered the influenza vaccine. R72 was admitted to the facility with diagnoses including Alzheimer's disease, schizophrenia, diabetes mellitus, and coronary atherosclerosis. The resident's MDS assessment dated 2/9/25 showed a BIMS score of 11 out of 15, indicating moderately impaired cognition, and the resident had an activated POAHC for medical decisions. The resident's medical record showed the most recent influenza vaccine was administered on 10/31/23. The facility's Infection Prevention and Control Program policy stated residents would be offered the influenza vaccine each year between October 1 and March 31, education would be provided regarding benefits and potential side effects before offering the vaccines, residents would have the opportunity to refuse immunizations, and documentation would reflect the education provided and whether the resident received the immunizations. On 3/11/26, the Infection Preventionist confirmed the influenza vaccine was not offered to R72, consent or declination was not obtained, and education about the vaccine was not provided. The Infection Preventionist stated it was their responsibility to review vaccination status, obtain consent, provide education, and administer vaccines at admission.
Failure to Offer COVID-19 Vaccine and Provide Education
Penalty
Summary
The facility did not ensure that two sampled residents, R2 and R72, were offered the COVID-19 vaccine, and it did not obtain consent or declination for either resident. The facility also did not provide education about the vaccine to either resident. The Infection Prevention and Control Program policy, revised 7/2025, states residents and staff will be offered the COVID-19 vaccine when available, screened for prior immunization, precautions, and contraindications, educated about the vaccine before it is offered, given the opportunity to accept or refuse, and documented regarding education and vaccination status. R2 was admitted with diagnoses including traumatic subdural hemorrhage with loss of consciousness, COPD, and altered mental status. R2's MDS dated 12/22/25 indicated R2 was rarely/never understood and could not effectively participate in the BIMS due to severe cognitive impairment, communication barriers, or non-sensical/absent responses; R2 also had an activated POAHC for medical decisions. R2's record showed the most recent COVID-19 vaccine was on 2/16/21. R72 was admitted with diagnoses including Alzheimer's disease, schizophrenia, diabetes mellitus, and coronary atherosclerosis. R72's MDS dated 2/9/25 showed a BIMS score of 11/15, indicating moderately impaired cognition, and R72 also had an activated POAHC for medical decisions. R72's record showed the most recent COVID-19 vaccine was on 2/21/23. The Infection Preventionist confirmed that the vaccine was not offered and education was not provided for either resident, and stated it was the Infection Preventionist's responsibility to review vaccines, obtain consent, provide education, and administer vaccines at admission.
Failure to Submit Final Abuse Investigation Report Within Required Timeframe
Penalty
Summary
The deficiency involves the facility’s failure to submit the final results of an abuse investigation to the State Agency (SA) within the required five working days. The facility’s Abuse/Neglect/Exploitation policy states that the Administrator will confirm the initial report was received and report the results of the investigation to government agencies within five working days of the incident, as required by state agencies. For one resident, R4, the facility submitted an initial allegation of abuse to the SA on 11/22/25 following a reported concern involving possible illicit substances provided by a family member. The final investigative report, documented on the facility’s Misconduct Incident Report, was not completed and submitted until 12/3/25 at 1:55 PM by the Chief Nursing Officer, which exceeded the required timeframe. R4’s admission record showed that R4 had been admitted earlier in the month, and the admission MDS with an ARD of 11/16/25 documented a BIMS score of 15/15, indicating intact cognition. The incident prompting the abuse allegation occurred after a family visit on 11/22/25, during which R4 exhibited a significant escalation in behavior, and a family member reported that another family member may have previously provided R4 with illicit substances. Staff interviews confirmed that the facility understood the requirement to submit the final investigative report within five working days of the initial report, with the CNO stating the report was due on 11/28/25 and the Administrator stating it was due on 12/1/25. Both acknowledged that the final report was not submitted to the SA within the required timeframe.
Failure to Maintain Adequate Resident Care Supplies
Penalty
Summary
The facility failed to ensure sufficient supplies of personal care items, including briefs, wipes, and wash cloths, for residents. One resident, who was dependent on staff for toileting and required partial to moderate assistance with hygiene, reported that the facility frequently ran out of the correct size briefs, resulting in staff having to use two different briefs to make one. The same resident also stated that the facility ran out of wipes, and staff did not cleanse the resident during changes on multiple occasions since admission. Staff interviews confirmed that supply shortages were a recurring issue, with supplies often depleted by the end of the week and residents complaining about the lack of necessary items. Additional staff, including an LPN and a CNA, corroborated that the facility regularly ran out of briefs, wipes, and wash cloths, and that the issue had persisted especially after the departure of the previous supply clerk. The central supply clerk, who had been in the position for a month and a half, indicated that supply orders were based on estimates from the previous week and census, and acknowledged that the facility had run out of supplies before. The nursing home administrator confirmed that supplies were ordered weekly and was aware of a recent shortage of wipes, but was not aware of shortages of briefs or incorrect sizes. No policy related to supplies was provided during the survey.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Watertown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Marquardt Memorial Manor | 0.4 mi | ★★★★★ | 20 | 0 |
| Shorehaven Hlth & Rehab Ctr | 10.6 mi | ★★★★★ | 2 | 0 |
| Lake Mills Health Services | 12.9 mi | ★★★★★ | 0 | 0 |
| Clearview | 13.6 mi | ★★★★★ | 0 | 0 |
| Clearview Brain Injury Center | 13.6 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.