8 CMS Surveys
Inspection Report — Jun 18, 2025
Complaint Investigation
Date: Jun 18, 2025
Visit Reason
Investigation of a complaint received on 2025-03-27 about inadequate supervision leading to resident elopement.
Complaint Details
Inadequate supervision leading to resident elopement: established.
Findings
The facility failed to provide adequate supervision to Resident #101, who exited the facility unattended and descended 16 concrete steps to a parking lot, posing a risk of serious injury.
Deficiencies (1)
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to provide adequate supervision to Resident #101, a high fall risk and active exit seeker, who eloped unattended on 3/27/25 and descended multiple flights of stairs to a parking lot.
Inspection Report — Feb 26, 2025
Complaint Investigation
Date: Feb 26, 2025
Visit Reason
Investigation of a complaint received about wound care treatment and monitoring.
Complaint Details
Failure to provide wound care treatment as ordered for Resident #34: established.
Findings
The facility failed to implement consistent venous ulcer interventions, monitoring, and treatments consistent with physician orders for 1 of 5 residents reviewed, resulting in potential worsening of wounds and further skin breakdown.
Deficiencies (1)
F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals: Resident #34 missed wound care treatment on 2/25/25 due to nurse RN N documenting treatment as missed because resident was sleeping, which was deemed unacceptable by facility management.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN N | Registered Nurse | Named in the wound care treatment deficiency for documenting missed treatment due to resident sleeping. |
Inspection Report — Feb 26, 2025
Complaint Investigation
Date: Feb 26, 2025
Visit Reason
Investigation of a complaint received about care plan implementation, wound care, respiratory care, adaptive equipment use, food safety, and infection control.
Findings
Multiple deficiencies were found including failure to update care plans for assistive devices, inadequate assistance with activities of daily living, inconsistent wound care treatments, failure to implement contracture management, inadequate respiratory care for tracheostomy, improper use of adaptive feeding equipment, food safety violations in the kitchen, and failure to implement enhanced barrier precautions and maintain equipment.
Deficiencies (9)
The facility failed to update and revise care plans for residents' assistive devices such as PRAFO braces and splints, resulting in lack of interventions and staff awareness.
The facility failed to provide assistance with activities of daily living, including shaving and changing clothes daily for residents #13 and #54.
The facility failed to implement consistent wound care treatments for Resident #34, missing treatments and allowing wound size to increase.
The facility failed to implement care plan interventions to prevent worsening of contractures for Resident #13, including failure to ensure use of splints.
The facility failed to provide adequate respiratory care for Resident #35 with a tracheostomy, including failure to replace empty oxygen tank, suction phlegm, and document events.
The facility failed to provide or use adaptive feeding equipment correctly for Resident #25, who was observed using prohibited cups with straws despite orders for Provale cup only.
The facility failed to prepare and store food in accordance with professional standards, including lack of soap at hand sink, uncovered raw meat, dirty equipment, expired and unlabeled food, and improper hand hygiene by food service staff.
The facility failed to implement enhanced barrier precautions properly, with staff not wearing gowns and gloves during high-contact care activities for residents requiring precautions, increasing risk of infection spread.
The facility failed to maintain equipment and surfaces to reduce bacterial harborage, including leaking vacuum breaker, leaking toilet with black staining, non-cleanable shelving, and chipping walls.
Inspection Report — May 30, 2024
Complaint Investigation
Date: May 30, 2024
Visit Reason
Investigation of a complaint received on 2024-04-25 about failure to safely transfer a resident resulting in a fall and serious injury.
Complaint Details
Failure to safely transfer resident using sit to stand lift resulting in fall and injury: established.
Findings
The facility failed to safely transfer Resident #101 using the sit to stand mechanical lift, resulting in a fall and serious injury requiring surgery. Staff did not follow the care plan or facility policy requiring two staff to assist and proper use of straps.
Report Facts
Date of complaint: Apr 25, 2024
Date of survey completed: May 30, 2024
Inspection Report — Mar 14, 2024
Complaint Investigation
Date: Mar 14, 2024
Visit Reason
Investigation of a complaint received on 2023-09-07 about misappropriation of narcotic medications.
Complaint Details
Misappropriation of narcotic medications for Resident #163: established.
Findings
The facility failed to prevent misappropriation of Resident #163's narcotic medications resulting in missing oxycodone packages. The nurse suspected of diversion was suspended and terminated. The facility implemented corrective actions including education and audits, and maintained compliance at the time of survey.
Deficiencies (1)
F 0602 Protect each resident from the wrongful use of the resident's belongings or money: the facility failed to prevent misappropriation of Resident #163's oxycodone medications resulting in missing narcotics and count sheets.
Inspection Report — Mar 14, 2024
Complaint Investigation
Date: Mar 14, 2024
Visit Reason
Investigation of a complaint received on 2023-09-07 about misappropriation of narcotic medications, inadequate activities of daily living care, insufficient staffing, lack of qualified dietary staff, incomplete medical records, and infection control deficiencies.
Complaint Details
Misappropriation of narcotic medications: established. Inadequate activities of daily living care: established. Insufficient nursing staffing: established. Lack of qualified dietary staff: established. Incomplete medical records (code status): established. Infection control deficiencies with shared equipment: established.
Findings
Multiple deficiencies were found including misappropriation of narcotic medications, failure to provide scheduled showers and personal care due to staffing shortages, insufficient nursing staff to meet resident needs, lack of a full-time qualified dietitian or certified dietary manager, incomplete documentation of residents' code status, and inadequate cleaning of shared resident equipment.
Deficiencies (6)
F 0602 Protect each resident from the wrongful use of the resident's belongings or money: the facility failed to prevent misappropriation of Resident #163's narcotic medications resulting in missing oxycodone 5 mg packages and termination of the responsible nurse.
F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable: the facility failed to provide scheduled showers and grooming for Residents #11, #16, and #41 due to staffing shortages, causing frustration, anxiety, and self-consciousness.
F 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift: the facility failed to provide sufficient nursing staff for Residents #10, #11, #16, and #41 resulting in long call light wait times, missed showers, incontinence, and unmet care needs.
F 0801 Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician: the facility failed to employ a full-time Registered Dietitian or Certified Dietary Manager to oversee kitchen and clinical nutritional services.
F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards: the facility failed to maintain complete and accurate medical records for Residents #16 and #40, specifically missing documentation of residents' code status in the electronic medical record, physician orders, and medication administration records.
F 0880 Provide and implement an infection prevention and control program: the facility failed to ensure infection control practices were followed for cleaning shared resident equipment such as sit to stand lifts and hoyer lifts, which were visibly soiled with dust, debris, food crumbs, and dried substances, increasing risk of bacterial harborage and cross contamination.
Inspection Report — May 3, 2023
Monitoring
Date: May 3, 2023
Visit Reason
Interim inspection to determine compliance.
Findings
Multiple deficiencies were found related to resident care, staffing, and safety, including failure to provide timely assistance, misappropriation of narcotic medication, inadequate showering and hygiene care, failure to follow pre-surgical preparation procedures, inadequate pressure ulcer care and prevention, and insufficient staffing levels resulting in unmet resident needs and harm.
Deficiencies (6)
F 0550 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights: Residents #14 and #42 experienced neglect in toileting assistance, resulting in degrading conditions and pain due to delayed response and inadequate staffing.
F 0602 Protect each resident from the wrongful use of the resident's belongings or money: The facility failed to prevent misappropriation of narcotic pain medication for Resident #21, resulting in missing oxycodone tablets and potential delayed pain treatment.
F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable: Residents #6, #11, and #48 did not consistently receive scheduled showers, resulting in poor hygiene and potential psychosocial harm.
F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals: Resident #64's pre-surgical preparation was not properly followed, including failure to provide ordered Hibiclens showers and bedding changes, resulting in surgery cancellation due to infection risk.
F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing: Residents #7, #65, #11, #48, and #317 experienced inadequate pressure ulcer prevention and treatment, including lack of proper wound care supplies, delayed wound identification, insufficient repositioning, and lack of pressure offloading devices, resulting in new or worsened pressure ulcers and potential for further harm.
F 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift: The facility failed to maintain adequate staffing levels, resulting in unmet resident care needs, delayed responses to call lights, inability to provide showers, and increased risk of harm including falls and pressure ulcers for residents #31, #14, #42, #11, and #48.
Inspection Report — May 3, 2023
Monitoring
Date: May 3, 2023
Visit Reason
Interim inspection to determine compliance.
Findings
Multiple deficiencies were found related to resident care, staffing, infection control, medication management, and facility maintenance, including a resident fall with fracture, pressure ulcer care issues, inadequate staffing, and infection prevention lapses.
Deficiencies (14)
Resident #14 fall with fracture: resident slid out of the sit to stand lift during transfer due to improper use and lack of two-person assist, resulting in a right distal femur fracture.
Resident #11 pressure ulcer care: staff failed to reposition resident every two hours consistently, resulting in reopening of a stage 3 pressure injury on the right medial buttock.
Resident #48 developed a new unstageable deep tissue injury on the left heel; staffing shortages contributed to delayed repositioning and care.
Resident #65 pressure ulcer care: delayed identification and treatment of deep tissue injury and stage 2 pressure injury on feet; facility failed to monitor and document skin conditions accurately.
Resident #317 pressure ulcer care: resident had a painful stage 4 sacral pressure ulcer; staff failed to reposition every two hours, provide offloading pillows, or provide an alternating pressure mattress.
Facility failed to maintain adequate nurse and aide staffing levels, resulting in unmet resident care needs, delayed assistance, missed showers, and increased risk of adverse outcomes.
Facility failed to ensure proper cold holding temperatures in the walk-in cooler, with temperatures recorded above 41°F, risking food safety.
Facility failed to maintain proper hot water sanitizing temperatures in the dish machine, with multiple recorded temperatures below required minimums for effective sanitization.
Resident #27 medical record was incomplete and inaccurate; documentation of UTI symptoms and related behaviors was missing until a late entry was made after surveyor inquiry.
Facility failed to limit PRN psychotropic medication orders to 14 days and document rationale; Resident #38 had a Lorazepam PRN order for 90 days without discontinuation or reevaluation.
Facility failed to ensure proper infection prevention practices during incontinence care for Resident #44; staff did not remove soiled gloves before handling clean areas, risking cross contamination.
Facility failed to maintain an active water management plan for Legionella and other opportunistic pathogens; documentation was outdated and incomplete, increasing risk of waterborne infections.
Facility failed to offer COVID-19 immunization to 4 residents (#319, #38, #315, #320) and maintain documentation of offers or declinations.
Facility failed to ensure all staff received required COVID-19 vaccinations and maintain accurate vaccination records; two dietary staff had incomplete vaccination status documentation.
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