Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rosewood Center during CMS and state inspections, most recent first.
Failure to provide qualified social services and follow-up on resident allegations. The facility did not have a full-time social worker despite a census above 60, and the social services role described advocacy, abuse reporting, and grievance investigation responsibilities. A resident’s debit card misappropriation allegation was not fully tracked or documented, with no bank records maintained and no clear outcome documented. Additional resident interviews identified concerns about staff sleeping and inappropriate behavior, and several residents stated a social worker would have made reporting easier.
The facility failed to ensure proper disposal of discontinued meds in a medication storage room. During observation, 11 discontinued meds, including carvedilol, tamsulosin, clopidogrel, dapagliflozin, prednisolone, and 6 vials of haloperidol lactate, were found in random drawers instead of being removed from active storage or returned to the pharmacy. The DON confirmed the meds were no longer in use and should have been processed for disposal per facility policy.
Damaged Resident Wheelchairs and Geri-Chair With Exposed Padding: Multiple resident wheelchairs and one Geri-chair were observed with rips, tears, cracks, and broken zippers exposing inner padding on armrests, head rests, back rests, foot pads, and leg padding. The DON acknowledged the damaged equipment during a walk-through and said it would be reported to maintenance for repair or replacement.
The facility failed to follow its abuse reporting policy when a cognitively intact resident reported that two nurses were frequently sleeping on duty and later provided an audio recording of a nurse calling the resident a "jerk." The allegation was reported by the resident to an LPN and then to an RN Infection Preventionist, but the Administrator remained unaware until the survey, and the incident was not reported to authorities within the required 2-hour timeframe. In a separate case, another resident had a verbal abuse incident reported to the state, but the facility did not complete or submit the required 5-day follow-up report, and the Administrator confirmed there was no record of that follow-up.
A resident reported unknown charges on her debit card and alleged that a former roommate had used the card without permission, estimating losses of several hundred dollars. The facility documented initial steps such as notifying external agencies, involving law enforcement, cancelling the card, separating the roommates, and assisting the resident in obtaining bank statements. However, the facility did not maintain or retain key documentation, including copies of bank statements, the total amount of funds involved, or clear follow‑up on the status and outcome of the allegation. The resident reported not receiving updates, and the BOM acknowledged that the facility lacked the resident’s financial records because they had been turned over to law enforcement and were not requested or reviewed by facility staff until shortly before the survey, resulting in an incomplete internal investigation record of the alleged misappropriation.
Verbal Abuse by Staff: A cognitively intact resident reported that two nurses were upset after the resident complained to administration, and an audio recording captured an RN telling the resident, “You are a jerk,” and repeating the statement when questioned. Another resident identified the staff involved as an RN and an LPN. The facility’s abuse policy defined verbal abuse and required prompt reporting of abuse allegations, but the Administrator stated she was unaware of the situation until later.
A resident’s oral care plan directed staff to provide mouth care twice daily and as needed, but surveyors observed the resident’s teeth covered in debris with a thick white substance around the gum lines on two occasions. Record review confirmed the oral hygiene intervention, and the DON acknowledged the resident did not appear to have received oral hygiene.
A resident with paraplegia and spina bifida was discharged from PT with the plan to restart therapy once a new custom HKAFO arrived. Survey review found the HKAFO had been received, but therapy was not resumed and the rehab dept had not followed up to confirm receipt of the device. A brand new HKAFO was observed in the resident’s room, and the resident stated he was no longer going to PT.
A resident's electronic record did not reflect signed physician order changes from MRRs, including discontinuation of Atorvastatin and added instructions for Digoxin and Lidocaine patches. The Administrator verified the orders were overlooked and not entered into the chart.
Incorrect Daily Nurse Staff Posting Date: Surveyors found the Nurse Staff Posting still showed an outdated date and had not been updated for two days. An RN manager stated there had been a call off and the posting had not yet been changed.
Failure to Provide Routine Dental Services: A resident was observed with teeth covered in debris and a thick white substance around the gum lines on multiple occasions. The resident’s care plan called for oral hygiene twice daily, but record review found no dental consults since admission and a note showing a scheduled dental visit could not occur because the MPOA was not present to sign forms. The DON confirmed there was no record of dental services being provided since admission.
A resident’s record was incomplete because the chart did not list a diagnosis of intellectual disability, even though the PASARR and H&P both identified mental retardation/intellectual disability and noted the resident was unable to communicate much. The Administrator confirmed the diagnosis was not included in the medical record.
A facility failed to educate staff on the COVID-19 vaccine and did not provide information on the vaccine’s benefits, risks, or potential side effects. Record review for a CNA showed no documentation that vaccine education was provided or that the vaccine was offered, and the NHA confirmed the CNA was not educated and that no employee documentation existed for COVID-19 vaccination education or offers.
Call Light Not Within Reach A resident's call bell was not within reach after a bed bath and was found behind the back of the bed. The resident said staff forgot to put it back, and an LPN acknowledged it was not within reach before clipping it back to the resident's shirt. The DON was later made aware of the issue.
The facility failed to inform residents of their rights and rules annually, both orally and in writing, in a language they understood. A review of Resident Council meeting minutes and interviews with residents and staff revealed that resident rights were not discussed since admission. The DoSS and DON admitted to not discussing resident rights with residents during their tenure.
The facility did not post notice of the availability of the most recent survey results in prominent and accessible areas. Residents were unaware of their right to view these results, and a facility walk-through confirmed the absence of necessary signage. The former Interim Administrator acknowledged this deficiency.
The facility failed to provide the required SNF ABN forms to two residents and the NOMNC letter to another resident during the annual survey process. This oversight involved residents who were receiving Medicare Part A skilled services, with the facility unable to provide evidence of these notices being given, as confirmed by the Interim Administrator.
The facility did not inform residents of their right to file grievances, including anonymously. During a resident council meeting, residents knew they could file grievances with the social worker but were unaware of anonymous filing procedures. A walk-through with the Administrator confirmed the absence of grievance forms and signs for anonymous filing.
A resident was involved in multiple altercations with other residents, including pushing, hitting, and making verbal threats. Despite staff presence and intervention, the facility failed to prevent these incidents, resulting in injuries and a lack of a safe environment for residents.
A facility failed to implement its 1:1 Supervision policy after a resident-to-resident altercation. A resident, who was supposed to be under 1:1 supervision, was left unsupervised and kicked another resident. The investigation revealed a communication breakdown when the assigned NA went on break. Despite identifying the need for staff retraining, several staff members had not been retrained on the supervision policy.
The facility failed to develop comprehensive care plans for several residents, leading to deficiencies in addressing their specific needs. A resident's care plan lacked details on activities preferences, nutritional risk, and dental issues. Another resident's care plan was incomplete regarding anticoagulation therapy, while another's did not include monitoring for side effects of psychotropic medications. A resident's history of aggressive behavior was not reflected in their care plan, despite multiple incidents. Additionally, a resident's frequent unsupervised leaves of absence were not addressed in their care plan.
The facility failed to follow care plans and physician orders for three residents, leading to missed medications, treatments, and incorrect diagnoses. A resident's request to be moved was delayed, and another's medical appointments were rescheduled without proper documentation.
The facility did not follow the corporate recipe for Tuna Melt Sandwiches, omitting tomato slices due to a shortage. This deviation was observed during a meal service and had the potential to affect multiple residents, as the facility census was 64. A DM confirmed the omission during an interview.
The facility failed to provide appetizing and appealing food to residents, as observed and reported by residents and their family members. A resident reported their lunch sandwich was mushy and microwaved, confirmed by a surveyor. Another resident's family member described the food as horrible and unidentifiable. A test food tray revealed the Tuna Melt was unappealing, appearing dry and missing ingredients as per the facility's recipe.
The facility did not offer bedtime snacks to all residents, as confirmed by resident interviews and a council meeting. Two residents noted that snacks are only provided if requested or ordered by a physician. An observation showed limited snack options available, and a nurse aide confirmed that snacks are distributed only to those with physician orders, while others must ask for them.
The facility failed to follow professional standards for food service safety. A cook/aide was observed preparing drinks without a beard net, and a kitchen aide had her hair not fully contained in a hair net. Improper food storage and disposal were noted, with expired items found in the refrigerator. Additionally, gloves were improperly disposed of on a food preparation counter by the district manager.
The facility failed to properly contain kitchen waste, as observed during a tour where a large trash can was overflowing with trash spilling onto the floor. The District Manager acknowledged that the trash should have been contained and emptied.
The facility failed to maintain an effective pest control program, potentially affecting all residents. An exterminator report revealed cockroaches in the kitchen, and the Maintenance Director admitted no exterminator had serviced the facility since the report. The maintenance department attempted to use boric acid for extermination. An Account Manager observed roaches in the kitchen, prompting a pest control company to service the facility.
The facility failed to ensure a safe environment due to unclean PTAC units in several rooms. Observations showed that the units were filled with lint, dirt, and debris, with filters that were old, torn, and covered with thick lint. The Maintenance Director confirmed the lack of cleaning and filter changes, as well as the absence of a cleaning schedule. This issue potentially affects all 63 residents.
The facility failed to maintain an effective pest control program, as evidenced by an exterminator report indicating cockroaches in the kitchen. The Maintenance Director admitted no exterminator had serviced the facility since November, and attempts to use boric acid were made. An Account Manager observed roaches, and the pest control company eventually serviced the facility, confirming ongoing issues.
A facility failed to serve meals simultaneously to two residents sharing a room, compromising their dignity. One resident received her meal late, after her husband requested it from the staff. The meal was reported to have mushy bread and was too hot, indicating it might have been microwaved. The resident chose to eat only the meatballs from the sandwich. The staff did not provide an explanation for the delay.
A resident was not informed about the reason for receiving hospice care, believing hospice nurses visited everyone. Despite being admitted after hospitalization for sepsis and having hospice documents signed by their MPOA, the resident's cognition was intact, and they were unaware of their hospice status. Facility staff confirmed the lack of explanation, with no documentation showing hospice services were explained to the resident.
A resident was not notified or included in their care planning process, despite expressing a desire for a re-evaluation of their medical status. The interdisciplinary team held a care plan meeting with the resident's MPOA without the resident's knowledge, due to a lapse in notification responsibilities. The resident's cognition was intact, yet their physician had concerns about their self-care abilities.
A resident on hospice care, diagnosed with ASCVD, expressed a desire to ambulate independently but was repeatedly stopped by staff despite being classified as independent with no restrictions. The facility failed to assess his potential for ambulation and did not provide necessary assistance, violating his right to self-determination.
A facility failed to maintain a safe, clean, and homelike environment for a resident. The resident's room had multiple drywall patches, a large crack, and needed painting and caulking. The resident's personal items were displayed on the affected wall, which the resident proudly showed to the surveyor. The DON acknowledged the need for repairs.
The facility failed to report a resident-to-resident abuse incident to APS within the required two-hour window. An altercation between two residents was promptly reported to OHFLAC, but APS was not notified until two days later. The former Interim Administrator acknowledged the delay, noting the incident occurred over a weekend.
A facility failed to update a resident's care plan to reflect the correct level of assistance needed for ADLs, specifically in bathing. The care plan inaccurately stated the resident required partial/moderate assistance, while the MDS assessment indicated a need for substantial/maximal assistance. This discrepancy was confirmed by the DON during an interview.
A resident on hospice care expressed a desire to ambulate independently but was consistently stopped by staff and not evaluated for therapy services. Despite being classified as independent with no restrictions, the resident reported continued restrictions on ambulation. The Director of Occupational Therapy later evaluated the resident and submitted a request for services.
A facility failed to provide adequate assistance with activities of daily living for a dependent resident. The resident required substantial assistance for bathing, but documentation showed significant gaps in care, with multiple days without bathing. No refusals were noted, and the DON confirmed the lack of documentation.
The facility failed to provide adequate hearing care for a resident with malfunctioning hearing aids and did not schedule vision services for another resident who lost his glasses. Despite staff being aware of these issues, there was a lack of immediate action and communication to address the residents' needs.
A facility failed to ensure an environment free from accident hazards when a resident was found with an opened box of Aspercreme with Lidocaine in their bathroom, which was not supported by a physician order. The resident stated a nurse had suggested its use for back pain, but there was no authorization for self-administration. The DON confirmed the product's presence without orders and acknowledged it should be removed.
A facility failed to adhere to professional standards of practice in pain management for a resident. The resident was prescribed Norco for a pain scale of 5-10, but the medication was administered when the pain level was rated below this threshold on several occasions. The DON confirmed that the medication should not have been given outside the physician's order parameters.
A facility failed to provide trauma-informed care for a resident with PTSD. Despite the resident's care plan indicating PTSD-related mood symptoms, there was no documentation confirming the diagnosis, and the resident was not receiving appropriate services or counseling. Staff interviews revealed a lack of documentation and understanding of the resident's PTSD, leading to inadequate care planning.
The facility failed to accurately post daily nursing staffing information for three days during a survey. Observations showed that the required resident census was not documented, and staffing data was outdated, having been printed without reflecting changes to scheduled staff levels. Previous postings on several dates also lacked updates. The Interim Administrator confirmed these inaccuracies.
A facility failed to provide routine dental care for a resident who was edentulous upon admission. Although a progress note indicated the resident had discussed obtaining dentures with a VA representative, no dental appointments were scheduled. The DON confirmed the oversight during an interview.
A facility failed to maintain an accurate medical record for a resident on anticoagulation therapy. A physician's order for Warfarin 3mg lacked a diagnosis, which was confirmed by the Administrator. This oversight highlights a lapse in maintaining records according to professional standards.
A facility failed to maintain an effective infection control program, as a resident's urinary catheter bag was repeatedly observed on the floor without a receptacle. An LPN confirmed the improper placement and took steps to correct it.
A resident was found unresponsive with no pulse or respirations, but CPR was delayed for 34 minutes due to the absence of documented code status in their medical record. The RN on duty did not initiate CPR immediately, citing uncertainty about the resident's code status and waiting for instructions from the DON. The delay occurred despite the standard of care requiring CPR in the absence of an advance directive.
The facility failed to include dementia management and abuse prevention in its staff training on abuse and neglect. A review of five nurse aides' training records revealed that their training lacked these critical components, despite receiving 40 minutes of training on protecting residents from assault and abuse. This deficiency was confirmed by the Clinical Advisor and Nursing Home Administrator, indicating a systemic issue in the facility's training program.
The facility did not complete a required 12-month performance evaluation for a nurse aide, potentially affecting resident care. The oversight was attributed to the DON being on leave.
Failure to Provide Qualified Social Services and Follow-Up on Resident Allegations
Penalty
Summary
The facility failed to employ a qualified social worker from 10/14/25 through the time of survey, and administration confirmed during interview that no full-time social worker had been employed during that period. The facility stated it had a contract social worker who came twice a week, but the census was above 60 and the facility did not obtain a full-time social worker. The Director of Social Services job description stated the role includes advocacy, protecting resident rights and psychosocial well-being, preventing and reporting abuse, and serving as an active contributor in grievance and concern investigations and resolution. For Resident #32, the facility did not maintain ongoing social service follow-up and oversight related to an allegation of misappropriation of property. The resident reported unauthorized use of her debit card, and although the allegation was reported and initially investigated, the facility did not maintain documentation of the resident’s bank records, determine the total amount of funds misappropriated, or track the outcome of the investigation. A subpoena dated 01/14/26 related to the incident was present, but the facility could not provide additional follow-up documentation at the time of survey. The resident stated she had not received updates, and the Business Office Manager confirmed the facility did not maintain copies of the resident’s financial records or request and review bank statements until the time of survey. The survey also identified resident interviews and an investigation involving staff behavior and resident concerns. Resident #3 reported hearing a staff member call him a jerk on a recorded conversation, and the administrator stated she was unaware of the entire situation before initiating an investigation that remained ongoing at the end of survey. In addition, the facility’s resident interviews asked about staff sleeping and inappropriate behavior; Residents #36, #54, and #30 each answered yes to a question about concerns with a staff member and named the same NA. During interviews, Residents #36, #30, and #3 stated that having a social worker would have made it easier to report the allegations, and the State Agency determined the issue had the potential to affect all 67 residents in the facility.
Discontinued Medications Left in Storage Room Drawers
Penalty
Summary
The facility failed to ensure that medications were disposed of in accordance with professional standards of practice in one medication storage room. During observation of the storage room, 11 discontinued medications were found stored in random drawers instead of being removed from the active storage area and sequestered for destruction or returned to the pharmacy. The medications observed included carvedilol 3.125 mg, tamsulosin HCL 0.4, clopidogrel 75 mg, dapagliflozin 10 mg, prednisolone 20 mg, and 6 vials of haloperidol lactate 5 mg with an expiration date of October 2025. The facility policy stated that discontinued medications must be removed from active storage immediately and documented for disposal to prevent accidental administration. The DON confirmed that the medications were no longer in use and stated they should have been pulled and processed for disposal but were left in the drawers.
Damaged Resident Wheelchairs and Geri-Chair With Exposed Padding
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections with regard to residents’ personal products. During observations and interviews, multiple resident wheelchairs and one Geri-chair were found with damaged coverings, including rips, tears, cracks, and broken zippers that exposed the inner padding. Resident #12 had a wheelchair near the bed with rips and holes in the plastic cover on the left side of the head rest and both arm rests, exposing the inner padding. Resident #17’s Geri-chair had cracks and tears down the right side of the back rest and on both arm rests, also exposing the inner padding. Additional observations identified similar damage on Resident #39’s wheelchair, including cracks and tears in both armrests and tears on the front and back edges of the foot pad with exposed inner padding. Resident #68’s wheelchair had worn plastic covering on the right armrest with exposed inner padding. A wheelchair outside room [ROOM NUMBER] had tears in both arm rests and an open broken zipper in the leg padding with exposed inner padding. During a facility walk-through, the DON acknowledged the wheelchairs and Geri-chair had areas with exposed inner padding and stated they would be reported to maintenance for repair or replacement.
Failure to Timely Report Verbal Abuse Allegation and Submit Required 5-Day Follow-Up
Penalty
Summary
The facility failed to follow its abuse prohibition policy requiring that allegations of abuse be reported to the proper authorities within two hours of identification and that required follow-up reports be completed. The policy defined verbal abuse as the willful use of disparaging or derogatory language toward residents or within their hearing. A cognitively intact resident with a BIMS score of 15 reported that two nurses who worked Monday through Thursday were "always sleeping" and that, after he reported this to administration, one of the nurses called him a "jerk." The resident had an audio recording dated 03/11/26 capturing a staff member calling him a "jerk" and confirming this characterization when questioned by the resident. The resident stated he informed an LPN, who then reported it to the RN Infection Preventionist. The RN Infection Preventionist acknowledged awareness of a phone conversation in which someone called the resident a jerk but stated she did not know the full details and thought it might have been discussed in a care plan meeting. The Administrator reported being unaware of the situation until interviewed by the surveyor, at which time the incident had not been reported within the required two-hour timeframe. The facility also failed to complete and submit a required five-day follow-up report for a separate allegation of verbal abuse involving another resident. Record review showed that this resident had been admitted and later discharged to the hospital, and that a verbal abuse incident involving this resident had been reported to the state agency on 04/15/25. However, review of the facility’s list of reportable incidents for one year revealed no evidence that the corresponding five-day follow-up report was ever sent. The Administrator confirmed there was no record of that reportable incident or of a five-day follow-up. These failures were identified for two of two residents reviewed for abuse, with a facility census of 67.
Failure to Thoroughly Investigate and Document Alleged Financial Exploitation
Penalty
Summary
The deficiency involves the facility’s failure to ensure a thorough investigation and ongoing documentation of an allegation of misappropriation of resident property for one resident. Record review showed that the resident reported unknown charges on her debit card, and the facility initiated an investigation and notified OHFLAC, APS, the Ombudsman, and local law enforcement. Progress notes documented that law enforcement interviewed the resident, the resident cancelled her debit card, and she planned to obtain information from her bank. Notes also showed that the resident obtained bank statements, attempts were made to contact the investigating officer, and law enforcement later returned to obtain the resident’s banking information and ask additional questions. The facility’s 5‑day investigation report documented that the Administrator and DON reported the allegation, assisted the resident in obtaining bank statements, reviewed charges with her, identified the alleged perpetrator as the former roommate, separated the residents, and deactivated the debit card. The investigation was labeled inconclusive with law enforcement continuing the investigation, and a later Grand Jury subpoena was issued for the resident related to alleged fraudulent use of her debit card. Despite these initial steps, at the time of survey the facility was unable to provide additional documentation or evidence of follow‑up regarding the alleged misappropriation, including the total amount of funds involved, the outcome of the investigation, or any ongoing tracking of the allegation until requested by the State Agency. In interviews, the resident stated that her former roommate used her debit card without permission, estimated that approximately $800–$900 had been spent, and reported she had not received any updates about the situation. The BOM stated the facility did not have copies of the resident’s bank statements because they had been turned over to law enforcement and that law enforcement would not release information due to an ongoing investigation. In a follow‑up interview, the resident reported that no one from the facility had requested or attempted to review her bank statements, aside from law enforcement, until shortly before the interview when the BOM inquired, demonstrating that the facility did not maintain documentation necessary to determine the extent of the alleged misappropriation. A staff member later provided a written statement that they accompanied the resident to a Grand Jury proceeding related to fraudulent use of the debit card, but the facility still lacked internal documentation of the scope and outcome of the allegation.
Verbal Abuse by Staff
Penalty
Summary
The facility failed to ensure residents were free from verbal abuse by staff. A review of the facility’s abuse prohibition policy defined verbal abuse as oral, written, or gestured language that willfully includes disparaging or derogatory terms to patients or their families, or within their hearing distance. The policy also required the administrator or designee to report allegations of abuse, including verbal abuse, no later than two hours after the allegation was made. Resident #3, who had a BIMS score of 15 and was cognitively intact, stated during interview that two nurses who worked Monday through Thursday were always sleeping and were upset after the resident complained to administration. The resident reported having a recording of one nurse calling the resident a jerk. Another resident played the recording for surveyors, and the audio captured a staff member saying, “You are a jerk,” followed by the resident asking if the staff member was calling them a jerk and the staff member replying, “Because you are a jerk.” Resident #15 identified the two staff members as RN #1 and LPN #2, and stated the staff member on the phone was RN #1. RNIP #4 stated they did not know entirely what happened and believed it may have been discussed in a care plan meeting. The Administrator stated she was unaware of the entire situation and that she immediately reported the incident and started an investigation, which was ongoing at the end of survey.
Failure to Provide Ordered Oral Hygiene
Penalty
Summary
Facility staff failed to implement Resident #70’s oral hygiene care plan. The resident had an oral health care plan revised on 03/19/25 that directed staff to provide oral hygiene and mouth care twice per day and as needed. During survey observations, Resident #70 was seen in the dining room waiting for lunch and later in bed, and on both occasions the resident’s teeth were covered in debris with a thick white substance around the gum lines. A record review confirmed the oral care intervention in the care plan, and the DON later confirmed that Resident #70 did not appear to have had oral hygiene completed.
Failure to Resume PT After New HKAFO Received
Penalty
Summary
The facility failed to provide necessary care and services to maintain or improve a resident’s ability to perform ADLs, specifically mobility, for one resident reviewed. Resident #60 had paraplegia and spina bifida and was identified in the record as being at risk for decreased ability to perform ADLs due to decreased mobility and increased weakness. During an initial room observation, a brand new custom HKAFO was seen against the wall by the bed, and the resident stated he had had the device for a few weeks and was no longer going to PT. Record review showed the resident was discharged from PT with the plan to resume therapy once the new HKAFO arrived. The PT discharge summary stated that therapy services would be addressed again when the new orthotics arrived, and a patient document receipt showed the HKAFO was received at the resident’s appointment. However, no documentation was found showing when the resident was measured or casted for the HKAFO, and as of the surveyor review the resident had not been picked back up for PT. The Director of Rehab stated the therapy department was not aware the resident had received the new HKAFO and had not followed up with the resident to determine whether it had been received.
Missing Physician Order Updates in Resident Medication Record
Penalty
Summary
The facility failed to ensure that Resident #4 received treatment and care in accordance with professional standards of practice because physician orders related to medication changes and instructions were not entered into the electronic record. The Medical Regimen Review dated 07/25/25 recommended discontinuing Atorvastatin 40 mg at bedtime, and the physician agreed and signed off on the discontinuation, but the order remained active in the electronic record on 03/24/2026. The record review also showed that a Medical Regimen Review dated 12/30/25 recommended daily apical pulse readings before Digoxin administration, with hold parameters if the pulse was less than 60, and the physician agreed and signed off on that recommendation, but the instructions were not added to the electronic physician orders. In addition, a Medical Regimen Review dated 02/25/26 recommended adding a removal time of 2200 to the Lidocaine patch order for shoulders, and the physician agreed and signed off, but that instruction was also not entered into the electronic record. During interview, the Administrator verified that the Atorvastatin discontinuation and the Digoxin and Lidocaine patch instructions were overlooked and could not explain why they were not added.
Incorrect Daily Nurse Staff Posting Date
Penalty
Summary
The facility failed to ensure the daily Nurse Staff Posting had the correct date. Upon entrance on 03/22/26 at 11:30 AM, surveyors reviewed the Nurse Staff Posting and found it still displayed the date of 03/20/26, showing it had not been updated for two days. During an interview on 03/22/26 at 11:39 AM, the Nurse Manager stated that there had been a call off and that the posting had not yet been updated.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to ensure Medicaid residents received routine dental services for Resident #70. The facility policy titled, Dental Services, stated the center would provide or obtain routine and emergency dental services, including 24-hour emergency dental care, and defined routine dental services to include an annual oral cavity inspection, diagnosis of dental disease, dental radiographs as needed, dental cleaning, fillings, denture adjustments, smoothing broken teeth, and limited prosthodontic procedures. Resident #70 was observed with teeth covered in debris and a thick white substance around the gum lines while in the dining room waiting for lunch, and again while in bed. The resident’s oral health care plan, revised on 03/19/25, directed oral hygiene and mouth care twice per day and as needed. Record review showed the resident had been admitted in 2022, but no dental consults could be found since admission. A note dated 01/09/26 stated a dental appointment had been scheduled, but the resident could not be seen because the MPOA was not present to sign forms, so the appointment needed to be rescheduled. The DON stated she could not find any dental consults in the medical record and confirmed there was no record since admission in 2022 that any dental services had been provided.
Incomplete Medical Record for Intellectual Disability Diagnosis
Penalty
Summary
The facility failed to maintain a complete and accurate medical record related to intellectual disability for one resident reviewed for unnecessary medications. Record review showed the resident’s most recent PASARR identified a diagnosis of Mental Retardation (intellectual disability), and the History and Physical also stated that the resident had underlying mental retardation and was unable to communicate much. However, there was no diagnosis of Mental Retardation (intellectual disability) listed in the resident’s medical record. During interview, the Administrator confirmed that the diagnosis was not listed in the resident’s medical record.
Failure to Educate Staff on COVID-19 Vaccine
Penalty
Summary
The facility failed to ensure staff were educated and informed on the COVID-19 vaccine and failed to provide education on the benefits, risks, and potential side effects of the vaccine to staff. Record review for Certified Nursing Assistant #18 showed no record existed to verify that COVID-19 vaccine education or information was provided or that the vaccine was offered. During interview, the Nursing Home Administrator confirmed that CNA #18 was not educated on the COVID-19 vaccine and stated that no documentation existed showing any employee was offered or educated on COVID-19 vaccinations.
Call Light Not Within Resident Reach
Penalty
Summary
The facility failed to ensure a resident's call light was within reach. During an observation and interview with Resident #27, the resident stated he could not find his call button because staff forgot to put it back after his bed bath and that it is usually clipped to his shirt. When the surveyor pushed the roommate's call button, Employee #84 entered the room and found the call bell behind the back of the bed, then reclipped it to the resident's shirt. Employee #84 acknowledged that the call bell had not been within the resident's reach, and the Director of Nursing stated she had been made aware that the call button was not within the resident's reach.
Failure to Inform Residents of Their Rights Annually
Penalty
Summary
The facility failed to inform residents of their rights and the rules and regulations governing resident conduct and responsibilities on a yearly basis, both orally and in writing, in a language that the residents understood. This deficiency was identified through a review of Resident Council meeting minutes, a Resident Council meeting, and staff interviews. The review of the past 12 months of Resident Council meeting minutes revealed that resident rights were not discussed. During a Resident Council meeting, residents confirmed that their rights had not been discussed since their admission. The Director of Social Services (DoSS) admitted that she had not discussed resident rights with the residents since her employment at the facility and was unaware of any such discussions prior to her tenure. Similarly, the Director of Nursing (DON) acknowledged that she did not recall any staff members discussing resident rights with the residents during her multiple years of employment at the facility.
Failure to Post Survey Results Notice
Penalty
Summary
The facility failed to post notice of the availability of the most recent survey results in areas that were prominent and accessible to the public. During a resident council meeting, residents expressed that they were unaware of their right to view the most recent state survey results and did not know where these results were located within the building. A subsequent facility walk-through confirmed the absence of signage regarding the availability of the survey results. The former Interim Administrator acknowledged the lack of a posted notice for residents and visitors to review the survey results.
Failure to Provide Required Medicare Notices
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) form to two residents during the annual survey process. Resident #218 began receiving Medicare Part A skilled services on September 5, 2024, with the last covered day being October 16, 2024. Similarly, Resident #317 started Medicare Part A skilled services on October 17, 2024, with the last covered day on October 22, 2024. There was no evidence that the SNF ABN form was provided to either resident, as confirmed by the Interim Administrator during an interview on February 19, 2025. Additionally, the facility did not provide the required Notice of Medicare Non-Coverage (NOMNC) letter to Resident #318. This resident began Medicare Part A skilled services on January 17, 2022, with the last covered day being February 5, 2025. The Interim Administrator stated on February 20, 2025, that the facility was unable to verify that the NOMNC form was given to Resident #318. This failure placed residents at risk of not being informed of their rights prior to the end of Medicare Part A covered services.
Failure to Inform Residents of Grievance Filing Procedures
Penalty
Summary
The facility failed to adequately inform residents of their right to file grievances, both orally and in writing, including the option to file anonymously. During a resident council meeting, residents expressed awareness of the ability to file grievances with the social worker but were unaware of how to file anonymously. A subsequent walk-through with the Administrator confirmed the absence of grievance forms and posted signs indicating the option for anonymous grievance filing. This deficiency was identified through interviews and observations involving multiple residents, highlighting a lack of proper communication and resources regarding grievance procedures.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from resident-to-resident abuse, as evidenced by multiple incidents involving a particular resident. This resident was involved in several altercations, including pushing another resident in a wheelchair, resulting in a fall and injuries, and making verbal threats to a resident's family. The resident also attempted to hit another resident, causing red marks, and was involved in further physical altercations, including hitting and kicking other residents. These incidents were documented through record reviews and staff interviews, indicating a pattern of aggressive behavior by the resident. The facility's investigations revealed that staff were present during these incidents but were unable to prevent the aggressive actions. In some cases, staff intervened to separate the residents and assess for injuries, but the repeated nature of the incidents suggests a failure to adequately address the resident's behavior. The former Interim Administrator acknowledged the resident's involvement in these altercations, which were substantiated as either verbal or physical abuse. Despite staff interventions, the facility did not ensure a safe environment free from abuse for all residents.
Failure to Implement 1:1 Supervision Policy
Penalty
Summary
The facility failed to complete their self-identified corrective action following a resident-to-resident physical altercation that was verified as abuse. On 12/28/24, Resident #54, who was supposed to be under 1:1 supervision due to a previous incident, was left unsupervised in the dining room. During this time, Resident #54 approached Resident #218 and kicked him in the shin. The Activities Assistant, who was about 20 feet away, intervened by removing the victim and seeking assistance for Resident #54. The investigation revealed that the lack of supervision occurred because the assigned Nurse Aide had gone on break, leading to a communication breakdown. The facility identified the need to retrain staff on the 1:1 Supervision policy to prevent such incidents. However, a review of the facility's training records showed that several staff members, including Nurse Aides, Registered Nurses, and the Director of Social Services, had not been retrained on the policy. These staff members had been assigned to supervise Resident #54 since the incident, indicating a failure to implement the corrective action fully. The former Interim Administrator acknowledged the oversight, noting that evidence of staff training could not be found.
Incomplete Care Plans and Resident Safety Concerns
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in addressing their specific needs. Resident #219's care plan was incomplete, lacking details on activities preferences, nutritional risk due to significant weight loss, and dental issues, despite being edentulous and having met with a VA representative about dentures. The care plan also failed to include interventions for visual impairments, and there was no documented weight for September 2024, which was confirmed by the Regulatory Compliance Advisor. Resident #220's care plan was incomplete regarding anticoagulation therapy, with a goal that lacked a specific timeframe for monitoring signs and symptoms of bleeding. Similarly, Resident #42's care plan did not include monitoring for side effects and behaviors associated with psychotropic medications, despite being prescribed multiple such medications. The care plan also failed to reflect individualized care planning, as the resident was observed to stay in bed all the time and required one-on-one activities, which was not addressed. Resident #54's care plan did not reflect a history of physically aggressive behaviors, despite multiple documented incidents of resident-to-resident altercations. These incidents included physical abuse towards other residents, resulting in injuries such as abrasions and red marks. Additionally, Resident #8's care plan did not address his frequent leaves of absence using an electric wheelchair, and there were inconsistencies in the sign-in/sign-out sheet, with missing signatures and times. The Director of Nursing acknowledged the oversight, and the resident's capacity to make his own decisions was noted, but the care plan did not reflect these activities.
Failure to Follow Care Plans and Physician Orders
Penalty
Summary
The facility failed to provide care to residents based on their comprehensive assessments and in accordance with professional standards and care plans. For Resident #219, there were multiple instances where medication and treatment orders were not followed. This included missed doses of medications such as Synthroid and Sodium Bicarbonate, and treatments like catheter care and wound care. Additionally, the facility did not adhere to the physician's order for monthly weight checks, as there was no documentation of a weight for September 2024. Furthermore, Resident #219's outside medical appointments were rescheduled without documented reasons, and the facility failed to provide transportation as required. Resident #42 was prescribed the antipsychotic medication Seroquel, but the facility did not update the diagnosis to reflect 'dementia with behaviors' as recommended by the pharmacy reviews. Instead, the diagnosis remained as 'anxiety and behaviors,' which was incorrect. This oversight persisted despite multiple recommendations from the pharmacy over several months. Resident #7 expressed a preference to be moved from a recliner back to his bed, but this request was not fulfilled in a timely manner. The resident, who required a mechanical lift for transfers, was left waiting for approximately two hours before being moved. The delay was attributed to the nursing staff's assumption that the resident was scheduled for therapy, which was not an adequate reason for not honoring the resident's request promptly.
Failure to Follow Recipe for Tuna Melt Sandwich
Penalty
Summary
The facility failed to adhere to the corporate recipe for Tuna Melt Sandwiches, as observed during a meal service. On the specified date, the tuna melt served to residents was missing tomato slices, which are a required ingredient according to the corporate recipe. The recipe specifies that each sandwich should include two tomato slices, along with tuna, mayonnaise, bread, and cheese. During an interview, a dietary manager (DM) explained that the omission occurred because the facility ran out of tomatoes. This deviation from the recipe had the potential to affect more than an isolated number of residents, given the facility's census of 64.
Unappealing and Unappetizing Food Served to Residents
Penalty
Summary
The facility failed to provide food that was appetizing and appealing to residents, as observed and reported by both residents and their family members. Resident #20 reported that their lunch sandwich was mushy and microwaved, and the surveyor confirmed the food was unappealing with mushy bread. Additionally, Resident #55's daughter reported that the food served was horrible and unidentifiable. A test food tray provided by the kitchen was observed by the survey team, revealing that the Tuna Melt was unappealing, appearing dry and missing the tomato as per the facility's recipe.
Failure to Offer Bedtime Snacks to Residents
Penalty
Summary
The facility failed to offer bedtime snacks to all residents, as revealed through staff and resident interviews, as well as a resident council meeting. Two residents reported that evening snacks are not offered unless specifically requested or ordered by a physician. An observation of the nutrition room showed limited food items available, including bread, potato chips, lunch cakes, coffee, Kool-Aid, and condiments. During a resident council meeting, concerns were expressed that snacks must be requested rather than being offered proactively. A nurse aide confirmed that snacks are distributed only to those with physician orders, while other residents must ask for them.
Food Service Safety Deficiencies in Kitchen Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. In the kitchen, a cook/aide was seen preparing resident drinks without a beard covering, which he acknowledged and corrected by putting on a beard net. Additionally, a kitchen aide was observed with her hair not fully contained in a hair net during meal preparation, which was acknowledged by the district manager who instructed her to readjust it. Furthermore, improper storage and disposal of food were noted in the walk-in refrigerator, where a large vat of prepared tea was found on the floor, and expired food items, including diced potatoes and pitchers of prepared kool-aid, were stored and subsequently disposed of. Lastly, the district manager was observed improperly disposing of gloves by throwing them on the counter where food was being prepared, acknowledging that the correct practice would be to dispose of them in the trash.
Improper Containment of Kitchen Waste
Penalty
Summary
The facility failed to properly contain kitchen waste in the kitchen waste receptacles. During an initial tour and observation of the kitchen area, a large kitchen trash can was found overflowing, with the lid unable to fit and trash spilling onto the kitchen floor. This trash can was located at the hand washing sink, and trash was observed spilling out of the top of the container and onto the floor. An interview with the District Manager confirmed that the trash should have been contained and emptied from the receptacle.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, which has the potential to affect all residents residing in the facility. An exterminator report dated 11/19/24 revealed findings of cockroaches in the kitchen area. During an interview on 02/19/25, the Maintenance Director (MD) disclosed that no exterminator had serviced the facility since 11/19/24, and the maintenance department had been attempting to exterminate the roaches using boric acid in the remodeled walls. Additionally, an Account Manager (AM) observed roaches in the kitchen area two days prior to the interview. A pest control company serviced the facility on 02/20/25 and returned on 02/26/25 for weekly treatments.
Failure to Maintain Clean PTAC Units
Penalty
Summary
The facility failed to maintain a safe and homelike environment due to issues with the packaged terminal air conditioner (PTAC) units in several rooms. Observations revealed that the PTAC units in rooms #104, #210, #118, #123, and #124 were filled with lint, dirt, and debris. The filters in these units were found to be old, torn, and covered with thick lint. During an interview, the Maintenance Director confirmed that the PTAC units had not been cleaned, nor had the filters been changed, and admitted that there was no cleaning schedule in place for these units. This deficiency has the potential to affect all residents living in the facility, which has a census of 63 residents.
Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, which had the potential to affect all 63 residents residing in the facility. An exterminator report from November 19, 2024, indicated the presence of cockroaches in the kitchen area. However, the Maintenance Director revealed that no exterminator had serviced the facility since that date, and the maintenance department attempted to address the issue using boric acid in the remodeled walls. An Account Manager observed roaches in the kitchen area two days prior to the interview conducted on February 19, 2025. The pest control company eventually serviced the facility on February 20, 2025, and returned for weekly treatments on February 26, 2025. During this treatment, the exterminator confirmed ongoing issues with roaches in the kitchen and service hall areas.
Failure to Serve Meals Simultaneously in Shared Room
Penalty
Summary
The facility failed to promote dignity by not serving meals to residents residing in the same room at the same time. On February 18, 2025, at 12:35 PM, a resident and her roommate were observed in their room during lunch. The roommate had been served a meal and was eating, while the resident was being visited by her husband and had not received her meal. At 1:05 PM, the resident's husband was seen opening her food tray, which he had to request from the staff. He reported that the meal was served late, with the bread of the meatball sandwich being mushy and the food too hot, suggesting it had been microwaved. The resident decided to eat only the meatballs from the sandwich. The husband inquired why his wife was not served at the same time as her roommate, but the staff did not provide an explanation.
Resident Unaware of Hospice Care Reason
Penalty
Summary
The facility failed to inform a resident of the reason they were receiving hospice care. During an interview, the resident expressed that they did not know what hospice was and believed that hospice nurses visited everyone at the facility. The resident was unaware of the specific hospice services being provided to them. A record review revealed that the resident had been admitted to the facility after an acute hospitalization for sepsis due to a urinary tract infection. The physician's admitting note indicated that the resident lacked decision-making capacity and likely had advancing dementia, leading to a hospice consultation. However, a Brief Interview for Mental Status (BIMS) evaluation conducted later showed that the resident's cognition was intact. Interviews with facility staff, including the Director of Social Services (DSS) and the Director of Nursing (DON), confirmed that the resident was unaware of their hospice status. The hospice documents were signed by the resident's Medical Power of Attorney (MPOA), and the admitting diagnosis for hospice was documented as coronary artery disease (CAD). Despite this, there was no documentation in the hospice record that hospice services were explained to the resident. The facility's Administrator and DON both noted that hospice nurses typically explain their services, but in this case, the resident did not understand why they were receiving hospice care.
Failure to Involve Resident in Care Planning Process
Penalty
Summary
The facility failed to notify or include a resident in the development and implementation of their person-centered care plan. The resident expressed a desire to have their medical status re-evaluated, as their physician had documented that they lacked the capacity to make medical decisions. Despite the resident's request for a meeting with facility staff, the interdisciplinary team conducted a care plan meeting with the resident's Medical Power of Attorney (MPOA) without notifying or inviting the resident. This oversight occurred because the staff member responsible for sending notifications was no longer at the facility, and the task was not reassigned. The resident's Brief Interview for Mental Status indicated intact cognition, yet the physician had reservations about the resident's ability to care for themselves. The Director of Social Services confirmed the resident was not informed of the care plan meeting. Additionally, the resident requested a capacity evaluation by another physician, which the current physician agreed to facilitate. The failure to involve the resident in their care planning process constitutes a deficiency in the facility's compliance with regulations regarding resident rights and participation in care planning.
Failure to Support Resident's Ambulation Choices
Penalty
Summary
The facility failed to assess a resident's potential for independent ambulation and did not provide the necessary assistance to support his choices, which is a violation of the resident's right to self-determination. The resident, who was on hospice care with a diagnosis of Atherosclerotic Cardiovascular Disease, expressed a desire to ambulate independently. Despite being classified as independent with no restrictions in his care plan, staff continued to prevent him from ambulating by himself, asking him to sit in his wheelchair instead. Interviews with the Director of Nursing and the Director of Occupational Therapy revealed that the resident had no restrictions, yet he was not referred to therapy services due to his hospice status. The resident requested an evaluation by occupational therapy, which was eventually conducted after the surveyor's intervention. This indicates a failure in the facility's processes to honor the resident's choices and provide appropriate assessments and support for his desired activities.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for a resident, as observed during a long-term care survey. The resident's room, specifically room 210-A, was found to be in disrepair. Observations revealed multiple drywall patches on the right side of the wall, including one large patch approximately the size of a basketball and three smaller patches beside the resident's bed. Additionally, a crack measuring approximately 6 to 8 inches in length was noted in the right corner of the wall. The wall also had nine square drywall patches, each approximately 3 x 3 inches in size. This wall displayed the resident's artwork, pictures, and personal items, which the resident took pride in showing to the surveyor. The Director of Nursing acknowledged the need for painting and caulking in the room and indicated that the maintenance work order system would be updated to address these issues.
Delayed Reporting of Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse within the mandated two-hour window to the appropriate state agencies. This deficiency was identified during a review of nine sampled resident-to-resident altercations. Specifically, an altercation occurred between two residents, Resident #54 and Resident #216, on 12/01/24 at 4:15 PM. The facility notified the Office of Health Facility Licensure and Certification (OHFLAC) promptly at 4:46 PM on the same day. However, the notification to Adult Protective Services (APS) was delayed and not made until two days later, on 12/03/24 at 10:36 AM. During an interview, the former Interim Administrator acknowledged the delay, attributing it to the incident occurring over a weekend and the absence of evidence of the original notification being sent within the required timeframe.
Failure to Revise Care Plan for ADL Assistance
Penalty
Summary
The facility failed to revise the care plan for a resident regarding the level of assistance needed for activities of daily living (ADLs), specifically in bathing. The care plan inaccurately listed the resident as requiring partial/moderate assistance for bathing, while the Minimum Data Set (MDS) quarterly assessment indicated that the resident needed substantial/maximal assistance. This discrepancy was identified during a record review and confirmed in an interview with the Director of Nursing (DON), who acknowledged that the care plan was incorrect and the MDS was accurate.
Failure to Assess and Facilitate Independent Ambulation
Penalty
Summary
The facility failed to assess a resident's potential for independent ambulation and did not provide appropriate treatments and services to maximize the resident's functional abilities. The resident, who has been on hospice care since November 2024 with a diagnosis of Atherosclerotic Cardiovascular Disease, expressed a desire to ambulate independently. Despite his attempts to walk behind his wheelchair, staff consistently stopped him and instructed him to sit in his wheelchair. The resident requested an evaluation by occupational therapy to understand any restrictions on his ambulation. The resident's care plan was updated to classify him as independent with no restrictions on February 11, 2025. However, the resident reported continued restrictions on his attempts to ambulate independently, and no services were offered to facilitate his independence. Interviews with the Director of Nursing and the Director of Occupational Therapy revealed that residents on hospice were not typically referred for therapy services, but the resident's request for therapy evaluation was acknowledged. The Director of Occupational Therapy later confirmed that an evaluation had been conducted and a request for services was submitted.
Failure to Provide Adequate Assistance with ADLs
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living for a dependent resident, identified as Resident #45. During an initial interview, a foul body odor was noted, indicating a lack of proper hygiene care. A review of the resident's Minimum Data Set revealed that the resident required substantial to maximal assistance for bathing. However, documentation showed significant gaps in bathing care, with the resident going multiple days without any form of bathing. Specific instances included a ten-day gap between showers and an eleven-day gap before another shower. There were no documented refusals by the resident, and the Director of Nursing confirmed the absence of further documentation regarding the resident's activities of daily living during this period.
Failure to Provide Hearing and Vision Services
Penalty
Summary
The facility failed to provide adequate hearing care for a resident who was experiencing difficulty with his hearing aids. The resident, who wore hearing aids due to hearing loss, reported to staff that his hearing aids were not functioning properly, which was confirmed by a registered nurse. Despite the resident's complaints and the acknowledgment by staff, there was no immediate action taken to address the malfunctioning hearing aids until the issue was brought to the attention of the Director of Nursing, who then scheduled an evaluation. Additionally, the facility did not provide vision services for another resident who had lost his glasses. Progress notes indicated that the resident's glasses had been missing for several days, and although staff were informed and efforts were made to locate them, no vision services were scheduled to replace the lost glasses. The Interim Administrator was unaware of the issue, indicating a lack of communication and follow-up regarding the resident's vision needs.
Failure to Ensure Environment Free from Accident Hazards
Penalty
Summary
The facility failed to maintain an environment free from accident hazards, as evidenced by the presence of an opened box containing a 2.5 fluid oz. bottle of maximum strength Aspercreme with Lidocaine in a resident's bathroom. The resident reported that a nurse had informed them that the product would help with back pain. However, there was no physician order authorizing the resident to self-administer medication, nor was there a physician order for the Aspercreme with Lidocaine. The Material Safety Data Sheet (MSDS) for the product indicated that it is not intended for oral consumption or ophthalmic use and may cause irritation if inhaled, ingested, or in contact with skin or eyes. The Director of Nursing (DON) confirmed the presence of the product in the resident's room without supporting physician orders and acknowledged that it should be removed.
Inappropriate Pain Management Administration
Penalty
Summary
The facility failed to provide pain management in accordance with professional standards of practice for a resident. The resident had a physician's order for Norco, a controlled drug, to be administered as needed for a pain scale of 5-10. However, the Medication Administration Record for December 2024 showed that Norco was administered on multiple occasions when the resident's pain level was rated below the prescribed threshold. Specifically, Norco was given when the resident's pain level was rated as 0 on two occasions and as 2 and 3 on two other occasions. During an interview, the Director of Nursing acknowledged that Norco should not have been administered outside the parameters of the physician's order.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for a resident diagnosed with post-traumatic stress disorder (PTSD). The deficiency was identified during a survey when it was observed that the resident's care plan included a focus area for PTSD-related mood symptoms, yet there was no documentation in the medical record to confirm the diagnosis. Despite the resident exhibiting behaviors consistent with PTSD, such as believing people were coming through mirrors and windows, there was no evidence of the resident receiving appropriate services or counseling for PTSD. Interviews with staff, including the Director of Rehabilitation Services and the Corporate Registered Nurse, revealed a lack of documentation and understanding of the resident's PTSD diagnosis. The Director of Rehabilitation Services acknowledged the resident's PTSD symptoms, while the Corporate Registered Nurse confirmed the absence of any PTSD-related information in the resident's medical record. The facility's failure to document and address the resident's PTSD needs resulted in inadequate care planning and services for the resident.
Inaccurate Daily Nursing Staffing Information
Penalty
Summary
The facility failed to ensure the daily nursing staffing information was accurately posted for three days during the long-term care survey process. Observations on February 18 and 19, 2025, revealed that the required resident census was not documented, and the staffing data was outdated, having been printed on February 12, 2025, without reflecting any changes to the scheduled staff levels. Additionally, a review of previous postings on several dates, including July 7, August 18, September 22, December 21 and 22, 2024, and January 24 and 25, 2025, showed that the postings were printed prior to the date of posting and did not include updates to the scheduled staff levels. During an interview on February 22, 2025, the Interim Administrator confirmed that the census was not documented and the staffing levels were not updated to reflect accurate levels.
Failure to Provide Routine Dental Care
Penalty
Summary
The facility failed to provide routine dental care for Resident #219, who was identified as edentulous upon admission. Despite a progress note from a regulatory visit indicating that the resident had met with a Veteran's Administration representative about obtaining dentures, no dental appointments were scheduled for the resident. This deficiency was confirmed by the Director of Nursing during an interview, acknowledging the lack of scheduled appointments to address the resident's dental needs.
Incomplete Medical Record for Anticoagulation Therapy
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident receiving anticoagulation therapy. During a record review, it was discovered that a physician's order for Warfarin (Coumadin) 3mg to be administered orally in the evening was missing a diagnosis for its use. This oversight was confirmed by the Administrator, indicating a lapse in ensuring that the resident's medical records were in accordance with accepted professional standards. The deficiency was identified for one resident under the care area of anticoagulation, within a facility with a census of 64 residents.
Infection Control Deficiency: Catheter Bag on Floor
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by repeated observations of a resident's urinary catheter bag being placed directly on the floor. This deficiency was observed on three separate occasions on the same day, with the catheter bag of Resident #59 found lying on the floor without any receptacle or barrier. During an interview, an LPN confirmed that the catheter bag should not be on the floor and subsequently took action to address the issue by instructing a nurse aide to retrieve a receptacle for the catheter bag.
Delayed CPR Initiation Due to Lack of Code Status Documentation
Penalty
Summary
The facility delayed initiating Cardiopulmonary Resuscitation (CPR) for a resident who was found unresponsive with no pulse or respirations. The resident's medical record did not contain documentation of their code status or advance directives, which led to confusion among the staff about whether to initiate CPR. The standard of care dictates that in the absence of an advance directive, CPR should be administered. However, CPR was not initiated until 34 minutes after the resident was found unresponsive. The incident involved a resident with multiple medical conditions, including noninfective gastroenteritis, type 2 diabetes mellitus, and a malignant neoplasm of the esophagus. The resident was found unresponsive by a Certified Nursing Assistant (CNA) at approximately 6:45 AM, and the staff noted that the resident was still warm to the touch. Despite this, the Registered Nurse (RN) on duty did not initiate CPR immediately, citing uncertainty about the resident's code status and waiting for instructions from the Director of Nursing (DON). The delay in initiating CPR was compounded by the lack of a Physician Order for Scope of Treatment (POST) form in the resident's medical record. The RN on duty attempted to contact the resident's next of kin and the attending physician but did not proceed with CPR until instructed by the DON at 7:19 AM. Emergency medical personnel arrived shortly after and took over the code, but the resident was pronounced dead at 7:55 AM.
Removal Plan
- The Director of Nursing (DON/Designee) conducted an audit for all residents to ensure all residents had a code status listed in the Physician Orders.
- The DON conducted an audit for all licensed nursing staff including any non-licensed nursing personnel to validate their current Cardiopulmonary Resuscitation (CPR) certification with corrective action immediately upon discovery.
- Re-education was provided by the DON/Designee to all licensed nurses to ensure if there is no order for code status in the resident chart the resident is considered a full code and CPR to be initiated and documented on the CPR/AED flow sheet with a posttest to validate understanding.
- Any licensed nurses not available during this time frame will be provided re-education, including post-test during orientation by the DON/Designee.
- The unit managers (UM)/designee will monitor new admission/readmissions and/or change in resident advance directives order to ensure the resident has an order for code status and the CPR/AED flowsheet is utilized for all CPR daily including weekends and holidays, then five times a week, then three times a week then randomly thereafter.
- The nurse Practice Educator (NPE)/designee will conduct mock code drill daily across all shifts, then weekly, then monthly, then randomly thereafter.
- Results of monitors will be reported by the Director of Nursing (DON)/designee to the Quality Improvement Committee (QIC) for any additional follow up and or in servicing until the issue is resolved, then randomly thereafter as determined by the QIC committee.
Deficiency in Staff Training on Dementia and Abuse Prevention
Penalty
Summary
The facility failed to ensure that its staff training on abuse and neglect included specific components related to dementia management and resident abuse prevention. This deficiency was identified through a review of the training records of five nurse aides, all of whom had received training titled 'Protecting residents from assault and abuse' for a total of 40 minutes. However, the learning objectives for this training did not cover dementia management or resident abuse prevention, which are critical components for ensuring the safety and well-being of residents, particularly those with dementia. The nurse aides involved had varying hire dates, ranging from 2000 to 2022, and their training records were reviewed for the period from January 1, 2023, to December 31, 2024. Despite the training they received, the absence of specific content on dementia management and abuse prevention was consistent across all reviewed records. This oversight was confirmed during an interview with the Clinical Advisor and the assisting Nursing Home Administrator, indicating a systemic issue in the facility's training program that could potentially affect a significant number of residents.
Failure to Conduct Timely Performance Evaluation for Nurse Aide
Penalty
Summary
The facility failed to ensure that Nurse Aide (NA) #14 had a performance evaluation completed every 12 months as required. This deficiency was identified during a review of five nurse aide files, where it was found that NA #14, hired on February 8, 2022, did not have a performance evaluation on record. The absence of this evaluation was confirmed by Clinical Advisor #22, who attributed the oversight to the Director of Nursing (DON) being on leave. This lapse in procedure had the potential to affect more than an isolated number of residents, given the facility's census of 62.
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 136 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Grafton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Taylor Healthcare Center | 0.8 mi | ★★★★★ | 5 | 0 |
| Maplewood Healthcare Center | 10.1 mi | ★★★★★ | 8 | 0 |
| Fairmont Rehabilitation And Healthcare Center Llc | 10.9 mi | ★★★★★ | 0 | 0 |
| United Transitional Care Center | 11 mi | ★★★★★ | 0 | 0 |
| Majestic Care Of Manchin | 11.3 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.