Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 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 The Legacy Living And Rehabilitation Center during CMS and state inspections, most recent first.
Transfer notices for several residents did not include a specific reason for the acute-care transfer. Records showed residents with events such as unwitnessed fall, low O2 sat, emesis, respiratory distress, and suspected aspiration were sent to the ER, but the notices only stated that needs could not be met in the facility and welfare was impacted. For one resident, no discharge notice was found after the hospital transfer, and the ADM confirmed the notices did not include a specific reason.
Failure to supervise residents with dementia and wandering behaviors. A resident with severe cognitive impairment and food scavenging behaviors was observed taking food from a dirty dish bin, licking dishes, and handling another resident’s plate while staff were not present or did not intervene fully. Another resident with severe cognitive impairment and exit-seeking behavior was observed wandering into another resident’s room and later attempting to open an exit door with no staff present in the area; staff said they relied on knowing behavior patterns and had limited ability to monitor residents when multiple staff were needed elsewhere.
Failure to allow a resident to return after bed-hold expired. After an unwitnessed fall, the resident was transferred to the ER with A&Ox1 status, decreased LOC, abnormal pulse, clammy skin, and incontinence. While the resident remained hospitalized beyond 30 days, staff documented that bed-hold had expired, return rights were lost, and readmission was declined because the facility was not accepting admissions. No discharge notice was found in the record, and the admin confirmed the resident was not allowed back despite available beds.
A resident with depression and a psychotic disorder had a prior PASARR Level I that found no psychiatric diagnosis or evidence of mental illness. After a new diagnosis of psychotic disorders with hallucinations related to a physiological condition was added, the facility did not complete the PASARR II, and the NHA confirmed the issue during interview.
Failure to provide resident-preferred activities: A cognitively intact resident with documented interests in cribbage, music, westerns, and reading said staff did not offer choices and would not play cards with him/her, leaving the resident to wait for family visits to play. Records showed limited 1:1 activity documentation, no evidence the resident’s preferences were included, no card games on the activity calendar, no documented group activity participation or refusals, and no updated activity assessment. The AD confirmed card games were not scheduled and the resident was not assisted to join card-playing groups.
A resident with severe cognitive impairment, Alzheimer's Disease, and dementia had a care plan identifying fall risk and poor safety awareness, yet staff interviews and record review showed the resident fell in the dining room after trying to climb over a chair arm when unable to move the chair back. The resident also had prior falls while attempting to ambulate on his/her own, including one with an untied shoelace and another unwitnessed fall in the dining room.
Two cognitively intact residents experienced repeated mental abuse and sexual harassment from another resident, including exposure and inappropriate propositions, with staff present during at least one incident but failing to intervene. The facility did not revise care plans or implement required assessments for the resident exhibiting aggressive behavior, contrary to policy.
Failure to Report Abuse Allegations and Investigation Findings: The facility did not report abuse allegations and investigation findings to the State Survey Agency for 3 residents. Records showed one resident reported another resident made an inappropriate sexual request at breakfast, another resident reported genital touching before lunch and said they did not feel safe, and a third resident alleged exposure of genitals but later gave an uncertain account and said they felt safe. The incident database showed no reports for these events, and the administrator and DON confirmed the reporting failure.
Failure to Investigate Abuse Allegations: The facility did not thoroughly investigate abuse allegations involving two residents. One resident was accused by another resident of inappropriate sexual behavior at breakfast, and another resident reported that a peer exposed genitals and 'flashed' him/her. Staff interviews and documentation showed the allegations were not reported to the state survey agency and no facility incident investigation was completed.
Inadequate Care Planning for Dementia-Related Sexual Behaviors: A resident with severe cognitive impairment, dementia, and a Foley catheter repeatedly made sexually explicit comments and gestures toward staff and other residents, including asking others to touch the resident's genitals and entering another resident's doorway while exposing and grasping the genital area. Notes showed the resident was often only educated or redirected, while interviews confirmed the resident's behavior was ongoing and upsetting to other residents. The DON and administrator confirmed the behavior care plan was not fully developed for the resident's behaviors or facility interventions.
Multiple residents with severe cognitive impairment and behavioral challenges were involved in physical altercations, resulting in injuries such as a hematoma, abrasion, skin tear, and bruising. The incidents occurred when one resident followed others into a suite and was pushed, and when another resident entered a room uninvited, leading to a struggle. Insufficient supervision and ineffective implementation of care plan interventions contributed to the failure to prevent these incidents.
Several residents with severe cognitive impairment and behavioral challenges were involved in unwitnessed altercations, resulting in minor injuries, after one resident entered another's room and another was pushed to the floor. Both incidents occurred during a period of increased activity and insufficient supervision, despite care plans identifying risks and the need for staff intervention.
A facility failed to report an allegation of drug toxicity or overdose for a resident who was found unresponsive and later pronounced deceased. Despite being aware of the allegation, the facility did not report it to the state survey agency, as they believed a previous report was sufficient, although it did not include the specific allegation.
A resident with severe cognitive impairment and a history of wandering exited a facility unnoticed and was found deceased outside after over nine hours in winter conditions. Despite door alarms sounding, staff failed to check outside, violating protocols for monitoring high-risk residents.
A resident with Alzheimer's disease and severe cognitive impairment exited a facility unnoticed and was found deceased after being outside in freezing temperatures for over nine hours. The facility failed to provide adequate supervision and did not respond properly to door alarms, leading to the resident's unsupervised exit and death.
A resident with multiple health conditions expressed concerns about having pneumonia and a heart attack, requesting to be sent to the hospital. Despite these complaints and unusual symptoms, the nursing staff did not notify the physician or take appropriate action, leading to the resident's death. The nurse responsible was terminated for failing to respond to the resident's needs.
A resident with severe cognitive impairment was neglected and abused by CNAs in an LTC facility. Surveillance showed a CNA neglecting the resident for 13 hours, while another CNA was caught on video verbally and physically abusing the resident. The resident expressed fear about calling for help after these incidents.
The facility failed to protect residents from abuse by other residents, resulting in harm to three residents. One resident experienced sexual abuse on two occasions, another resident was physically abused resulting in bruising and skin tears, and a third resident was pushed, resulting in a fall and head injury. The facility's documentation and follow-up on these incidents were inadequate.
A facility failed to provide appropriate treatment and services for a resident with dementia, resulting in multiple incidents of aggressive behavior, wandering, and incontinence. Despite severe cognitive impairment and documented behavioral issues, the facility did not develop a comprehensive care plan or analyze behavior triggers, leading to actual harm.
The facility failed to monitor temperatures for six refrigerator/freezers storing food for resident use, with internal temperatures often exceeding the recommended 40 degrees Fahrenheit. Additionally, a cook did not perform proper hand hygiene after handling raw hamburger patties, and had not completed the required Serve Safe certification. These actions were not in compliance with the facility's policy and the 2022 FDA Food Code.
The facility failed to ensure mail was delivered to residents on Saturdays. Seven residents reported that the transportation aide, who was previously responsible for Saturday mail delivery, informed them that this service would no longer occur. The DON confirmed the transportation aide's responsibility for weekend mail delivery, and the aide confirmed that mail had not been delivered on Saturdays for about four months.
The facility failed to ensure a safe and homelike environment in the Pine unit, as residents from the Cottonwood unit frequently wandered into the Pine unit, causing disturbances and safety concerns. Staff and family members reported increased behavioral issues, missing items, and resident altercations. Despite grievances, the facility did not adequately address the concerns, leaving Pine residents and their families worried about safety.
The facility failed to provide food service at safe and appetizing temperatures, with issues such as incorrect serving scoops, insufficient food, and delays in meal service. Residents complained of cold, dry, burnt food, and warm drinks. The dietitian confirmed the need for education to dietary aides to improve efficiency.
The facility failed to ensure advance directives were properly formulated for two residents, leading to discrepancies between physician orders and the residents' Cardiopulmonary Resuscitation Directives. Staff interviews revealed inconsistencies in how advance directives were determined.
The facility failed to report an allegation of abuse involving a resident with severe cognitive impairment and Alzheimer's disease. The incident, where another resident had their hand down the resident's pants, was not followed up on or reported to the state licensing division as required by facility policy.
The facility failed to investigate an allegation of abuse involving a resident with severe cognitive impairment and diagnoses including Alzheimer's disease and depression. Despite documentation of the incident, the facility did not follow up, and the DON and ADON were initially unable to identify the involved resident. It was later confirmed that the allegation had not been investigated or reported to the state licensing division as required.
The facility failed to ensure a discharge notice included care and services for a resident which should not or cannot be provided by the facility. The family was involved in inappropriate wound care, refused pain management, and made medical decisions without informing the facility. The facility issued a 30-day discharge notice, and the family felt it was in retaliation for filing a grievance. The DON confirmed the facility could meet the resident's care needs, but the family's requests were against the resident's wishes.
The facility failed to ensure accurate MDS assessment information for a resident, incorrectly coding them as taking an antibiotic despite no evidence of a prescription in their medical records. The MDS coordinator confirmed the error.
The facility failed to ensure a PASARR level II was performed for a resident who had a PASARR level I indicating the need for a level II. The resident had diagnoses including PTSD and major depressive disorder, and the DON confirmed the PASARR level II was not requested at the time of admission.
The facility failed to develop comprehensive person-centered care plans for three residents with severe cognitive impairments. One resident's care plan did not specify hypersexual behaviors, another's did not address the use of an antianxiety medication, and a third's lacked an analysis of triggers for physical aggression.
A resident with severe cognitive impairment and multiple diagnoses did not receive prescribed antibiotics on four occasions due to delays in medication delivery and failure to utilize available alternatives in the pyxis emergency inventory.
The facility failed to ensure a safe environment for two residents with severe cognitive impairments, leading to multiple incidents including altercations, ingestion of harmful substances, and inadequate supervision. Despite being identified as requiring constant supervision, the residents were observed wandering and engaging in unsafe behaviors. The facility did not develop effective interventions to ensure their safety.
The facility failed to ensure proper handling of urinary Foley catheter bags to prevent urinary tract infections for a resident with neurogenic bladder and a history of urinary tract infection. A CNA was observed lifting the catheter bag above the resident's waist, causing urine to flow back toward the bladder, contrary to facility policy.
The facility failed to follow enhanced barrier precautions for a resident with an indwelling catheter and a urinary tract infection. Staff did not wear gowns and gloves as required, improperly managed the urinary catheter, and did not post the necessary signage indicating the precautions.
Transfer Notices Lacked Specific Reasons
Penalty
Summary
The facility failed to ensure transfer and/or discharge notices included the reason for transfer or discharge for 4 of 5 sampled residents reviewed for transfer and discharge. Medical record review and staff interview showed that transfer notices for residents #1, #3, #77, and #79 stated only that the residents were being transferred to an acute care facility because their needs could not be met in the facility and their welfare was impacted, without a specific reason for the transfer. The facility administrator confirmed in interview that the transfer notices provided to the residents or their representatives did not include a specific reason for the transfer to acute care. For resident #79, the record showed an unwitnessed fall with decreased level of consciousness, abnormal pulse, clammy skin, and incontinence, followed by transfer to the ER. A notice of transfer was issued, but the record contained no evidence that a discharge notice was issued after the acute care transfer. Progress notes also documented discussion with the POA about bed-hold status, Medicaid pending status, and that the resident had been out of the facility beyond 30 days, with staff stating the resident was no longer on bed hold and had lost return rights. For resident #77, the record documented severe oxygen desaturation after the resident removed oxygen, coughing after being given a drink, and transfer to the ER after the NP gave permission to send the resident if family could not be reached. For resident #1, the record documented repeated emesis, respiratory distress, tachypnea, low oxygen saturation, suspected aspiration, and transfer to the ER after an order from the on-call provider. For resident #3, the record showed a notice of transfer to acute care, but the notice did not include a specific reason for the transfer.
Failure to Supervise Residents With Dementia and Wandering Behaviors
Penalty
Summary
The facility failed to ensure residents with dementia received appropriate treatment and services to attain their highest practicable physical, mental, and psychosocial well-being for 2 of 8 residents reviewed. Resident #63 had severe cognitive impairment with a BIMS score of 2, diagnoses including non-traumatic brain dysfunction, non-Alzheimer's dementia, and anxiety, and a care plan addressing wandering into other residents’ rooms and scavenging for food. Observations showed the resident took a dish from a dirty dish bin and licked it while food dripped onto the shirt, ate food chunks from the dirty dish bin when no staff were present, and removed another resident’s plate and placed it in the dirty dish bin before licking the fingers clean. During one of these events, a CNA did not prevent the resident from licking the hands or provide hand hygiene. A progress note also documented three resident-to-resident altercations in the same month and stated current care planning, supervision, environmental controls, and/or behavioral interventions may not be sufficient to prevent recurrence, but there was no evidence the effectiveness was re-evaluated. Resident #37 had severe cognitive impairment with a BIMS score of 5, diagnoses including non-traumatic brain dysfunction, Alzheimer's disease, and depression, and was identified as an elopement risk with wandering and exit-seeking behaviors. The care plan included monitoring location, documenting wandering behavior, and attempting diversional interventions. However, a prior alert note showed the resident wandered into another resident’s room and upset that resident, with no evidence of evaluation of interventions or behavior triggers. Another observation showed the resident at the exit attempting to open the door while four other residents were in the dining/living area, and no staff were present at that time. Staff interviews indicated they relied on knowing residents’ behavioral patterns, that staffing limitations affected their ability to watch other residents when two or more staff were needed elsewhere, and that there was no wander guard in use on the locked unit.
Failure to Allow Return After Bed-Hold Expired
Penalty
Summary
The facility failed to ensure that a resident whose hospitalization exceeded the bed-hold period under the State plan was allowed to return to the facility. After an unwitnessed fall, the resident was assessed as alert and oriented times 1 with slightly decreased level of consciousness, abnormal pulse on the left wrist, clammy skin, and incontinence at the time of the fall, and the on-call provider approved transfer to the emergency room. A transfer notice was issued stating the resident’s needs could not be met in the facility and that welfare was impacted. During the hospital stay, staff documented that the resident had been out of the facility greater than 30 days, was no longer on bed hold, and would require a new admission because the facility was not currently taking admissions. Another note stated the resident remained continuously inpatient beyond 30 days, the bed-hold had expired, the resident had lost return rights, and readmission was declined because the resident was considered a new admission. The medical record contained no evidence that a discharge notice was issued after the acute care transfer, and the administrator confirmed the resident was not allowed to return because the facility treated the case as a readmission and was not accepting admissions, even though available beds existed when the resident was ready to return.
PASARR Not Completed After New Psychosis Diagnosis
Penalty
Summary
The facility failed to ensure pre-admission screening was completed after a resident developed a new diagnosis of mental illness. Review of the annual MDS for resident #6 showed diagnoses including depression and psychotic disorder (other than schizophrenia). The PASARR Level I assessment completed on 3/8/21 stated the resident did not have a psychiatric diagnosis and did not present evidence of mental illness, including a possible disturbance in orientation, affect, or mood not attributable to dementia or another medical diagnosis. The medical record later showed a new diagnosis of psychotic disorders with hallucinations due to a known physiological condition was entered on 9/5/25. During interview, the NHA stated the resident had a new diagnosis of psychosis related to urinary tract infections that did not trigger the initial PASARR, and confirmed the PASARR II should have been completed.
Failure to Provide Resident-Preferred Activities
Penalty
Summary
The facility failed to ensure individual activities of preference were provided for a resident who had a BIMS score of 14 out of 15, indicating cognitive intactness, and whose activity assessment identified interests including team roping and cribbage. The resident’s activity care plan also listed preferences such as listening to music while bathing, watching westerns and the news, reading mystery and action books, and playing cribbage. The resident stated s/he did not feel offered choices and wanted to play cards, but staff would not play with him/her, and s/he had to wait for family visits to play cards. The resident also reported not participating in other activities because of decreased mobility. Record review showed the resident participated in 1:1 activities only on a few dates, with no evidence those activities included the resident’s stated preferences or that cards were offered or played with the resident. There was also no evidence of any activity assessment completed since the prior assessment, no card game activities on the activity calendars reviewed, and no documentation that the resident was offered, refused, or participated in group activities or activities identified as interests on the activity assessment. The activity director confirmed card games were not on the calendar, that the resident was not assisted to play cards with groups, and that staff should document refusals. The activity director and administrator also confirmed that 1:1 activities were not being completed as they should be and that the activity assessment had not been completed since the prior assessment.
Failure to Provide Adequate Supervision to Prevent Falls
Penalty
Summary
The facility failed to ensure adequate supervision was provided to prevent resident injuries for one resident with severe cognitive impairment and poor safety awareness. The resident had a BIMS score of 0 and diagnoses of Alzheimer's Disease and Non-Alzheimer's Dementia. The care plan identified the resident as being at risk for falls related to dementia and poor safety awareness, and a risk management note documented that the resident had poor impulse control and a desire to clean and tidy immediate areas. Staff interviews and record review showed the resident was in the dining room sitting at the end of a long table with the chair pushed up to the table. The resident attempted to move the chair, could not get back far enough, climbed over the arm of the chair, and fell to the floor; one staff member stated she was not close enough to assist. Another staff member reported the resident tried to step over the arm of the chair and fell because the resident could not lift the leg high enough to clear it. The resident also had prior falls, including a witnessed fall in the living room while attempting to ambulate on his/her own with an untied shoelace and an unwitnessed fall in the dining room while attempting to ambulate on his/her own.
Failure to Protect Residents from Mental Abuse by Peer
Penalty
Summary
The facility failed to protect residents from mental abuse by another resident, as evidenced by multiple incidents involving inappropriate sexual behavior and harassment. One cognitively intact resident with a history of non-traumatic brain dysfunction, cerebral palsy, anxiety disorder, depression, and bipolar disorder reported that another resident exposed their genitalia and made inappropriate requests in a common area. The affected resident expressed feeling unsafe and fearful due to repeated unwanted advances, including gestures that were perceived as threatening, though no physical contact occurred. Another cognitively intact resident with medically complex conditions reported a similar incident where the same resident entered their room, grasped their own genitals through their pants, and made sexually suggestive comments. This resident also reported previous inappropriate propositions from the same individual in the dining room and noted that other residents had experienced similar behavior but were unwilling to speak up. Staff were reportedly nearby during at least one incident but did not intervene at the time. The facility's policy required assessment and care plan revision in response to resident aggression, but these measures were not implemented for the resident involved in the incidents.
Failure to Report Abuse Allegations and Investigation Findings
Penalty
Summary
The facility failed to ensure allegations of abuse and the findings of investigations were reported to the State Survey Agency for 3 of 6 residents reviewed for abuse allegations. A progress note for one resident documented that another resident reported being told during breakfast that the resident wanted to touch the other resident’s genitals, and staff told the other resident to alert staff if it happened again. An incident report for a second resident documented that the resident reported another resident had touched the resident’s genitalia before lunch, and the resident told the other resident to go away and later told the unit manager the resident did not feel safe. A third resident’s progress note documented that the resident stated another resident exposed his or her genitals, but the social worker’s follow-up noted the resident was uncertain about where or when it occurred, stated no one else was around, and repeatedly said the resident felt safe and was not afraid. Nursing staff stated the resident had been told a negative story about the accused resident and that no staff or residents witnessed any incident. Review of the State Survey Agency incident database showed no evidence that the incidents involving these 3 residents were reported, and the administrator and DON confirmed the allegations and investigation findings were not reported.
Failure to Investigate Abuse Allegations
Penalty
Summary
The facility failed to ensure allegations of abuse were thoroughly investigated for 2 residents. For resident #9, a CNA documented that another resident reported #9 was being inappropriate at breakfast and had asked the other resident to touch his/her genitals. The note showed the other resident was told to alert staff if it happened again, but the allegation was not reported to the state survey agency and there was no evidence of a facility investigation in the incident records. For resident #41, a late-entry progress note documented that the resident reported a male/female resident exposed his/her genitals and had 'flashed' him/her. Social work and nursing staff interviewed the resident and other staff, and the documentation stated the resident was uncertain about where or when it occurred, denied fear of the accused resident, and staff believed the accusation was based on a story heard from another resident. The administrator and DON confirmed the allegation was not investigated, and review of the state survey agency incident database and facility incident records showed no evidence that the allegation was reported or investigated.
Inadequate Care Planning for Dementia-Related Sexual Behaviors
Penalty
Summary
The facility failed to ensure a resident with dementia received treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Resident #9 had severe cognitive impairment on the annual MDS, diagnoses of non-Alzheimer's dementia and unspecified dementia with psychotic disturbance, and a Foley catheter in place. The care plan identified a behavior risk related to sexually suggestive comments to other residents, often associated with the catheter, and included limited interventions such as cutting paper, anticipating needs, and assisting the resident to develop more appropriate methods of coping and interacting. The record showed repeated incidents in which the resident made sexually explicit comments and gestures toward staff and other residents over many months. Documentation included statements about wanting someone to "play with" the resident's genitals, touching the resident's own genital area in public settings, asking staff and residents to touch the resident's genitals, and entering another resident's doorway while grasping the resident's genitals and asking to "play house." Other notes described the resident being educated, redirected, or laughed at the education, but the behaviors continued. One incident report showed another resident reported being touched by Resident #9 and stated feeling unsafe, and another resident reported an embarrassing encounter after the resident entered the room and made sexual comments. Interview with the administrator and DON showed the resident spent much of the day in the facility, liked to visit and watch activities, and was not well liked by other residents because of intrusive behavior. They stated the facility had offered counseling, alone time, magazines, spouse contact, and activities, and that issues occurred more often when the resident had blood in the urine or urinary obstruction pain. The administrator and DON later confirmed the resident's care plan was not fully developed for the resident's behaviors or facility interventions. The facility abuse policy stated that when a resident experiences a behavior change resulting in aggression toward other residents, the facility conducts further assessment, notifies the physician/NP, and revises the care plan to include new approaches to reduce or eliminate further chance of abuse.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect multiple residents from physical abuse during a series of resident-to-resident altercations. One incident involved a resident with severe cognitive impairment and a history of wandering and entering others' personal space, who was pushed to the ground by another resident after following them into their suite. This resulted in the resident sustaining a hematoma above the left eyebrow and an abrasion under the left eye. The care plan for this resident had identified the risk of harm from others due to cognitive deficits, but interventions to prevent such incidents were not effectively implemented at the time of the altercation. Another incident involved a resident with severe cognitive impairment and anxiety who experienced distress when another resident entered their room without permission. The two residents were found on the floor kicking at each other after one entered the other's room, resulting in minor injuries including a skin tear, bruise, and scratch. The care plan for the resident who was protective of personal space included interventions to redirect other residents, but these measures were not sufficient to prevent the altercation. Staff interviews and documentation revealed that the facility was undergoing a transition that increased resident agitation and led to a rise in resident-to-resident incidents. The root cause was identified as insufficient supervision throughout the unit, which contributed to the failure to prevent these altercations. The lack of timely staff intervention allowed the incidents to escalate, resulting in actual harm to at least one resident.
Failure to Prevent Resident-to-Resident Altercations Due to Insufficient Supervision
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for four residents involved in two unwitnessed resident-to-resident altercations. In one incident, a resident with severe cognitive impairment, non-traumatic brain dysfunction, Alzheimer's disease, and a history of wandering entered another resident's room. The second resident, also with severe cognitive impairment, Alzheimer's disease, Parkinson's disease, and anxiety, became agitated, resulting in both residents being found on the floor kicking at each other. Both sustained minor injuries, including a skin tear and bruising. The incident was unwitnessed, and the resident who was entered upon had a care plan indicating significant anxiety about others entering their room, preferring the door open but being highly protective of personal items. In another event, a resident with severe cognitive impairment and a history of being close to others was found on the floor near another resident's room. The second resident, also with severe cognitive impairment, hallucinations, delusions, and a history of verbal and physical behaviors, admitted to pushing the first resident, stating the other had been annoying. The incident was not witnessed by staff, and the resident who was pushed did not sustain injuries. Both residents had care plans identifying risks related to proximity to others and potential for physical aggression, with interventions to redirect and separate them as needed. The facility was undergoing a transition from two secure units to one, which increased resident activity and contributed to a rise in resident-to-resident incidents. Staff interviews and documentation revealed that insufficient supervision throughout the unit was identified as a root cause of these incidents. The lack of adequate staff presence and monitoring allowed for unwitnessed altercations to occur, despite existing care plans outlining the need for supervision and redirection for residents with behavioral challenges and cognitive impairments.
Failure to Report Allegation of Drug Toxicity
Penalty
Summary
The facility failed to report an allegation of drug toxicity or overdose for a resident, which was a reasonable suspicion of a crime. The resident, who was cognitively intact and had multiple diagnoses including heart failure, hypertension, and diabetes mellitus, was found unresponsive and later pronounced deceased. A newspaper article indicated that the police were investigating the death as a potential overdose of a prescription medication. Despite being aware of this allegation, the facility did not report it to the state survey agency. Interviews with the resident's physician and nurse practitioner confirmed their awareness of the drug toxicity allegation. The Director of Nursing and the administrator acknowledged that the facility had initiated an investigation but did not report the specific allegation of drug toxicity or overdose, as they believed a previous report surrounding the resident's death was sufficient. However, the previous report did not include the specific allegation of drug toxicity or overdose.
Neglect Leads to Resident's Death Due to Elopement
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in the resident's death. The resident, who had severe cognitive impairment and a history of exit-seeking behavior, exited the facility unnoticed and was outside in winter conditions for over nine hours. The resident was dependent on staff for various activities of daily living and had a care plan indicating the need for close supervision due to wandering behaviors. On the night of the incident, staff on the Cottonwood unit were unable to locate the resident at approximately 4 AM. A search was initiated, and the resident was found outside without signs of life. Closed-circuit camera footage revealed that the resident exited the facility at 7:08 PM the previous evening and fell to the ground shortly after. The resident remained outside in the snow until being discovered by staff the following morning. The facility's protocol required staff to visually check the area outside when an alarm sounded, but this was not done. Interviews with staff indicated that door alarms went off during the night, but staff did not check outside due to concerns about being locked out or because other residents were near the doors. The facility's policy required interventions to mitigate wandering risks, including door alarms and staff rounding, but these measures were not effectively implemented. The failure to provide necessary services to prevent harm led to the determination of immediate jeopardy.
Failure to Supervise Resident Leads to Fatal Elopement
Penalty
Summary
The facility failed to ensure adequate supervision and prevent accidents for a resident with severe cognitive impairment and a history of wandering. The resident, who had Alzheimer's disease and required substantial assistance with daily activities, was able to exit the facility unnoticed. The resident's care plan indicated a need for close supervision due to exit-seeking behavior, but this was not effectively implemented. On the night of the incident, the resident exited the facility into the courtyard and was outside in freezing temperatures for over nine hours. Closed-circuit camera footage showed the resident leaving the building and falling to the ground, where they remained until discovered deceased the following morning. Staff interviews revealed that door alarms were not properly responded to, and the resident was not accounted for during routine checks. The facility's policy required staff to visually check outside when alarms sounded, but this was not done. Staff on duty failed to follow protocols for monitoring high-risk residents and responding to door alarms, contributing to the resident's unsupervised exit and subsequent death. The deficiency was identified as an immediate jeopardy situation due to the lack of intervention and supervision.
Failure to Respond to Resident's Change in Condition
Penalty
Summary
The facility failed to respond appropriately to a change in condition for a resident who was cognitively intact and had multiple diagnoses, including heart failure and diabetes. The resident expressed concerns about having pneumonia and requested to be sent to the hospital. Despite these complaints, the resident's vital signs were noted as within normal limits, and no distress was observed. The resident was given a breathing treatment and was later found unresponsive, leading to their death. Interviews with staff revealed that the resident had expressed concerns about having a heart attack and not feeling well, which were reported to the nursing staff. However, the nurse responsible did not notify the resident's physician or take further action beyond administering a breathing treatment. The resident continued to exhibit unusual symptoms, such as needing assistance with transfers and experiencing seizure-like shaking, which were not typical for them. The facility's Director of Nursing and Assistant Director of Nursing confirmed that the nurse did not follow protocol by failing to notify the physician of the resident's change in condition and request for hospitalization. The nurse was subsequently terminated for not responding to the resident's needs, which ultimately resulted in the resident's death.
Resident Abuse and Neglect by CNAs
Penalty
Summary
The facility failed to protect a resident from physical and verbal abuse, as well as neglect, as evidenced by incidents involving two CNAs. The resident, who had severe cognitive impairment and was dependent on staff for personal care, was left unattended in the bathroom and went unchecked for 13 hours during a CNA's shift. This neglect was captured on audio/video surveillance, and other staff reported concerns about the conditions of residents, such as saturated briefs and beds, and dried feces and urine left on beds. In another incident, the resident's daughter provided video footage showing a CNA verbally and physically abusing the resident. The footage showed the CNA pushing the resident in bed, pulling the resident up by one arm, and using aggressive and threatening body language. The CNA was also observed turning off the resident's call light and refusing to take the resident to the bathroom, leading to the resident expressing fear about calling for help. Interviews revealed that the CNA involved in the physical and verbal abuse had complained about being overwhelmed and needing help. The CNA stated that she had no intention of hurting the resident and was frustrated during the shift. The resident's daughter reported these incidents to the facility, and the resident exhibited new fearful behavior following the incidents.
Removal Plan
- Resident assessment
- CNA suspension
- Facility reported to adult protection agency, state survey agency, and state board of nursing
- Disciplinary action for the perpetrators
Failure to Protect Residents from Abuse by Other Residents
Penalty
Summary
The facility failed to protect residents from abuse by other residents, resulting in harm to three residents. Resident #106, who has severe cognitive impairment due to Alzheimer's disease, experienced sexual abuse on two occasions. On one occasion, another resident was found with their hand up Resident #106's shirt, and on another occasion, the same resident had their hand down Resident #106's pants. The facility did not follow up on these incidents adequately, and the Director of Nursing (DON) and Assistant Director of Nursing (ADON) were unable to identify the resident involved in one of the incidents during an interview. Resident #63, who also has severe cognitive impairment, was physically abused by another resident, resulting in bruising and skin tears. The aggressor resident grabbed Resident #63's left forearm and attempted to twist it, causing injuries. The facility's documentation of the extent of the injuries and post-event monitoring was incomplete, as confirmed by the ADON and DON. Resident #26 was involved in an altercation with another resident, resulting in a fall and head injury. The aggressor resident pushed Resident #26, causing them to fall and hit their head on the floor. Both residents were transported to the emergency department, and Resident #26 did not require stitches. The facility implemented one-to-one staff supervision for the aggressor resident following the incident. The facility's policy emphasizes the importance of providing a safe environment and protecting residents from abuse, but these incidents indicate a failure to adhere to these standards.
Failure to Provide Appropriate Dementia Care
Penalty
Summary
The facility failed to ensure that a resident with dementia received appropriate treatment and services to attain their highest practicable physical, mental, and psychosocial well-being. The resident, who had severe cognitive impairment and diagnoses including Alzheimer's disease, traumatic brain injury, and depression, exhibited multiple behavioral issues such as wandering, physical aggression, and incontinence. Despite these behaviors, the facility did not develop or implement a comprehensive, resident-centered care plan to address these issues effectively. The care plans lacked specific non-medication interventions for pain management, and there was no evidence of an analysis of triggers for the resident's aggressive behaviors or appropriate interventions for their neurological deficits. The resident's behavior included wandering into other residents' rooms, urinating and defecating on the floor, and being physically aggressive towards staff. Multiple incidents were documented where the resident was combative during care, such as hitting and kicking staff during incontinence care and showering. The resident also engaged in disruptive behaviors like drinking hand sanitizer, eating other residents' food, and intruding into other residents' rooms, which caused distress among other residents. Despite these documented behaviors, the facility did not update the resident's care plan to include specific interventions to manage these behaviors. Interviews with staff, including LPNs and CNAs, revealed that the resident was difficult to care for due to their aggressive behaviors and wandering tendencies. Staff reported that the resident often refused care and was not easily redirected. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that a thorough analysis of the resident's behavior triggers and professional evaluations had not been completed. This lack of comprehensive assessment and intervention led to the resident's continued behavioral issues and actual harm, as evidenced by multiple documented incidents of aggression and self-harm.
Temperature Monitoring and Hand Hygiene Deficiencies in Food Service
Penalty
Summary
The facility failed to ensure proper temperature monitoring for six refrigerator/freezers storing food for resident use outside of the kitchen. Observations revealed discrepancies between external and internal thermometer readings, with internal temperatures often exceeding the recommended 40 degrees Fahrenheit. Additionally, one refrigerator lacked an internal thermometer altogether. Interviews with the dietitian confirmed that monitoring of these refrigerators and freezers was not being conducted. The facility's policy required daily documentation of refrigerator/freezer temperatures, which was not being followed, leading to potential food safety issues for the residents. In the food preparation area, a cook was observed handling raw hamburger patties with gloved hands and then, without performing hand hygiene, donning new gloves to handle seasoning containers. This practice was confirmed by the dietitian as incorrect, and the cook had not completed the required Serve Safe certification by the designated deadline. The facility's policy and the 2022 FDA Food Code mandate proper hand hygiene and temperature monitoring to ensure food safety, both of which were not adhered to in this instance.
Failure to Deliver Resident Mail on Saturdays
Penalty
Summary
The facility failed to ensure mail was delivered to residents on Saturdays. During a group interview, seven residents reported that the transportation aide, who was previously responsible for Saturday mail delivery, informed them that this service would no longer occur. The Director of Nursing (DON) confirmed that the transportation aide was responsible for weekend mail delivery. The transportation aide further confirmed that the post office delivered mail after he left the facility at 11 AM, resulting in no Saturday mail delivery for about four months.
Failure to Ensure Safe and Homelike Environment in Pine Unit
Penalty
Summary
The facility failed to ensure a safe and homelike environment in the Pine unit, as residents from the Cottonwood unit frequently wandered into the Pine unit, causing disturbances and safety concerns. Multiple observations and interviews revealed that Pine staff had to redirect Cottonwood residents who intruded into Pine residents' rooms, leading to missing items and resident altercations. Medical records showed that one particular resident from Cottonwood exhibited aggressive behaviors, intruding into rooms, taking belongings, and causing distress among Pine residents and their families. Interviews with staff and resident representatives highlighted the negative impact of opening the doors between the Cottonwood and Pine units. Staff reported increased behavioral issues and safety concerns, with Pine residents feeling fearful and unsafe. The facility's decision to open the doors was based on an initial risk evaluation that deemed the dementia levels similar between the units, but no reevaluation was conducted. Staffing levels were not adjusted to accommodate the increased supervision needs, leading to further strain on Pine unit staff. Family members of Pine residents expressed frustration and concern over the lack of privacy and safety, with some documenting multiple instances of uninvited intrusions and missing personal items. Despite grievances and complaints, the facility's management did not address the concerns adequately, leaving the Pine unit residents and their families dissatisfied and worried about their safety and well-being.
Deficiency in Food Service Temperature and Quality
Penalty
Summary
The facility failed to provide food service in a manner that ensured a safe and appetizing meal for residents in the Pine, Cottonwood, and Birch units. During an observation, the steam table food cart was transported from the kitchen to the Pine unit, and the temperature of the turkey casserole was recorded at 180 degrees Fahrenheit. However, several issues were identified: the dietary aide did not have the correct serving scoops, had to redirect a wandering resident, and did not have enough food for all diet types, causing delays. The nutrition supervisor had to assist, and the meal service, which should have been completed within 20 minutes, extended to 40 minutes. On the Cottonwood unit, the meal service started late, and the turkey noodle casserole was served at 128 degrees Fahrenheit, which was lukewarm when tasted by the surveyor. Residents complained of food being served cold, dry, burnt, and with inconsistent portion sizes, as well as warm drinks with no ice. The dietitian confirmed the need for education to dietary aides to increase speed and efficiency in serving meals, with an expectation for food to be held at 140 degrees Fahrenheit. The facility's Food Preparation Practices policy requires hot food to be served immediately after preparation and held at a temperature of 135 degrees Fahrenheit and above. The 2022 FDA Food Code also mandates that time/temperature control for safety food should be maintained at 135 degrees Fahrenheit or above. The facility's failure to adhere to these guidelines resulted in food being served at unsafe and unappetizing temperatures, leading to resident complaints and observations of deficiencies in the food service process.
Failure to Ensure Proper Formulation of Advance Directives
Penalty
Summary
The facility failed to ensure advance directives were properly formulated for two residents. For resident #14, there was a discrepancy between the physician's order, which indicated a do not resuscitate (DNR) status, and the resident's Cardiopulmonary Resuscitation Directive, which requested full code status. For resident #21, the physician's order indicated a DNR status, but the advance directive was unselected in the resident's medical record. Interviews with staff revealed inconsistencies in how advance directives were determined, with some staff consulting the resident's profile and others looking at an advance directive binder or a blue dot on the resident's door nameplate, which indicated full code status.
Failure to Report Allegation of Abuse
Penalty
Summary
The facility failed to ensure allegations of abuse were reported for one resident reviewed for abuse. Resident #62, who had severe cognitive impairment and diagnoses including Alzheimer's disease and depression, was involved in an incident where another resident had their hand down Resident #62's pants. The facility did not follow up on the incident and was initially unable to identify the involved resident. Upon identification, it was confirmed that the allegation of abuse had not been reported to the state licensing division. A review of the state licensing division incident database showed no evidence that the incident had been reported, despite the facility's policy requiring immediate reporting of such allegations.
Failure to Investigate Allegation of Abuse
Penalty
Summary
The facility failed to ensure allegations of abuse were investigated for one resident reviewed for abuse. Resident #62, who had severe cognitive impairment with a BIMS score of 5 out of 15 and diagnoses including Alzheimer's disease and depression, was involved in an incident where another resident had their hand down Resident #62's pants. Despite this incident being documented in a progress note, the facility did not follow up on the incident, and the Director of Nursing (DON) and Assistant Director of Nursing (ADON) were unable to identify the involved resident at the time of the interview. It was later confirmed that the resident involved was Resident #62, and the allegation of abuse had not been investigated or reported to the state licensing division as required by the facility's abuse policy.
Failure to Provide Adequate Discharge Notice and Care Coordination
Penalty
Summary
The facility failed to ensure a discharge notice included care and services for a resident which should not or cannot be provided by the facility. The interdisciplinary team met with the family to discuss care decisions that violated the resident's wishes as outlined in the Medical Durable Power of Attorney (MDPOA). The family was involved in inappropriate wound care and refused to make decisions to treat the resident's pain, which was ongoing due to their perceptions of pain medicine. The family also made medical orders and provided prescription-level wound care supplies without the knowledge of the wound care team and facility providers. Additionally, the family reported an allergy to digoxin and a UTI to outside providers without informing the facility, despite the resident receiving appropriate care for these conditions. The family scheduled appointments without notifying the facility, making transportation arrangements unfeasible. The family was inconsistent in care decisions, impacting the resident's care, and pursued clinical efforts outside the physician's patient management, leading to the facility's decision to issue a 30-day discharge notice. A progress note showed that the DON contacted the family member to follow up on the resident's status and discussed the care transition, explaining that the facility could not meet the resident's needs and issued a 30-day discharge notice. The family member was informed about the appeal process and the contact information for the State ombudsman and licensing agency. The family member initially requested a camera in the resident's room but later declined, stating it would be a waste of money if the resident was being discharged. Referrals for long-term care were sent to other nursing facilities and skilled nursing facilities. An interview with a family member revealed that they felt the discharge notice was issued in retaliation for filing a grievance related to neglect. The DON confirmed that the facility could meet the resident's care needs, but the family's requests for care were against the resident's wishes. The care and services provided at the referred nursing facilities and skilled nursing facilities were the same level of care and services the facility was able to provide.
Inaccurate MDS Assessment for Antibiotic Use
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment information accurately reflected the resident's status for one resident reviewed for antibiotics. Specifically, the annual MDS assessment for the resident indicated that they were taking an antibiotic, with the indication noted box also checked. However, a review of the resident's physician orders and the medication administration records for January and February 2024 showed no evidence that the resident had been prescribed an antibiotic. An interview with the MDS coordinator confirmed that the resident had not been prescribed an antibiotic and that the MDS assessment was coded incorrectly. This discrepancy was identified based on staff interviews, medical record reviews, and a review of the Resident Assessment Instrument (RAI) manual.
Failure to Complete PASARR Level II for Resident
Penalty
Summary
The facility failed to ensure a pre-admission screen and resident review (PASARR or PASRR) was performed for a resident who had a PASARR level II indicated. The medical record review showed that the resident was admitted to the facility and the PASARR level I completed at the time of admission indicated the need for a PASARR level II. However, there was no evidence that a PASARR level II was completed at that time. An Authorization Request Summary later showed a review type as PASRR Level 2, indicating the resident had diagnoses including post-traumatic stress disorder and major depressive disorder, with mental health rehabilitation services potentially recommended. The Director of Nursing (DON) confirmed in an interview that the PASARR level II was not requested when the PASARR I was completed and was unsure why it was not requested until a later date. The facility's policy stated that all residents are required to have a PASARR Level I screen completed prior to nursing facility admission and that PASARR Level I and II (when applicable) will be kept on file in the resident's medical record and kept accurate according to OBRA and state regulations.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for three residents with severe cognitive impairments. Resident #62, who had Alzheimer's disease and depression, was receiving an antidepressant for depression and hypersexuality. However, the care plan did not specify the hypersexual behaviors exhibited by the resident, despite the facility's awareness of the resident's preference for residents of the opposite gender. This was confirmed during an interview with the DON and ADON. Resident #63, also with severe cognitive impairment and diagnosed with Alzheimer's disease, unspecified dementia, and anxiety, was prescribed buspirone for anxiety. The care plan, however, only addressed the use of an antidepressant for depression and did not include a plan for the antianxiety medication. The ADON mistakenly believed buspirone was an antidepressant. Resident #98, who had a traumatic brain injury and severe cognitive impairment, had a care plan that included analyzing triggers for physical aggression but lacked evidence that this analysis was completed. The DON and ADON confirmed that the analysis had not been done.
Failure to Administer Prescribed Antibiotics
Penalty
Summary
The facility failed to ensure that a resident received medications as ordered by the physician. The resident, who had severe cognitive impairment and multiple diagnoses including cancer, anemia, malnutrition, Alzheimer's disease, and recurrent UTIs, was prescribed 500 mg of ampicillin to be administered four times a day. However, the facility did not administer the medication four times between the order date and the next administered dose. The delay was attributed to the unavailability of the medication from the primary and backup pharmacies, and the nursing staff did not explore the option of substituting amoxicillin, which was available in the pyxis emergency inventory. Interviews with the nursing staff and the Director of Nursing (DON) revealed that the process for obtaining medications involved ordering from the primary pharmacy, with a potential delay if the order was placed after 2 PM. The staff could use the pyxis for immediate needs, but this option was not utilized in this case. The facility's medication administration policy required new medication orders to be started on the same day, but this was not adhered to, resulting in missed doses for the resident.
Failure to Ensure Safe Environment for Residents with Severe Cognitive Impairments
Penalty
Summary
The facility failed to ensure a safe environment for two residents with severe cognitive impairments, leading to multiple incidents. Resident #26, diagnosed with Alzheimer's disease and having a BIMS score indicating severe cognitive impairment, was observed wandering between units and picking up items and food. The resident was involved in an unwitnessed altercation with another resident, resulting in a fall and head injury. Additionally, the resident was found with zinc oxide paste in their mouth, which was stored in resident rooms for incontinence care. These incidents indicate a lack of adequate supervision and intervention to prevent harm to the resident. Resident #98, also with severe cognitive impairment and diagnosed with Alzheimer's disease, traumatic brain injury, and depression, was involved in several incidents due to inadequate supervision. The resident was involved in an unwitnessed altercation with another resident, resulting in a scratched earlobe. The resident was also found drinking hand sanitizer and consuming various items from the kitchen. Despite being identified as requiring constant supervision, the resident was observed wandering into staff areas and other residents' rooms, taking belongings and becoming agitated when redirected. The facility's failure to develop and implement effective interventions to ensure the safety of these residents was confirmed in an interview with the DON and ADON.
Improper Handling of Urinary Catheter Bags
Penalty
Summary
The facility failed to ensure proper handling of urinary Foley catheter bags to prevent urinary tract infections for a resident with neurogenic bladder and a history of urinary tract infection. During an observation, a CNA was seen lifting the urinary catheter bag above the resident's waist while untangling the tubing, causing cloudy urine to flow back toward the resident's bladder. Additionally, the CNA held the urinary bag above the bladder when transferring the resident to a wheelchair. The CNA later confirmed that she had been educated to keep the urinary catheter bag below the bladder. The ADON and infection preventionist also stated that it was the facility's expectation for staff to maintain the catheter bag below the bladder. Review of the facility's policy on urinary catheter care confirmed that the drainage bag must be positioned lower than the bladder at all times to prevent backflow of urine.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure enhanced barrier precautions (EBP) were followed for a resident with an indwelling catheter and a urinary tract infection. The resident's care plan required staff to use gowns and gloves for high-contact activities, but observations showed that two CNAs only wore gloves while dressing the resident and handling the urinary catheter. Additionally, the CNAs improperly managed the urinary catheter, causing cloudy urine to flow back towards the resident's bladder. No signage indicating the required EBP was posted on the resident's door or wall. Interviews with the ADON and infection preventionist confirmed that the facility's policy required gowns and gloves for care involving catheters and wounds. The EBP sign was found tucked inside the PPE storage unit on the resident's door, and staff had been trained on EBP in the previous months. The facility's policy on EBP, dated 1/6/23, specified the use of gowns and gloves for high-contact activities and required signage to be posted outside the resident's room indicating the type of precaution and PPE required.
What surveyors are citing around you — mapped
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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 citations issued around you in the last 12 months — including the 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
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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 August 2026) and official state health department websites.