Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bluestone Health And Rehabilitation during CMS and state inspections, most recent first.
A resident with a smoking safety evaluation requiring a smoking apron and supervision was observed in the smoking area and allowed to start smoking without the apron. The Corporate RN confirmed the evaluation required the apron for safety, and a CNA verified it was not used.
The facility failed to prevent accident hazards and adequately supervise residents when two residents obtained cannabis gummies and CBD products via DoorDash, kept them in a bedside box with vape pens and OTC medications, and offered gummies to another resident, resulting in altered mental status, red eyes, paranoia, and ER transfers without a documented thorough investigation by administration. In a separate incident, a resident with decision-making capacity reportedly used a vape in a room with an active oxygen concentrator and refused a room search, leaving a potential fire hazard unresolved. Additional observations showed that a resident care planned for bilateral fall mats was in bed with one mat propped against the wall instead of on the floor, and another high-fall-risk resident was in bed with the bed not in the lowest position as required by the care plan, with staff confirming these fall-prevention interventions were not in place.
Two residents were not protected from neglect when one was left overnight in a soiled brief despite requests for incontinence care, resulting in raw, excoriated skin to the sacrum and scrotum, and another was served a grilled cheese sandwich despite an order for a mechanical soft diet, causing coughing before the tray was replaced. Staff interviews and documentation confirmed that the first resident had not been changed during the night and that prior skin assessments showed no issues, while the second resident’s diet order and the facility’s nutrition manual identified grilled sandwiches as inappropriate for a mechanical soft diet; neither incident was entered into the facility’s reportables or grievance systems.
The facility failed to accurately post daily nurse staffing information, with incorrect dates, unclear corrections, and mismatched total hours worked on most reviewed days. The daily staffing sheet was not readily visible on entry and, when located, contained multiple discrepancies between posted staffing and actual time-punch records. During one night shift, the posted sheet listed more LPNs and NAs than were actually present, with one NA found sleeping and another conducting personal business on a laptop in the breakroom, while one NA was assigned 1:1 to a resident, leaving two NAs to care for the remaining residents. These issues were confirmed through record review, observation, and staff interviews.
Person-centered activity care plans were not developed for several residents, as documented preferences such as one-on-one activities, preferred TV shows, music genres, outings, and self-directed activities were missing from the plans. An Activity Director confirmed the plans were not individualized. In another event, a resident’s fall mat was found leaned against the wall instead of placed on both sides of the bed as directed in the care plan, and an LPN confirmed the mat was not in place.
A facility failed to maintain adequate staffing, report and investigate neglect and contraband-related incidents, and provide a person-centered activity program. A resident reported being left overnight in a soiled brief with resulting skin breakdown, while staff described raw, red skin and the record showed excoriation to the sacrum and scrotum without a prior skin assessment. The facility also did not report or investigate an incident involving cannabis gummies brought in through DoorDash and offered to residents, including one resident who developed AMS, reddened eyes, lethargy, and tachycardia and was sent to the ED. Residents also reported repetitive, non-age-appropriate activities and limited evening engagement, with observations showing residents idle without organized programming.
Incomplete and inaccurate resident medical records were identified for multiple residents. One resident with NPO status had oral medication orders despite being fed and medicated via G-tube, another NPO resident had oral medication orders and MAR documentation showing oral administration even though staff said nothing by mouth was given, and a resident’s transfer records and MDS did not match staff observations that he had not been out of bed since surgery.
The facility failed to ensure adequate nursing staff on all shifts, leading to prolonged call light response times and unmet care needs. Multiple residents reported waiting from 45 minutes to several hours for assistance, including toileting and incontinence care, and described staff leaving the floor during smoke breaks and meal tray pass, leaving minimal coverage. Staffing records showed nursing HPPD below required minimums on at least one reviewed day, and an external report flagged low weekend staffing. One resident reported being left overnight in a soiled brief while having diarrhea, later found with raw, red skin to the sacral and scrotal areas, and this incident was not documented as a grievance or reportable event. A night-shift observation also revealed fewer staff on duty than posted, with one NA sleeping and another conducting personal business, while only two NAs were left to care for more than fifty residents.
The facility failed to notify the LTC Ombudsman and the resident/resident representative of two residents’ transfers and did not provide complete bed-hold notification documentation. One resident lacked decision-making capacity and was transferred after being found unresponsive with abnormal VS and swelling; the other resident had capacity and was transferred after slurred speech, lethargy, twitching, pallor, and severe hypotension. Surveyors found missing proof of ombudsman notification and incomplete bed-hold notice documentation.
PASARR Not Updated After New PTSD Diagnosis: A resident’s PASARR was not updated after PTSD was added to the medical record. The PASARR had been completed when the resident transferred in, but it was not revised to reflect the new diagnosis. An RN confirmed the finding during interview.
Activity Program Did Not Meet Resident Needs: Residents reported the activity program was mostly bingo, cartoons, and coloring, with a need for more adult-oriented group activities and consistent evening programming. Record review showed repetitive calendars, limited late-day offerings, and a smoking break listed as a scheduled activity, while the AD had no structured sensory program for low-functioning residents and care plans were not consistently person-centered. Evening observations found residents sitting in common areas without staff-led engagement.
Meals were not palatable or attractive for multiple residents. Residents reported that the food was terrible, sometimes cold, and did not taste good, and one resident said they ordered all of their food in because of the poor quality. Surveyors observed a sample tray with a hamburger and french fries that looked unappetizing, with mushy, pale fries and an unseasoned hamburger, and an RN consultant confirmed the meal looked unappetizing.
A resident ordered a mechanical soft diet was served a grilled cheese sandwich, which is listed as a food to avoid for that diet. She ate part of the sandwich before a CNA noticed, then coughed a few times and was fine. An RN consultant confirmed the sandwich was not appropriate for her ordered diet.
Wet nesting was observed in the kitchen when two metal pans and one clear plastic serving container were found stacked while still wet, and another wet metal pan was later seen on a shelf. The Dietary Manager confirmed the items were wet and removed them.
Surveyors found that residents were not provided a way to file anonymous grievances and reported fear of retaliation for making complaints. During a Resident Council meeting, multiple residents stated they had no anonymous grievance option and felt their concerns raised in council were not taken seriously. The Social Worker confirmed there was no anonymous grievance mechanism and that residents and families had to request grievance forms from nursing or department heads, despite a written policy stating that residents and representatives have the right to file grievances orally or in writing and that staff will make prompt efforts to resolve them.
Two residents did not receive care according to physician orders and professional standards. One resident with a documented right hand contracture had orders and a care plan directing splinting of the left, functional hand, and surveyors observed the contracted right hand tightly fisted without a splint in place; the OT and DON later confirmed the order should have been for the right hand. Another resident with an order for Humalog Kwikpen requiring the provider to be called for blood sugar (BS) readings over 400 had multiple BS values above 400 documented on the MAR, but there was no documentation that the provider was notified on those occasions, which was confirmed by an RN consultant.
Call Light Not Within Resident Reach: A resident was observed seated in a geri chair beside the bed with the call light hanging off the back of the headboard and out of reach. An NA stated staff normally hook the call light to the resident's shirt, but also acknowledged it should be within reach, and the DON confirmed the call light should be within the resident's reach.
Failure to Provide Written Notice for Room and Roommate Changes: A resident was moved to another room for isolation needs and another resident was assigned a roommate, but the SW only gave verbal notice and did not provide written notice to either resident. One resident said she was not told until staff came to move her, and the other said she did not know she was getting a roommate until the roommate was moved in. Facility guidance required advance notice with the reason for the change.
The facility failed to report multiple incidents involving resident safety and possible abuse/neglect. A resident said staff left him overnight without changing his brief while he had diarrhea, another resident was served grilled cheese despite a mechanical soft diet and coughed after eating it, and two residents were involved in a cannabis gummy incident with altered mental status, red eyes, paranoia, and ER transfers. Records showed these events were documented, but the required reports and investigation were not completed.
Failure to investigate and report neglect and diet-order errors: A resident reported being left overnight in a soiled brief with diarrhea, with staff describing raw, red skin and excoriation, yet the event was not reported or thoroughly investigated. A second resident’s daughter reported the resident was found in the same soaked brief from the prior evening and that the DON did not classify it as neglect, while another resident was served grilled cheese despite a mechanical soft diet order, coughed after eating it, and the incident was not reported.
A resident who ate slowly and was observed falling asleep during lunch did not receive cueing or meal assistance while staff removed the tray after partial intake. Staff interviews confirmed aides typically left the tray because the resident took a long time to eat, and the DON acknowledged the resident did not receive meal assistance and had experienced weight loss.
A resident who required substantial to max assist for rolling lost one of his bed rails, which he had used to help turn for care. Staff reported the remaining rail was chosen due to entrapment concerns, but CNAs said the removed rail had helped with care and its absence made turning and providing care much more difficult. The DON confirmed there was no documentation explaining why the rail was removed.
Failure to Provide Accessible Fluids to Two Residents: Two residents were observed in bed without water within reach, despite a facility policy requiring staff to provide and encourage bedside fluids as part of daily care. One resident reported needing to ask for water and said he needed a lot of water due to a kidney transplant, while the other had an empty pitcher on the bedside table out of reach. RN confirmation and record review showed hydration instructions and care plan guidance for adequate fluid intake.
A resident's tube feeding syringe was observed left uncovered and exposed to the elements, and it remained exposed on a later observation. An LPN confirmed the syringe had not been covered and said it would be discarded, replaced, and dated.
The facility did not maintain appropriate temperatures in a shower room, as confirmed by the Director of Maintenance who measured the shower area at 61°F, which was too cold for resident use. Two residents reported the shower room was consistently cold, affecting their ability to bathe comfortably. The issue was traced to an open vent that allowed cold air in, and the facility's policy requiring temperatures between 71-81°F was not followed.
Several residents dependent on staff for ADL care experienced significant delays in receiving incontinence care and hygiene assistance, often waiting over an hour for help. Residents and observations indicated that call lights were frequently left unanswered, and staff shortages led to prolonged periods where residents remained soiled or unassisted, despite care plans documenting their need for substantial or maximal assistance.
Multiple residents and family members reported prolonged delays in receiving care, particularly with incontinence needs and call light responses, due to chronic understaffing. Staff interviews confirmed that only two NAs were often responsible for nearly 60 residents, leading to extended shifts and fatigue. Surveyors observed residents left unattended for significant periods, and staffing records verified the low staffing levels.
The facility did not ensure accurate and complete documentation of care and meal intake for three residents. In multiple instances, incontinence care and meal percentages were not recorded, even though staff stated that care was provided. The DON and Administrator confirmed these were documentation errors, resulting in incomplete medical records.
Surveyors observed multiple lapses in infection control, including soiled linens and trash barrels left overfilled and open in hallways, improper transport of soiled linen by staff wearing contaminated gloves, and unclean conditions in a shower room. A resident reported that the odor from the overfilled barrels caused nausea. These deficiencies reflect a failure to follow infection prevention protocols.
A resident with a care plan restricting blood pressure measurements and lab sticks in the left arm due to a mastectomy had blood pressures repeatedly taken from the restricted arm on several occasions, despite clear instructions in the care plan. The DON confirmed this should not have occurred.
Two residents experienced deficiencies related to incomplete and inaccurate medical records. One resident had blood pressures taken from a restricted arm despite a physician's order, and another resident's blood sugar checks and insulin administration were not documented as required. The DON confirmed these lapses in care and documentation.
Surveyors found that PTAC units in multiple rooms had filters covered in dust and one unit contained a dried, brown substance inside its vents. The Maintenance Director confirmed these conditions and indicated that housekeeping is usually responsible for cleaning the vents.
A review of nurse staffing postings revealed that, on multiple days, the posted staffing numbers were inaccurately reported as being below the required minimum, despite actual staffing levels meeting requirements according to staff punch forms. The DON confirmed the postings were incorrect.
A resident who was totally dependent for care and at risk for pressure ulcers developed multiple unrecognized and untreated pressure wounds during her stay. Despite care plans and risk assessments indicating the need for preventive interventions, there was no documentation of regular turning, repositioning, or wound care. After discharge, a nurse at a behavioral health home discovered multiple pressure injuries and bruising, leading to hospital admission. Facility records showed no evidence of wound identification or treatment, and the DON only acknowledged the wounds as pressure injuries after reviewing hospital documentation.
A resident was moved to a different room without prior notification to the responsible party. The responsible party reported not being informed before the move, and a review of records confirmed no documentation of notification. The DON acknowledged the lack of evidence that notification occurred.
A resident was reported to have developed bruises and multiple pressure ulcers after discharge, but the facility's investigation relied only on internal documentation and staff statements, without obtaining hospital records or contacting external care providers. Hospital records later revealed extensive documentation of wounds, confirming that the facility's investigation was incomplete.
A resident who was discharged to the hospital with a return anticipated was not readmitted to the first available bed when medically stable, despite ongoing communication from hospital staff and the ombudsman. The facility admitted multiple new residents of the same gender during this period, while repeatedly claiming no suitable bed was available for the returning resident. This resulted in the resident remaining in the hospital and experiencing significant psychosocial harm, including anxiety and distress.
A resident with a history of fear related to a mechanical lift experienced emotional distress during transfers on shower days. Despite the resident's intact cognition and documented anxiety, the facility failed to implement interventions to address the fear. Staff confirmed the resident's distress, but the care plan remained unchanged, leading to a deficiency in providing necessary services to avoid emotional harm.
The facility failed to accurately assess the overall acuity of its residents, as revealed during a review of the Facility Assessment. The assessment contained incorrect calculations for residents' needs, including assistance with ADLs, mobility impairments, and specialized care. The Administrator acknowledged the inaccuracies, which had the potential to affect more than a limited number of residents.
The facility failed to maintain a comfortable temperature in the shower room, leading to residents refusing showers due to the cold. A resident reported the room was too cold, and a nurse's note confirmed another resident's refusal for the same reason. The maintenance director found the temperature at 63.8°F, despite heaters being set to 72°F. During a Resident Council Meeting, multiple residents and staff expressed concerns about the cold conditions.
The facility failed to update care plans for three residents, leading to deficiencies in care. A resident's care plan was not revised when they became more independent, another's plan lacked non-pharmacological interventions for behaviors, and a third resident's fear of a mechanical lift was not addressed. Staff acknowledged these issues, but care plans remained unchanged.
A facility failed to provide a resident with activities of interest as per their care plan, which required one-on-one visits from the Activity Department. The Activity Director admitted that the resident had become more independent, and the care plan should have been updated to reflect this change, but it was not.
The facility failed to follow physician orders and complete necessary assessments for several residents. A resident's monthly weights were not recorded, and another's weekly weights were missed. Insulin was held without orders for a resident, and neurological checks were incomplete after an unwitnessed fall. The DON confirmed these deficiencies, indicating a lapse in adhering to professional standards of practice.
A storage room containing hazardous items, including razor blades, was found unlocked in a facility. An LPN confirmed the door should have been locked but did not close easily, remaining unlocked unless forcefully closed. This posed a potential hazard to residents who could access the room.
The facility failed to ensure a licensed pharmacist completed monthly drug regimen reviews and reported irregularities to the attending physician, with timely responses. This affected three residents, with missing reviews, absent pharmacy recommendations, and delayed physician responses, contrary to facility policy.
The facility failed to serve food at a palatable temperature, as evidenced by grievances and resident interviews reporting cold meals. The dietary manager's temperature checks confirmed that food items, such as chicken strips and coleslaw, were served below recommended temperatures, indicating a lapse in maintaining appropriate food temperatures.
The facility failed to store and serve food safely, with expired and undated items found in the walk-in cooler. Additionally, dust accumulation was observed around kitchen vents and on the HVAC filter, which was not dated for replacement. These issues were confirmed by the Dietary Manager and Maintenance Assistant, potentially affecting all residents receiving nutrition from the facility's kitchen.
The facility failed to follow infection control practices by mishandling milk cartons and sending uncovered coffee cups. Additionally, two residents with Enhanced Barrier Precautions (EBP) signage were not properly managed, as an LPN entered their rooms without wearing a gown, contrary to the facility's EBP policy. The Director of Nursing acknowledged the oversight.
The facility failed to administer pneumococcal vaccines according to updated CDC guidelines, affecting two residents. Despite CDC recommendations for PCV20 or PCV15 followed by PPSV23, the facility administered PPSV23 to unvaccinated residents. The Director of Nursing confirmed the facility was unaware of the guideline changes, leading to non-compliance with current vaccination protocols.
A resident with an unstageable ulcer expressed a preference not to be woken for night shift dressing changes, yet the facility continued to perform them at night, including early morning hours. Despite the resident's request and documentation of his preference, the facility did not adjust the timing of the care, leading to a deficiency in promoting resident self-determination.
Failure to Use Required Smoking Apron
Penalty
Summary
The facility failed to ensure that precautions were taken for a resident when the smoking assessment and care plan indicated the resident needed to wear a smoking apron for safety while smoking. Resident #7 had a smoking safety evaluation dated 05/08/26 that stated the resident was safe to smoke with a smoking apron and supervision. During an observation on 06/18/26 at 8:50 AM, Resident #7 was brought to the smoking area and was allowed to begin smoking without a smoking apron. At 8:53 AM, the Corporate RN verified that the active smoking evaluation indicated a smoking apron was necessary for the resident's safety, and at 8:55 AM, a CNA verified that a smoking apron was not used for Resident #7.
Failure to Control Resident Access to Non-Prescribed Substances and Implement Fall-Prevention Measures
Penalty
Summary
The facility failed to maintain an environment as free from accident hazards as possible and did not provide adequate supervision to prevent accidents, particularly related to resident access to non-prescribed substances and implementation of fall-prevention measures. An anonymous resident reported that two female residents purchased cannabis gummies via DoorDash and offered them to another resident, who refused. These two residents were later sent to the hospital after one was noticeably impaired. Record review showed no investigation documented in the facility’s reportable or grievance logs regarding these residents’ changes in condition due to cannabis gummies being brought into the facility and offered to other residents. Nursing documentation for one of the involved residents described a change in condition with altered mental status, suspicion of substance abuse, and tachycardia, leading to transfer to the ER for evaluation and toxicology screening. A late-entry note indicated the resident was educated on facility policies prohibiting OTC medications and CBD products in the room. Another nursing note detailed that a CNA reported a resident had consumed a gummy given by another resident, then discarded the second gummy, which the CNA retrieved from the trash. On assessment, the resident was found lying in bed with reddened eyes, reporting feeling tired, and vital signs were obtained. The resident stated she had consumed “pot gummies” and allowed the nurse to inspect a wooden box at the bedside, which contained several red sugar-coated gummies, three vape pens (including a suspected CBD vape pen), a bottle of Benadryl, and several Imodium tablets. The resident reported purchasing the gummies and CBD vape pen from DoorDash, and the items were removed with her consent. Further documentation showed that another nurse was informed that two residents had consumed an unknown gummy-like substance. On assessment, one resident had very red eyes and reported feeling paranoid, with vital signs recorded. This resident stated she had received two gummies from another resident and that a third resident knew about the gummies. The nurse interviewed the third resident, who reported that the resident supplying the gummies had told her she had gummies and THC pens and planned to give gummies to another resident. The nurse also noted that as staff were going to check on the resident who supplied the gummies, a DoorDash delivery person arrived and handed a bag to the nurse containing a pack of cigarettes and a receipt showing two CBD purchases. Facility administration had no evidence that a thorough investigation into this incident had been completed, and only limited action was taken following the event, leading surveyors to identify an immediate jeopardy situation due to residents being susceptible to drug abuse from other residents. The facility also failed to address other accident hazards and fall-prevention interventions for additional residents. One resident, who had capacity to make her own medical decisions, was involved in an incident where she reportedly used a vape in her room while an oxygen concentrator was present and turned on. The resident was verbally educated by the Administrator about the dangers of vaping near oxygen equipment, the smoking policy requiring smoking paraphernalia to be stored by nursing staff, and the prohibition of vaping inside the facility. However, during the survey period it remained unknown whether the resident still had vape pens in her possession, and she refused a room search, leaving a possible serious fire hazard unresolved at the time of review. In separate observations related to fall prevention, one resident was observed lying in bed with a fall mat that was supposed to be in place on the floor instead leaned against the wall behind the headboard. Record review confirmed the care plan required fall mats on both sides of the bed while the resident was in bed, and an LPN acknowledged that the floor mat was not in place. Another resident, care planned as at risk for falls due to multiple factors including muscle weakness, cognitive impairment, incontinence, psychoactive medication use, recent hospitalizations, visual impairment, and a history of traumatic brain injury and multiple CVAs, was observed lying in bed with the bed not in the low position despite a care plan intervention specifying that the bed should be in the lowest position. A RN consultant confirmed that the bed was not in the lowest position while the resident was in bed.
Failure to Prevent Neglect in Incontinence Care and Diet Texture Management
Penalty
Summary
The deficiency involves failure to protect residents from neglect by not providing timely incontinence care and by not providing the correct diet texture. One resident reported during interview that he had been left overnight without his brief being changed while experiencing diarrhea, despite requesting to be changed. Two CNAs separately stated that when they saw the resident the following morning, he reported not having been changed all night, that aides had come in only to change his roommate and then left, and that his skin was "raw," "pretty bad," and red. Both CNAs reported the condition of his skin to an LPN, and an order was written later that day for wound care to excoriated sacrum and scrotum every shift. Prior skin assessments from earlier in the month documented no issues to the sacrum or scrotum, and the incident was not found in the facility’s reportables or grievances. The Administrator confirmed that, if accurate, this situation would constitute neglect under the facility’s abuse policy, which defines neglect as failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress. A second deficiency concerns failure to provide the correct food texture to another resident who had an active diet order for mechanical soft texture. Progress notes document that this resident was served a grilled cheese sandwich on a dinner tray, which she began to eat before an NA noticed and removed the tray. The resident coughed a few times and then was fine, and the NA obtained another tray with food the resident could eat without problem. The resident’s diet order specified mechanical soft foods, and the facility’s Diet and Nutrition Care Manual lists grilled sandwiches as foods to avoid on a mechanical soft diet. A nurse consultant later confirmed that this incident occurred as documented and that it was not reported.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The deficiency involves the facility’s failure to accurately post daily nurse staffing information in a prominent, accurate manner as required, with inaccuracies identified on 22 of 23 reviewed days. Upon surveyor entrance, the daily nurse staffing sheet was not readily visible and was ultimately located on a wall near the nurse’s station. Review of posted staffing sheets and time punch detail reports revealed multiple discrepancies, including incorrect dates on several postings and numerous errors in the total hours worked for various dates. On some days, corrections were written over original entries, making it impossible to clearly determine the actual number of nurse aides working or the correct total hours. In several instances, the posted total hours did not match the actual hours worked as shown on time detail reports, with both understatements and overstatements of staffing hours documented. During a nighttime observation, the posted staffing sheet listed two LPNs, three NAs, and zero RNs on duty, but a visual count showed only one LPN and two NAs actually present, with no RN. One NA was found sleeping on duty upon arrival, and another NA was in the breakroom with a makeshift office setup using a table, laptop, battery charger, and large rolling briefcase. It was later learned that one NA was assigned 1:1 to a resident, leaving two NAs to cover the remaining 56 residents. When questioned, an LPN stated that another LPN listed on the staffing sheet had called in sick due to pregnancy. These observations and documentation reviews were discussed with the Regional Director of Operations and an RN consultant, confirming that the posted staffing information did not accurately reflect the actual staffing levels and hours worked on multiple dates.
Person-Centered Activity Plans and Fall Mat Intervention Not Followed
Penalty
Summary
The facility failed to develop and implement person-centered comprehensive care plans for activities for residents #37, #29, #25, #8, and #1. Record review showed each resident had documented activity preferences, including specific music genres, preferred television programs, one-on-one activities, self-directed activities, social visits, outings with family, and preferences to stay in bed or rest during the day. However, the corresponding care plans did not include these individualized preferences, and for some residents the plans lacked mention of one-on-one activities, preferred TV shows, or preferred music. During interview, the Activity Director confirmed the care plans were not person centered and did not set individualized goals. For resident #8, the activity preference evaluation documented that the resident preferred to stay in bed, did not want group or out-of-room activities, enjoyed talking on the cell phone with family and friends, and preferred inspirational/religious, jazz, and modern/current music. The care plan, however, did not include the resident’s music preferences. For resident #1, the record showed preferences for staying in bed most days, sitting in the hallway talking with residents and staff, country and modern/current music, and one-on-one activities of choice, but the care plan did not reflect personal specific goals for those one-on-one visits. The Activity Director confirmed the lack of person-centered planning during interview. The facility also failed to follow the care plan for accident prevention for resident #54. During a check for fall prevention measures, the resident was observed lying in bed with the right fall mat leaned against the wall behind the headboard. The care plan directed that fall mats be placed on both sides of the bed while the resident was in bed, but an LPN confirmed the floor mat was not in place and stated it would be put down after the resident had just been laid down.
Failure to Ensure Staffing, Abuse Reporting, and Meaningful Activities
Penalty
Summary
The facility failed to provide administrative oversight to ensure adequate staffing, resident protection systems, abuse/neglect reporting and investigation, and a person-centered activity program were implemented and monitored. Review of staffing schedules, punch detail reports, and HPPD calculations showed the facility did not maintain minimum staffing levels on 2 of 23 reviewed days. On 04/25/26, the HPPD was calculated at 1.99 using posted staffing data and 2.59 using punch detail sheets, and on 02/14/26 it was calculated at 2.19 using staffing data sheets and 2.14 using punch detail sheets, below the minimum required 2.25 HPPD. The CASPER report also triggered for low weekend staffing during Quarter 1 of 2026. Resident #1 stated he had been left overnight in a soiled brief while experiencing diarrhea despite requesting assistance from staff, and when changed the next morning his bottom was sore all the way up to the front. CNA #25 stated she changed the resident before leaving work and later learned he had not been changed overnight despite requesting help from night shift aides; she described the resident as raw with bad skin. CNA #58 also stated the resident reported staff changed his roommate during the night but did not return to change him, and that his skin was pretty bad, raw, and red. The medical record showed a wound care order for excoriation to the sacrum and scrotum, but no skin assessment had been completed before the order, and prior skin assessments documented no skin issues. The facility also failed to report and investigate allegations involving neglect and a crime involving cannabis gummies brought into the facility and offered to other residents. Facility reportable and grievance logs showed no investigation was initiated regarding Resident #1 being left overnight in a soiled brief resulting in excoriation and skin breakdown, and the Administrator confirmed the incident was not reported to the state agency. In addition, an anonymous resident reported that two residents purchased cannabis gummies through DoorDash and offered them to other residents, and one resident later became noticeably impaired and was sent to the hospital. Nursing documentation showed Resident #5 had altered mental status, reddened eyes, lethargy, and an elevated pulse after consuming a pot gummy, with additional gummies and vape pens found in the room and transfer to the emergency department for evaluation and toxicology screening. The facility also failed to provide an ongoing activity program that met residents’ interests and psychosocial needs, as residents reported repetitive and non-age-appropriate activities, limited evening activities, and little meaningful engagement, while observations showed residents sitting in hallways and the television room without staff interaction or organized activities.
Incomplete and inaccurate resident medical records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for multiple residents. For one resident with a gastrostomy tube and an NPO status, the care plan stated that all medications and liquids could be given via the gastrostomy tube, but the medication orders still listed lorazepam oral concentrate and neomycin sulfate as being given by mouth. An LPN stated the resident received all medications by G-tube and confirmed the oral orders were not correct. For another resident with NPO orders, the record contained orders for Neurontin and Zanaflex to be given by mouth, and the MAR documented oral administration even though an LPN stated she had not given anything by mouth during the month and that the MAR documentation was incorrect; the DON confirmed the resident was to have nothing by mouth and had two medications ordered by mouth with documentation showing oral administration. The record review also identified inaccurate documentation for a resident’s transfer status. The resident stated he had not been out of bed for about two months since back surgery, and a CNA and RN unit manager both stated he had not been up since surgery. Despite this, task documentation showed substantial/maximum assist or dependent transfers on several dates, dependent toilet transfers, dependent wheelchair mobility, and the 5-day MDS marked some transfer items as inapplicable or not attempted due to medical conditions or safety concerns, while the wheelchair use item was marked no. The DON confirmed the transfer documentation was incorrect.
Insufficient Staffing Leading to Delayed Care and Resident Neglect
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff on all shifts to meet residents’ needs, resulting in delayed responses to call lights and inadequate incontinence care. During a resident council meeting, multiple residents reported waiting 1–3 hours for call lights to be answered, with staff sometimes stating they would return but not coming back for hours, and some residents reporting staff said they had been outside smoking with a resident. Individual resident interviews corroborated these concerns, with residents stating that night shift took a long time to answer call lights, that it could take 45 minutes to an hour or more to receive assistance, and that staff would delay changing residents during meal tray pass or after a scheduled smoke break when most aides and a nurse accompanied residents outside, leaving only one nurse to cover the floor. Staffing record reviews for specific dates showed Hours Per Patient Day (HPPD) below the minimum required 2.25 on at least one day, and the facility’s CASPER report triggered for low weekend staffing. A specific incident of neglect was identified for one resident who reported being left overnight in a soiled brief while experiencing diarrhea, despite requesting to be changed. Two CNAs independently stated that when they saw this resident the following morning, he reported not having been changed all night, and both described his skin as raw, bad, and red; one CNA stated she had changed him the previous day and that he reported no changes overnight, and both CNAs reported the condition to an LPN, who then notified an RN, leading to a wound care order for excoriation to the sacrum and scrotum. Prior skin assessments earlier in the month showed no issues in those areas, and the incident was not documented in reportables or grievances. Additionally, a night-shift observation found a discrepancy between the posted staffing sheet and actual staff present: the sheet listed two LPNs, three NAs, and no RNs, but only one LPN and two NAs were observed, with one NA found sleeping on duty and another engaged in personal business on a laptop, while a third NA was assigned 1:1 to a resident, leaving two NAs to cover 56 other residents. The administrator confirmed that the described incontinence incident would constitute neglect if accurate.
Failure to Notify Ombudsman and Provide Bed-Hold Transfer Documentation
Penalty
Summary
The facility failed to notify the Long Term Care Ombudsman and the resident or resident representative of resident transfers and failed to provide documentation of the bed-hold notification for two residents reviewed during the survey. For Resident #62, who lacked capacity to make medical decisions, the record showed transfer to an acute care hospital after being found unresponsive, with nursing notes documenting abnormal vital signs, lethargy, swelling, and the nurse practitioner’s instruction to send the resident to the ER. The medical record also showed the MPOA was aware of the transfer, and the facility had a bed-hold notice signed by a facility representative, but there was no documentation supporting verbal notification, a second signature, or mailing of the notice to the resident’s representative for signature. For Resident #27, who had capacity to make medical decisions, the record showed transfer to an acute care facility after slurred speech, lethargy, twitching, pallor, and very low blood pressure, with EMS transport arranged and the physician, UM, and DON notified. The transfer paperwork reviewed by surveyors showed the ombudsman was not notified of the transfer. The transfer documentation for both residents was reviewed with the DON and later with the NHA, who acknowledged the findings.
PASARR Not Updated After New PTSD Diagnosis
Penalty
Summary
The facility failed to update the Pre-admission Screening and Resident Review (PASARR) for Resident #5 after a diagnosis of Post Traumatic Stress Disorder (PTSD) was added to the medical record. A review of the record showed that a PASARR had been completed when the resident was transferred from another facility, and the PTSD diagnosis was added afterward, but the PASARR was not updated to reflect that new diagnosis. This issue was identified for one of four residents reviewed for PASARR, and the RN confirmed the finding during interview.
Activity Program Did Not Meet Resident Needs
Penalty
Summary
The facility failed to provide an ongoing, person-centered activity program that met the interests and needs of the resident population, including age-appropriate activities, evening programming, and individualized or sensory activities for low-functioning residents. During the Resident Council meeting, residents voiced concerns that the activity program mainly consisted of bingo with candy prizes, cartoons, and coloring, and several residents stated they wanted more adult-oriented group activities such as music and interactive programming. One resident stated the activities were "elementary," and residents reported there were no consistent evening activities, with only occasional movie nights offered. Another resident stated activity staff hardly ever came into his room for activities. Record review showed the activity calendars from January through April 2026 were repetitive and included activities such as Connect Four, poster making, cartoons, Hungry Hippos, and [NAME] Says. The calendar also listed a daily scheduled item, Puff Masters and Pioneers, which was identified as a smoking break rather than a structured activity. Review further showed limited offerings after 3:00 PM, typically only one to two activities, such as an evening movie or Singing with [NAME]. The Activity Director stated there was no particular list of residents who required sensory stimulation activities and that room visits were done during one-on-ones, but no structured sensory programming was provided for review. Resident care plans were not consistently person-centered or reflective of individual preferences and needs, and observations in the evening showed residents seated in the hallway and television room without staff interaction or organized activities.
Meals Not Palatable or Appealing
Penalty
Summary
Food and drink were not provided in a palatable, attractive, and safe appetizing temperature. During interviews, Resident #2 stated that the food is terrible, Resident #35 stated that the food is sometimes cold and does not taste good, and Resident #27 stated that the food is terrible and that they order all of their food in because of how bad it is. A sample tray with a hamburger and french fries was observed and brought to surveyors; the hamburger was not appealing to the eye, the french fries were mushy and pale, and the hamburger lacked seasoning and left an undesired taste after eating. A Registered Nurse Consultant confirmed that the meal looked unappetizing.
Inappropriate Food Texture Provided to Resident on Mechanical Soft Diet
Penalty
Summary
The facility failed to ensure Resident #3 received food prepared in a form designed to meet her individual needs. Resident #3 had a mechanical soft diet order, which consists of foods that are moist, soft-textured, and easily formed into a bolus. On 04/26/26, progress notes documented that she was given a grilled cheese sandwich on her dinner tray, and she ate some of it before a CNA noticed. She then coughed a few times and was fine. The CNA removed the tray and obtained another tray that the resident could eat without problem. The provider was contacted and instructed staff to document the situation and to call back if there were any further coughing or congestion episodes. The Diet and Nutrition Care Manual for a mechanical soft diet lists grilled sandwiches as foods to avoid, and an RN consultant confirmed that a grilled cheese sandwich was not appropriate for the resident's ordered diet.
Wet nesting of kitchen pans and serving container
Penalty
Summary
The facility failed to ensure pans were dry before being stacked, resulting in wet nesting of washed items. During the initial kitchen tour on 04/20/26 with the Dietary Manager, two metal pans and one clear plastic serving container were observed stacked on a shelf while still wet. The Dietary Manager removed the items and stated, "I'll take care of these now." On 04/21/26 at 10:00 AM during a follow-up kitchen tour, another metal pan was observed wet on the shelf, and the Dietary Manager confirmed the pan was wet and removed it.
Failure to Provide Anonymous Grievance Process and Protect Residents From Fear of Retaliation
Penalty
Summary
Surveyors identified that the facility failed to honor residents’ rights to voice grievances without fear of reprisal and to provide a method for anonymous grievance submission. During a Resident Council meeting attended by 11 residents, residents reported they had no way to file an anonymous grievance, did not want to report complaints due to fear of retaliation, and felt that concerns raised in Resident Council were not taken seriously. An interview with the Social Worker confirmed there was no method for anonymous grievances and that residents and family members had to request a grievance form from a nurse or department head. Review of the facility’s Grievances/Complaints policy showed that residents and their representatives have the right to file grievances orally or in writing with facility staff or the designated agency, and that the Administrator and staff will make prompt efforts to resolve grievances, but the facility’s actual practice did not provide an anonymous option or alleviate residents’ fear of retaliation. This deficiency involved at least one identified resident (Resident #22) and the broader resident group, who reported barriers to exercising their grievance rights and lack of confidence that their concerns raised in Resident Council would be addressed, in contrast to the facility’s written grievance policy.
Failure to Follow Splinting and Blood Glucose Notification Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards and physician orders for two residents. For one resident with a documented right hand contracture, surveyors observed that the right hand was tightly fisted and that no splinting device was in place. Record review showed active orders to apply and remove a splint to the left hand every night shift for mobility, and the care plan directed left hand splinting as ordered, despite the medical record listing a diagnosis of a right hand contracture. During interviews, the occupational therapist confirmed the splinting order should have been for the right hand, and the Director of Nursing confirmed that both the orders and care plan were written to place a splint on the resident’s functional hand instead of the contracted hand. For another resident with an order for Humalog Kwikpen, the physician’s order specified to hold the medication for blood sugar (BS) less than 100 and to call the provider for BS over 400. Review of the Medication Administration Record for March and April showed multiple dates on which the resident’s blood sugar exceeded 400. The facility was unable to provide documentation that the provider was contacted on those dates when the blood sugar was over 400, as required by the order. A registered nurse consultant confirmed that, according to the documentation, the provider was not notified when the resident’s blood sugar readings were over 400 on the identified dates.
Call Light Not Within Resident Reach
Penalty
Summary
The facility failed to ensure the call light was within reach of Resident #54. On 04/22/26 at 2:10 PM, the surveyor observed Resident #54 seated in a geri chair beside the bed, with the call light hanging off the back of the headboard and out of reach. During an interview later that day, Nurse Aide #30 stated that staff normally hook the call light to the resident's shirt, but also said it should be within reach to get staff attention. The Director of Nursing later confirmed that the call light should be within the resident's reach.
Failure to Provide Written Notice for Room and Roommate Changes
Penalty
Summary
The facility failed to ensure that a resident received written notice, including the reason for the change, before her room was changed and before a roommate assignment was made. Resident #45 reported that she was not notified until staff came to move her room on 03/05/26 and stated she was never notified in writing. During interview, the Social Worker stated she verbally notified Resident #45 before moving her to another room because the room was needed for isolation, but did not provide written notice. Resident #25 reported that she was not told she was getting a roommate and did not know until the new roommate was moved into her room. The Social Worker stated she did not notify Resident #25 that she was getting a roommate and did not notify either resident in writing. Review of the facility's Room Change/Roommate Assignment guidance showed that all parties involved are to be given advance notice of a room or roommate change, and that advance notice of a roommate change includes the reason for the change and information to help the roommate become acquainted with the new roommate.
Failure to Report Neglect, Diet Error, and Suspected Drug-Related Incident
Penalty
Summary
The facility failed to report a resident allegation of neglect involving a resident who stated staff left him overnight without changing his brief while he had diarrhea. The resident reported that he requested to be changed and, when the brief was finally changed the next morning, his bottom was sore. Staff interviews confirmed that the resident had been changed the prior day, then was found wet and soiled the next morning with skin described as raw, red, and bad. A wound care order was entered for excoriation to the sacrum and scrotum, and the most recent skin assessments before that order did not show skin issues to those areas. The reportable and grievance records did not include this situation, and the Administrator confirmed it was not reported to the state office. The facility also failed to report an incident involving a resident who was given the wrong food consistency. A progress note documented that the resident was served grilled cheese on a dinner tray even though her diet order was mechanical soft. The resident ate some of the grilled cheese before the nurse aide noticed, coughed a few times, and then was given another tray she could eat without problem. The diet manual identified grilled sandwiches as foods to avoid on a mechanical soft diet. A nurse consultant later confirmed the incident occurred as documented and was not reported. In addition, the facility failed to report a reasonable suspicion of a crime involving cannabis gummies brought into the facility and offered to other residents. An anonymous resident reported that two female residents ordered cannabis gummies through Door Dash and offered one to her, which she refused. Facility notes documented that one resident was sent to the ER for altered mental status and suspicion of substance abuse, and another resident admitted consuming two gummies and had red eyes, paranoia, and abnormal vital signs. Staff documentation also described discovery of multiple gummies, vape pens, a suspected CBD vape pen, Benadryl, and Imodium in a resident’s belongings, along with a Door Dash delivery bag containing cigarettes and a receipt with CBD purchases. The facility administration had no evidence that this reasonable suspicion of a crime was reported to the state survey agency or that a thorough investigation had been completed.
Failure to Investigate and Report Neglect and Diet-Order Errors
Penalty
Summary
The facility failed to identify and thoroughly investigate allegations of neglect involving Resident #1, who reported that staff left him overnight without changing his brief while he had diarrhea and had asked to be changed. He stated that when the brief was finally changed the next morning, his bottom was sore all the way to the front. CNA #25 reported that she changed him before leaving on 04/18/26 and later found he had not been changed since then, with his skin described as raw and bad; CNA #58 also reported that he had not been changed all night and that his skin was pretty bad, raw, and red. Both CNAs stated they immediately reported the condition to LPN #69, who notified RN #63. An order was written for excoriation to the sacrum and scrotum, but the last skin assessments before that showed no skin issues, and the reportables and grievances did not include the situation. The Administrator confirmed the matter was not reported or thoroughly investigated. The facility also failed to classify and investigate allegations involving Resident #22, whose daughter reported that the resident was found wearing the same soaked brief from the prior evening and that the resident had been vomiting throughout the night. The daughter stated the resident’s condition had declined and she requested hospital transfer, and she also reported dissatisfaction with incontinence care and sheet changes, including that she had raised the issue with the DON and during a care plan meeting. The DON and RN consultant stated the incident was not considered abuse or neglect because the brief was not viewed as wet, and they said they would only have changed it if it had been wet and would only have reported it if they found abuse or neglect. The facility could not locate paperwork, grievances, or resolutions for the allegations reported by the daughter. The facility further failed to report an incident involving Resident #3, whose progress note documented that she was given grilled cheese on her dinner tray even though her diet order was mechanical soft. The note states she ate some of the grilled cheese, coughed a few times, and then was fine, after which the NA removed the tray and provided another tray she could eat. The diet manual listed grilled sandwiches as foods to avoid on a mechanical soft diet, and the nurse consultant confirmed the incident occurred as documented and was not reported.
Failure to Assist Resident With Meals
Penalty
Summary
The facility failed to recognize standards of practice related to assistance with activities of daily living for a resident who was unable to complete meals independently, resulting in the resident not receiving assistance with meals. During lunch observation, the resident was served a tray at 12:02 PM and was observed falling asleep periodically while eating. The resident did not receive cueing during the meal and was not offered reheated food, and the tray was removed after the resident ate 51-75% of the meal at 1:27 PM. Staff interviews confirmed the resident took a long time to finish meals and that aides typically left the tray because the resident ate slowly. An OTA stated she had provided cueing during a meal and the resident ate about 50% of it. Record review showed weight loss from 185 pounds to 170 pounds over five months, including a 3.41% loss in three months and a 5% loss over 30 days. The resident’s orders included one 4-ounce serving of fortified pudding in the afternoon, and the care plan called for set-up only for meals. The DON confirmed the resident did not receive any assistance with meals and had experienced weight loss.
Failure to Maintain Appropriate Bed Rail Support
Penalty
Summary
The facility failed to provide appropriate equipment to maintain mobility with the maximum practicable independence for Resident #2 related to bed rails. The resident stated that someone removed one of his bed rails, which he used to roll onto his side so aides could clean him up. The resident’s MDS showed that he required substantial to maximum assistance to roll to both the left and right, and the facility’s siderail consent forms showed that he previously had both handrails before being changed to one bed rail. The Director of Rehab stated he completed the most recent bed rail assessment and chose to use only one bed rail because of entrapment risk since the resident now required max assist for rolling. CNAs stated the resident had used the left bed rail during care and had no issues with it, but after it was removed, care became much more difficult and the resident now had to roll to the right because the left side of the bed was against the wall. The DON confirmed the resident had both bed rails until one was removed and there was no documentation explaining why the left bed rail was removed.
Failure to Provide Accessible Fluids to Two Residents
Penalty
Summary
The facility failed to ensure adequate hydration for Resident #48 and Resident #57, two of four residents sampled for hydration during the survey. A policy titled, Resident Hydration and Prevention of Dehydration, stated that nursing staff would provide and encourage intake of bedside, snack, and meal fluids on a daily and routine basis as part of daily care. During the initial tour, Resident #48 was observed in bed without water at the bedside and stated that if he needed water, he had to ask for it. He also stated that he needed a lot of water because he had undergone a kidney transplant. On a later observation, Resident #48 was again in bed without water available at the bedside, and the RN consultant confirmed that water was not within reach. A record review showed an ambulatory clinical summary instructing him to stay active and stay hydrated and to drink at least 2 liters of water daily. Resident #57 was also observed in bed without water at the bedside during the initial interview. On a later observation, Resident #57 was in bed with an empty water pitcher on the bedside table and out of reach, and the RN consultant confirmed that water was not within reach. A record review of Resident #57's care plan included the instruction to encourage adequate nutrition and hydration. The report documents that both residents lacked accessible fluids while in bed despite the facility policy and the documented hydration-related instructions in their records.
Tube Feeding Syringe Left Exposed
Penalty
Summary
The facility failed to maintain proper infection prevention and control when Resident #54's tube feeding syringe was observed left exposed and not covered or bagged, open to the elements. On 04/20/26 at 1:30 PM, the syringe was seen laying out uncovered, and on 04/20/26 at 2:20 PM it was still exposed. During interview, LPN #65 stated, "I was just in there; I will throw it away, get a new one and date it," confirming the syringe had not been covered.
Failure to Maintain Appropriate Temperature in Shower Room
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment by not ensuring appropriate temperatures in the residents' shower room. During a tour, it was observed that while the entrance to the shower room felt adequately warm, the area inside the shower stall where residents sit was notably cool. The Director of Maintenance measured the temperature in the shower area and confirmed it was 61 degrees Fahrenheit, which was acknowledged as too cold for showering. The Director of Maintenance also stated that despite installing two waterproof heaters, the larger shower room remained colder than the other shower room, which was warmer and less used. The issue was later traced to an open vent that was pulling in cold air, but the Director of Maintenance could not confirm how long the vent had been open. Resident interviews corroborated the issue, with one resident stating that the shower room was always cold, leading them to only have their hair washed instead of a full shower. Another resident, who had recently been admitted, reported that the shower room was cold during each of their three showers. A review of the facility's policy indicated that immediate action should be taken to maintain temperatures between 71-81 degrees Fahrenheit when heating or cooling systems are inoperable, but this standard was not met in the shower room.
Failure to Provide Timely ADL Care Due to Inadequate Staffing
Penalty
Summary
The facility failed to provide timely Activities of Daily Living (ADL) care to residents who were dependent on staff assistance. Multiple residents reported and were observed experiencing significant delays in receiving incontinence care and assistance with hygiene, despite having care plans indicating their dependence on staff for these needs. For example, one resident with a urinary tract infection (UTI) remained soiled for over 45 minutes while her call light went unanswered, and only received assistance after external intervention. Another resident described waiting over two hours to be changed, and others reported similar prolonged waits for care, often attributing these delays to chronic understaffing. Residents interviewed consistently described a pattern of inadequate staffing, with only one or two nurse aides available for the entire building at times, and reliance on staff working extended shifts or calling in off-duty personnel to provide basic care. Several residents expressed distress and frustration over the lack of timely assistance, with one resident stating that she had to wait for hours to be changed and another reporting that her call light was repeatedly turned off without her needs being met. Observations by surveyors confirmed that call lights were left unanswered for extended periods, and residents were left in soiled clothing or with emesis on their clothing without prompt help. Record reviews corroborated that the affected residents had care plans requiring substantial or maximal assistance with toileting, hygiene, bed mobility, dressing, and bathing due to chronic health conditions, impaired mobility, and cognitive impairment. Despite these documented needs, the facility did not ensure that staff were available or responsive enough to meet residents' ADL requirements in a timely manner, resulting in prolonged periods where residents remained soiled or unassisted.
Failure to Provide Sufficient Nursing Staff for Resident Care Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff at all times to meet the needs of residents, as evidenced by multiple resident and family interviews, staff interviews, and direct observations. Residents and their families reported frequent and prolonged delays in receiving assistance, particularly with incontinence care and response to call lights, especially during evening and night shifts. Several residents described waiting from two to eleven hours to be changed, with one resident developing a urinary tract infection (UTI) as a result of delayed care. Family members and residents also noted a high turnover of staff and a lack of adequate training among new staff members. Staff interviews confirmed that the facility often operated with only two nursing assistants (NAs) for the entire building, even when the census was close to 60 residents. Staff reported working extended shifts, sometimes up to 19 hours, and being called in on their days off to cover shortages. Restorative aides were pulled from their usual duties to provide basic care due to staffing shortages. Staff also indicated that nurses rarely assisted with call lights or direct care, further exacerbating delays in resident care. Direct observations by surveyors corroborated these reports, including an incident where a resident waited over 40 minutes for assistance after activating a call light, and was found covered in emesis. Review of staffing records confirmed that on multiple dates, only two NAs were scheduled for shifts covering the entire facility. These deficiencies affected all residents in the facility and were substantiated by both documentation and firsthand accounts.
Failure to Accurately Document Resident Care and Meal Intake
Penalty
Summary
The facility failed to maintain accurate and complete documentation of care and services provided to three residents. For one resident, a review of records and a facility-reported incident revealed that incontinence care was not documented at several specific times, despite the facility's investigation concluding that care had been provided. Similarly, another resident's records lacked documentation of incontinence care at multiple times, even though the facility determined that the care was rendered. In both cases, the Administrator and DON acknowledged that the lack of documentation was an error and that the care was not properly recorded. Additionally, for a third resident, meal intake percentages were not documented for an entire day, including breakfast, morning snack, lunch, and afternoon snack. The DON confirmed the absence of documentation for these meals and was unable to locate any records for that day. These findings indicate that the facility did not consistently safeguard resident-identifiable information or maintain medical records in accordance with accepted professional standards, as required.
Failure to Maintain Infection Control Practices
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in infection control practices. During a tour of the 100 hall shower room, surveyors found a soiled washcloth under the sink, a used hand wipe and candy wrapper on the floor, and an open bottle of soap left on the shower bar. These items were left unattended in a resident care area, indicating a lack of proper cleaning and maintenance. Additionally, trash barrels in the hallway were found to be overfilled with soiled briefs, preventing the lids from closing completely, which contributed to unpleasant odors in resident areas. Staff were observed transporting soiled linen through the hallway while wearing soiled gloves, contrary to infection control protocols. One staff member admitted to not knowing the correct procedure due to filling in for absent staff, while another confirmed that soiled linen should be bagged before being brought into the hall and that soiled gloves should not be worn in the hallway. A resident reported that the overfilled barrels left in the hallway caused unpleasant smells that made them feel nauseated. These observations demonstrate a failure to adhere to established infection control procedures, with the potential to affect more than an isolated number of residents.
Failure to Follow Care Plan for Blood Pressure Restrictions
Penalty
Summary
The facility failed to implement the care plan for a resident who had a restriction on blood pressure measurements and lab sticks in the left arm due to a mastectomy. Record review showed that, despite the care plan's special instructions, blood pressures were repeatedly taken from the resident's restricted left arm on multiple occasions over a two-month period. This was confirmed by documentation of specific dates and times when the restricted arm was used for blood pressure measurements. The Director of Nursing acknowledged that blood pressures should not have been obtained from the restricted arm.
Failure to Maintain Accurate Medical Records and Follow Physician Orders
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for two residents. For one resident with a history of malignant neoplasm of the left breast and a physician's order restricting blood pressure measurements and venipuncture from the left arm due to a mastectomy, blood pressures were repeatedly taken from the restricted arm on multiple documented occasions. This was confirmed by record review and acknowledged by the Director of Nursing. For another resident with an order for insulin administration before meals if blood sugar was less than 140, there was no documentation of blood sugar checks or insulin administration on the Medication Administration Record or vital records for a period of several days. The resident reported that a nurse did not check blood sugar or administer insulin, and the Director of Nursing confirmed that the blood sugar checks were not documented as required.
Failure to Maintain Clean and Safe PTAC Units in Resident Rooms
Penalty
Summary
Surveyors observed that Packaged Terminal Air Conditioner (PTAC) units in several resident rooms, specifically rooms 113, 125, 130, 131, and 132, had filters that were covered with layers of dust. Additionally, one PTAC unit contained a dried, brown substance inside its vents. These findings were confirmed during an interview with the Maintenance Director, who acknowledged the presence of dirty filters and the substance in the vents. The Maintenance Director also stated that housekeeping is typically responsible for cleaning the vents during routine room cleaning. This deficiency was identified during a complaint survey and was considered a random opportunity for discovery, with the potential to affect more than a limited number of residents in a facility with a census of 59.
Inaccurate Nurse Staffing Postings Identified
Penalty
Summary
The facility failed to provide accurate daily nurse staffing postings, as required. During a review of nurse staff postings over a 50-day period, it was found that on 16 days, the posted staffing numbers were below the minimum required level of 2.25. However, further examination of staff punch forms for those days showed that actual staffing met or exceeded the minimum requirement. The Director of Nursing confirmed that the staff punch forms were correct and that the postings for those 16 days were inaccurate. This discrepancy was identified during a complaint survey, and the facility census at the time was 59.
Failure to Prevent and Identify Pressure Ulcers Resulting in Harm
Penalty
Summary
A resident with dementia and total dependence for activities of daily living was admitted to the facility without any pressure ulcers. Throughout her stay, Braden scale assessments consistently indicated she was at risk for developing pressure ulcers, and her care plan included interventions for skin integrity and pressure ulcer prevention. However, there was no documentation that staff implemented or recorded key interventions such as regular turning and repositioning, despite the resident's immobility and high risk. Weekly skin assessments documented by nursing staff reported no skin issues, and there were no physician orders or treatments related to pressure ulcer prevention or care. Upon discharge, the resident was transferred to a behavioral health group home, where a nurse assessment conducted within hours identified multiple pressure wounds in various stages, as well as significant bruising. The wounds were severe enough to require hospital admission, where medical staff documented deep tissue injuries to the coccyx and right heel, as well as dehydration and hypernatremia. The hospital physician determined that the wounds could not have developed in the short time after discharge and must have occurred during the resident's stay at the facility, citing the chronic nature and varying stages of the wounds. Facility records and staff interviews revealed a lack of documentation or recognition of any wounds during the resident's stay. The facility's own investigation concluded the wounds were unsubstantiated, relying on the absence of documentation rather than clinical evidence. The Director of Nursing initially denied the wounds were pressure injuries but later acknowledged their nature after reviewing hospital photos and the facility's own policy definitions. The facility failed to identify, document, or treat the pressure ulcers, resulting in actual harm to the resident.
Failure to Notify Responsible Party of Resident Room Change
Penalty
Summary
The facility failed to notify a resident's responsible party prior to moving the resident to a different room. According to an interview with the responsible party, the resident was moved without any prior notification, and staff simply packed up the resident's belongings and relocated him. A review of the medical record confirmed there was no documentation indicating that the responsible party had been informed of the room change. The DON confirmed that there was no evidence of notification and stated that the social worker may have made an error in the notification process.
Failure to Thoroughly Investigate Alleged Abuse and Neglect
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse and/or neglect involving a resident who was reported to have developed bruises and multiple pressure ulcers of various stages after discharge. The incident was initially reported by a state agency worker, who alleged that the resident returned home with significant skin issues believed to have occurred during their stay at the facility. The facility's internal investigation relied solely on a review of the resident's chart and statements from nursing staff, all of which indicated no documentation or observation of bruises or pressure ulcers prior to discharge. Despite the allegations, the facility did not obtain or review hospital records or contact the behavioral health company or hospital for additional information regarding the resident's condition after discharge. When the state survey agency later reviewed the hospital records, it was found that the presence of pressure wounds was documented extensively, with references to wounds appearing numerous times in the medical record. The hospital records specifically noted that the resident was admitted for wounds on the sacrum and heels shortly after leaving the facility. Interviews with the current Nursing Home Administrator and DON confirmed that the investigation into the alleged abuse and/or neglect was not thorough. The lack of outreach to external care providers and failure to review relevant hospital documentation resulted in an incomplete investigation of the reported incident.
Failure to Readmit Resident After Hospitalization Despite Bed Availability
Penalty
Summary
The facility failed to ensure the timely readmission of a resident who was discharged to the hospital with a return anticipated, as required by regulation. Despite the resident being medically stable and cleared for discharge, the facility repeatedly claimed that no appropriate bed was available for him, while admitting multiple new residents of the same gender during the same period. Documentation from the hospital case management, the resident’s wife, and the long-term care ombudsman confirmed ongoing communication with the facility regarding the resident’s readiness for return, and that the facility received daily notifications listing the resident as ready for discharge. The resident, who had a history of behavioral issues and a pain pump, exhausted his Medicaid bed-hold days prior to hospital discharge. The facility’s own records and the hospital’s case management notes show that, from the time the resident was ready for discharge, the facility admitted at least seven new male residents and several female residents to private rooms, any of which could have accommodated the returning resident. The facility maintained that no suitable bed was available, but evidence showed that beds were available and offered to new admissions instead of the returning resident. The facility also failed to notify the resident’s wife, who was his MPOA, of certain room changes prior to his hospital discharge. As a result of the facility’s actions, the resident remained in the hospital for an extended period, experiencing significant psychosocial harm, including anxiety, agitation, and feelings of despair. The resident and his family expressed confusion and distress over the facility’s refusal to readmit him, especially as he wished to return to the facility where he had friends and family nearby. The facility did not assist in finding alternate placement and did not provide clear communication regarding the reasons for denial of readmission, despite ongoing involvement from the ombudsman and hospital staff.
Failure to Address Resident's Fear of Mechanical Lift
Penalty
Summary
The facility failed to protect a resident from emotional distress during transfers using a mechanical lift on shower days. The resident, who has a history of fear related to the lift due to a previous fall, expressed fear and anxiety during these transfers. Despite the resident's intact cognition, as indicated by a BIMS score of 15, the care plan did not include any interventions to address the resident's fear of the lift. Staff interviews confirmed that the resident would cry and scream during the transfers, indicating psychosocial harm. The resident's behavior was documented in multiple Behavior Observation Monthly Summaries, showing consistent anxiety and agitation related to Activities of Daily Living (ADL) care, including the use of the mechanical lift. Despite these documented behaviors, no interventions were implemented to minimize the emotional distress experienced by the resident. The facility's staff, including nurse aides and nurses, acknowledged the resident's distress but did not take steps to address the underlying fear or modify the care plan accordingly. Interviews with various staff members revealed a lack of awareness and action regarding the resident's fear of the lift. The Director of Nursing was unaware of the situation until it was brought to their attention during the survey. The resident expressed a preference for bed baths over using the lift, but this preference was not consistently honored. The facility's failure to address the resident's fear and distress during lift transfers constitutes a deficiency in providing necessary services to avoid emotional harm.
Inaccurate Facility Assessment of Resident Acuity
Penalty
Summary
The facility failed to complete an accurate facility-wide assessment regarding the overall acuity of care needed for its resident population. During a review of the Facility Assessment (FA) on January 14, 2024, it was found that the assessment, last reviewed on October 24, 2024, contained incorrect calculations for the overall acuity of residents. Specifically, the assessment inaccurately reported the percentages of residents requiring assistance with Activities of Daily Living (ADLs), mobility impairments, incontinence impairments, cognitive or behavioral impairments, and specialized care needs. The Administrator acknowledged missing a section and confirmed the inaccuracies in the overall acuity section of the FA. Further review of the tool used by the facility to determine acuity of care from October 2023 to October 2024 revealed significant percentages of residents with various health conditions, such as diseases of the musculoskeletal system and connective tissue (64.9%), factors influencing health status and contact with health services (53.2%), diseases of the genitourinary system (51.4%), and diseases of the skin and subcutaneous tissue (26.1%). The facility's policy on Facility Assessment requires consideration of factors affecting overall resident acuity, including the need for assistance with ADLs, mobility impairments, incontinence, cognitive or behavioral healthcare needs, and conditions requiring specialized care. The failure to accurately assess these factors had the potential to affect more than a limited number of residents during the Long-Term Care Extended Survey Process.
Inadequate Temperature Control in Shower Room
Penalty
Summary
The facility failed to maintain a comfortable temperature in the resident shower room, which led to residents refusing to take showers due to the cold environment. Resident #26 reported refusing a shower because the room was too cold, and this was corroborated by a nurse's note for Resident #13, who also refused a shower citing the cold temperature. The maintenance director confirmed that the temperature in the shower room was 63.8 degrees Fahrenheit, despite the heaters being set to 72 degrees. The heaters installed during a recent remodel were found to be insufficient for maintaining a comfortable temperature. During a Resident Council Meeting, multiple residents, including Residents #16, #49, #26, #27, and #30, expressed concerns about the cold temperature in the shower room, with some stating they would not take showers due to the discomfort. Additionally, it was noted that even Nurse Aides commented on the cold conditions. The Nursing Home Administrator mentioned that staff would try to warm the room by running hot water to create steam before bringing residents in, indicating an ongoing issue with the shower room's temperature control.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to revise the care plans for three residents, leading to deficiencies in their care. Resident #40 was care planned to receive one-on-one visits from the Activity Department, but the care plan was not updated when the resident became more independent and no longer required these visits. The Activity Director acknowledged the oversight during an interview. Resident #19's care plan included a focus on behaviors such as delusions and hallucinations, but it was not updated to include non-pharmacological interventions ordered on 12/30/24. These interventions were meant to address the resident's behaviors, which included delusions about people poisoning her food and drinks. The Director of Nursing confirmed that the care plan had not been updated to reflect these interventions. Resident #29 expressed fear of the mechanical lift used during shower days, which was not addressed in her care plan. Despite multiple staff members acknowledging her distress, no interventions were implemented to minimize her emotional distress. The resident's behavior observation summaries consistently noted anxiety and resistance to care, yet the care plan lacked interventions to address these issues. The Director of Nursing was unaware of the situation until it was brought to their attention.
Failure to Update Resident Activity Care Plan
Penalty
Summary
The facility failed to ensure that a resident was provided with activities of interest as outlined in their care plan. Specifically, the care plan for a resident indicated that they were to receive one-on-one visits from the Activity Department. However, upon review of the records, there was no evidence that these visits were being conducted. During an interview, the Activity Director acknowledged that the resident had become more independent with their activities and stated that the care plan should have been updated to reflect this change, confirming that the care plan was not updated when the resident no longer required one-on-one visits.
Failure to Follow Physician Orders and Complete Assessments
Penalty
Summary
The facility failed to ensure residents received treatment and care in accordance with professional standards of practice, affecting four residents. Resident #26 had an order for monthly weights, but weights were not recorded for November 2024 and January 2025, and no refusals were documented for those months. Resident #19 had orders for weekly weights, but no weight was taken during the week of January 5, 2025, to January 11, 2025. The Director of Nursing confirmed these omissions. Resident #32's insulin was held without physician orders or notification on three occasions in January 2025, despite having specific orders for insulin administration. Additionally, Resident #53 experienced an unwitnessed fall on November 1, 2024, and although initial neurological checks were initiated, the second, third, and fourth checks were not completed. The Director of Nursing confirmed the incomplete neurological checks. These deficiencies indicate a failure to follow physician orders and complete necessary assessments, potentially impacting resident care.
Unlocked Storage Room with Hazardous Items
Penalty
Summary
The facility failed to ensure that the resident environment was as free from accident hazards as possible. During an observation, a storage room labeled as a 'new linen room' was found to be unlocked, despite having a keypad lock. The room contained clean linens and toiletries, including razor blades, which posed a potential hazard to residents who could access the room. A Licensed Practical Nurse (LPN) confirmed that the door was unlocked and acknowledged that it should have been locked. It was noted that the door did not close easily and remained unlocked unless forcefully closed, which would then engage the lock.
Failure in Monthly Drug Regimen Review and Physician Response
Penalty
Summary
The facility failed to ensure that a licensed pharmacist completed a monthly drug regimen review and reported any irregularities to the attending physician, with the physician responding within the time frame established by the facility policy. This deficiency was identified for three residents during the long-term care survey process. For one resident, there was no evidence of a pharmacist's review for three consecutive months. Another resident's medical record was missing a pharmacy recommendation and physician's response for a specific month. Additionally, a third resident's records showed delayed physician responses to pharmacist recommendations, with both responses being provided on the same day, well beyond the 30-day policy requirement. The facility's policy required the consulting pharmacist to perform monthly medication regimen reviews for every resident and provide recommendations to the attending physician, medical director, and director of nursing within five working days. If the attending physician did not respond within 30 days, the medical director was to review the recommendations and/or contact the attending physician. However, the facility did not adhere to these guidelines, resulting in the identified deficiencies. The Director of Nursing confirmed the absence of required documentation and acknowledged the delays in physician responses.
Failure to Serve Food at Palatable Temperature
Penalty
Summary
The facility failed to ensure that food was served at a palatable temperature, as evidenced by multiple grievances and resident interviews. Several residents filed grievances over a period of time, reporting that their meals were often served cold. Specific grievances included complaints about cold food, such as pancakes and sausage, and the lack of use of plate warmers. Resident interviews corroborated these grievances, with residents consistently reporting that their meals, including soup and meat, were served cold and unappetizing. During a survey, the dietary manager measured the temperature of meal items and found that the chicken strips were served at 101.1 degrees Fahrenheit, which is below the recommended safe serving temperature. The coleslaw was also measured at 54.3 degrees Fahrenheit. There was a discrepancy in the reported temperature of a second chicken strip, but both the surveyor and the dietary manager agreed on the temperature of the first chicken strip. These findings indicate a failure in maintaining appropriate food temperatures, which could potentially affect the quality of care provided to the residents.
Food Storage and Cleanliness Deficiencies in Kitchen
Penalty
Summary
The facility failed to ensure that food was stored and served in a safe and sanitary manner, as observed during a kitchen tour with the Dietary Manager. In the walk-in cooler, several food items were found to be either out of date or not properly dated to indicate when they had been opened. Specifically, 37 individual cups of yogurt had expired, a prepackaged container of fruit salad was past its expiration date, and a five-pound bag of shredded cheddar cheese had a discard date that had passed. Additionally, an opened container of apple sauce and a five-pound container of scrambled egg mix were not dated, and two bags of mozzarella cheese were opened and undated. The Dietary Manager confirmed these findings and discarded the items. Further observations revealed cleanliness issues in the kitchen, including dust accumulation around two ceiling vents and on the metal grate covering the HVAC unit filter. One of the dusty vents was located directly over the steam table. The Maintenance Assistant confirmed that the HVAC filter, which was covered in dust, needed to be replaced and should have been dated for the last change. The Dietary Manager also confirmed that the areas around the vents required cleaning. These deficiencies had the potential to affect all residents receiving nutrition from the facility's kitchen.
Infection Control and EBP Failures
Penalty
Summary
The facility failed to adhere to proper infection control practices during meal service and resident care. During a lunch tray pass, a nurse aide dropped two cartons of milk on the floor and returned them to the cart with clean milk cartons, acknowledging the mistake but unable to explain the action. Additionally, a tray of uncovered coffee cups was sent from the kitchen, which was confirmed by another nurse aide who noted that lids were usually provided but were forgotten on this occasion. The facility also failed to implement Enhanced Barrier Precautions (EBP) for two residents. One resident had EBP signage due to a history of pressure ulcers, yet a licensed practical nurse (LPN) entered the room without a gown to perform a skin check, despite the resident having diarrhea. The LPN was unaware of the reason for the EBP. Another resident had EBP signage without corresponding orders, and the same LPN entered the room without a gown, interacting with the resident's bed covers. The Director of Nursing acknowledged that gowns should have been worn for these activities, as per the facility's EBP policy.
Failure to Administer Pneumococcal Vaccines per CDC Guidelines
Penalty
Summary
The facility failed to administer pneumococcal vaccines in accordance with the updated CDC guidelines, which had the potential to affect more than a limited number of residents. Specifically, two residents were involved in this deficiency. Resident #6 signed a consent to receive the PPSV23 vaccination, with the option to use PCV20 if PPSV23 was unavailable. The resident received the PPSV23 vaccine despite the CDC's updated guidelines recommending PCV20 or PCV15 followed by PPSV23 after a year for adults of a certain age who had not received prior pneumococcal vaccines. Similarly, Resident #17's representative signed a consent for PPSV23, and the resident received the PPSV23 vaccine, contrary to the updated CDC recommendations. The facility's policy on pneumococcal vaccination, which lacked an implementation or revision date, stated that residents would be offered the pneumococcal vaccine upon admission in accordance with CDC and ACIP guidelines. However, the Director of Nursing confirmed during an interview that the facility was unaware of the changes in CDC guidelines and continued to offer PPSV23 to unvaccinated residents, using PCV20 only when PPSV23 was unavailable. This oversight led to the administration of vaccines not aligned with the current CDC recommendations, highlighting a gap in the facility's adherence to updated vaccination protocols.
Failure to Honor Resident's Preference for Wound Care Timing
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not accommodating his preference for the timing of his wound care. The resident, who had an unstageable ulcer on his outer right ankle, had a physician's order for a dressing change every night shift. However, the resident expressed dissatisfaction with being woken up for these treatments, as documented in a nurse's note on January 4, 2025, where the resident refused treatment, stating it should be done at a more appropriate time. Despite this, the dressing changes continued to be performed during the night shift, including times as late as 3:38 AM and 3:43 AM on subsequent dates. The Director of Nursing acknowledged the resident's preference not to be disturbed during the night, yet the facility continued to perform the dressing changes during the night shift. The resident reiterated his preference during an interview, requesting that the dressing changes be done at a time that did not require him to be woken from sleep. This failure to accommodate the resident's choice regarding the timing of his care represents a deficiency in promoting and facilitating resident self-determination, as it did not align with the resident's expressed wishes.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 36 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bluefield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mercer Healthcare Center | 1.3 mi | ★★★★★ | 10 | 0 |
| Westwood Center | 1.8 mi | ★★★★★ | 0 | 0 |
| Glenwood Healthcare Center | 6.5 mi | ★★★★★ | 0 | 0 |
| Bland County Nursing & Rehab Center | 7 mi | ★★★★★ | 8 | 0 |
| Princeton Health Care Center | 8.5 mi | ★★★★★ | 10 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Bluestone Health And Rehabilitation.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.