Pine Knoll Nursing Center

Penalty

Fine: $327,700

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide appropriate care to maintain or improve range of motion for multiple residents. Resident #24, who was cognitively intact and admitted with diagnoses including osteoarthritis, heart failure, and hypertension, developed a left hand contracture after admission. The record showed no contracture on admission or on hospital paperwork after a January 2025 hospitalization, but later notes documented increasing tightness in the left hand and fingers. The resident’s health care proxy and staff reported that the contracture worsened over time, the resident had pain, and the left fifth finger was ultimately amputated after the contracture progressed. For Resident #24, OT evaluation was delayed after the need for OT was first documented, and once OT began, the resident did not receive therapy at the frequency ordered. OT notes repeatedly recommended orthotic devices such as a rolled towel, hand carrot, and later a palm guard, but the record did not show written orders for these devices or nursing documentation showing consistent use. OT documented that the resident’s hand improved after treatment but regressed between visits, and OT also noted nursing lack of follow-through with the hand carrot. The DON stated he had not been monitoring whether therapy referrals or treatments were completed. The record also showed multiple physician recommendations for botox injections for the left hand contracture, but appointments were cancelled by the facility and never rescheduled, and the resident never received the injections. Resident #6, who had dementia and severe cognitive impairment, was observed with both hands contracted and without splints. The left hand was in a fist and the right hand had fingers bent toward the palm. The record indicated the resident had no documented neurological disorder causing contracture, yet the facility failed to implement a splint for the left hand, and the deficiency report states this resulted in a stage four pressure wound. The report also states the facility failed to identify and treat a new contracture of the right hand. Resident #11 was also included in the deficiency for failure to implement a physician’s order for bilateral hand grips for contracture management. The report states the facility did not carry out the ordered hand grips. Facility policies required residents to receive care to prevent progression of contractures, physician notification when contractures were assessed, and monitoring of splint compliance, but the findings showed these interventions were not consistently implemented for the affected residents.

Penalty

Fine: $327,700

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to notify physicians and a legal guardian of significant changes in condition for four residents. The report states that the facility did not notify the physician or resident representative when Resident #24’s left-hand contracture worsened, when OT evaluation was delayed, when ordered OT treatment was not being completed at the prescribed frequency, or when the resident could not tolerate the hand orthotic because of increased pain and decreased range of motion. The resident was cognitively intact, had no left-hand contracture on admission/readmission assessments, and later developed a worsening left-hand contracture that ultimately resulted in amputation of the left fifth finger. For Resident #24, the medical record showed NP notes in July and August 2025 documenting stiffness and pain with OT evaluation pending, but the OT evaluation was not completed until 49 days after the first documented need. The OT plan called for 10 visits per 30-day period, but the resident received only 13 visits during the treatment period from September through December 2025. OT notes documented that the hand carrot was not being worn consistently, nursing staff were educated on its use, and later the OT discontinued the hand carrot because of nursing lack of follow-through and increased pain; the resident then refused a palm guard due to pain. The record did not show the physician was notified of the delayed evaluation, missed treatment frequency, orthotic intolerance, or worsening contracture. The resident was later hospitalized, and hospital paperwork described severe finger contractures and pain, followed by amputation of the left fifth finger. For Resident #6, who had severe cognitive impairment and was dependent on staff for all ADLs, the facility failed to notify the legal guardian of worsening left-hand contracture with a stage 4 pressure ulcer and a new right-hand contracture, and failed to notify the physician of the worsening left-hand contracture and new right-hand contracture. The resident was observed with both hands contracted, without a splint in either hand, and staff reported the left-hand splint had not been seen for a long time. The resident had pain when staff attempted to open the fingers. A wound was observed on the left third finger, and the wound care specialist later documented a new stage 4 wound with pressure etiology. The record did not show notification to the guardian or physician about the worsening contractures or the new wound. For Residents #21 and #9, both with COPD and severe cognitive impairment, the facility failed to notify the physician of a change in respiratory status when oxygen saturation dropped below the ordered parameters. On the survey date, both residents were observed with empty portable oxygen tanks while oxygen was ordered continuously at 2 liters via nasal cannula. Nurse #9 stated he did not know the ordered oxygen level and initially did not assess the residents’ oxygen status. When oximetry was obtained, Resident #21’s oxygen saturation was documented as low as 74% and Resident #9’s as low as 74% to 80%. The nurse stated that provider notification was required when oxygen saturation was below 90%, and the NP later stated he was never notified of the lowered oxygen saturation levels or the change in respiratory status.

Penalty

Fine: $327,700

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect two residents from abuse and neglectful supervision. Resident #36, admitted in April 2025 with anxiety disorder, paraplegia, and depression, had intact cognition on the most recent MDS and was dependent on staff for self-care and transfers. Despite repeated emails to the Administrator, DON, and SW describing sexually explicit comments and exposure by another resident, the facility did not document a care plan specific to the abuse, did not address the incident in progress notes, and did not show that the concern was communicated to the Psychiatrist, NP, or behavioral services. Resident #36 stated he/she lived in fear of the other resident and could not protect himself/herself or get up and run. Resident #36 reported that another resident approached him/her in the hallway, made vulgar sexual statements, and exposed his/her genitals. The resident emailed the NHA and DON about the incident and later called the police. The DON later acknowledged that the abuse should have been addressed and a plan made to prevent recurrence, but it had not been. The SW stated she was not informed of the incident at the time and said communication in the building was lacking. CNA #1 said Resident #36 would stop care when hearing the accused resident in the hallway because he/she was scared and uncomfortable, but this was not reported because it was treated as a regular occurrence. The facility also failed to protect Resident #24, who was admitted in December 2024 with osteoarthritis, heart failure, and hypertension and was cognitively intact with a BIMS score of 14. During observation, another resident repeatedly entered Resident #24’s room, attempted to climb into the bed, exposed buttocks, and touched the resident and belongings while staff did not intervene until the surveyor alerted them. Resident #24 said the other resident entered the room daily, made him/her feel afraid and unsafe, and that staff only told him/her to press the call light. The care plan did not reflect the repeated room intrusions or any interventions to deter them, and staff interviews showed they were aware of the wandering but had not implemented resident-specific measures. The DON, SW, NP, and Administrator each stated they were unaware of the full extent of Resident #24’s distress or that interventions specific to the resident had not been put in place.

Penalty

Fine: $327,700

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide necessary behavioral health services to two cognitively intact residents who were experiencing fear and emotional distress related to repeated intrusive and sexually inappropriate behavior by another resident. Resident #36, who had diagnoses including anxiety disorder, paraplegia, and depression, reported ongoing sexual harassment and threats from a peer, including an incident in which the peer made vulgar sexual comments while the resident was seated in the hall. Resident #36 stated that the behavior continued afterward, that he/she lived in fear of being hurt or touched, and that he/she did not receive talk therapy despite being willing to accept it. Resident #36 provided emails sent to the NHA, DON, and SW describing the abuse and pleading for help. The record showed no behavioral health intervention in the care plan after the incident, and the medical record did not show evaluation or treatment by behavioral health services. The psychiatrist stated he had not been told about the abuse, had not been asked to see the resident, and said the resident would benefit from talk therapy. The SW and DON acknowledged that the resident was distressed, that the facility had been without a psychotherapist since December 2024, and that no formal therapy was available. Resident #24, who had diagnoses including osteoarthritis, heart failure, and hypertension and was cognitively intact, was repeatedly exposed to another resident entering the room, attempting to get into bed, exposing buttocks, and touching belongings. During survey observation, the resident appeared frightened while the other resident attempted to get into the bed and expose himself/herself. Resident #24 stated that the other resident entered the room daily, made him/her feel unsafe, and caused fear and sleep disturbance. The care plan did not address the repeated intrusions, and the medical record did not show referral to or evaluation for behavioral health services. Staff, including the SW, DON, and psychiatrist, acknowledged that the resident’s fear and distress should have prompted behavioral health referral, but no such referral had been made.

Penalty

Fine: $327,700

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide specialized rehabilitative services for two residents. For one resident with a new left-hand contracture, the record showed that an OT evaluation was not completed until 49 days after the need for OT was first documented, and the resident did not receive OT at the frequency ordered after the evaluation. The resident was admitted without contractures, later developed a left-hand contracture in July 2025, and the contracture progressed over time. The resident’s NP documented stiffness and an OT evaluation pending in multiple progress notes, but those notes were later described by the NP as inaccurate because they referenced the right hand instead of the left. An OT order was written, the evaluation was eventually completed, and OT recommended 10 visits per certification period. However, the resident was seen only 13 times from the initial evaluation through discharge from services, despite repeated recertifications continuing to order 10 visits per period. The record did not show a reason for the delay in the initial OT evaluation or for the missed treatment frequency. The resident was later hospitalized, and discharge paperwork described severe left-hand contractures with the fifth finger swollen and pink, inability to visualize the nailbed, and the fifth finger was amputated. The resident and the health care proxy both stated the contracture worsened over months and that more therapy was desired but not available. For the second resident, the physician ordered a PT evaluation, but the clinical record did not show that the evaluation was completed. The resident had dementia, osteoarthritis, left shoulder pain, fatigue, major depressive disorder, and required moderate to maximum assistance with ADLs. The resident reported pain in both shoulders and difficulty lifting the arms, and later said no PT had been received recently. The NP stated PT was ordered because pain medication alone was not enough and that the evaluation was still pending. Nursing staff and the DON stated consults were to be communicated and tracked, while the DOR stated she never received the referral for the PT evaluation.

Penalty

Fine: $327,700

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report multiple allegations of abuse and resident-to-resident altercations to the Health Care Facility Reporting System within the required time frame. The report identified failures involving residents #36, #47, #25, #55, #10, and #45, including allegations of sexual abuse, physical abuse by staff, and resident-to-resident abuse or altercations. The facility policy stated that all allegations of abuse are to be reported to the Department of Public Health within 2 hours after the allegation is made, and that suspected sexual assault, physical abuse, neglect, and resident-to-resident altercations are to be reported immediately or within the required reporting window. Resident #36, who had intact cognition on the most recent MDS and required staff assistance for care and transfers, reported that another resident repeatedly made sexually explicit comments and exposed his genitals in the hallway. The resident emailed the DON and NHA about the incident and later called the police. The DON acknowledged that the allegation should have been reported to HCFRS within 2 hours, but the report was not filed. Resident #47, who had severely impaired cognition and wandering behaviors, was documented in progress notes as exposing himself to peers and using sexually explicit language toward them. The DON and NHA both stated that this resident-to-resident sexual abuse and altercation should have been reported, but the HCFRS record did not show that it was. Resident #25, who had severely impaired cognition and daily physical behaviors toward others, was documented as having a brief altercation with another resident and as being found soaked in water after a screaming incident. The DON stated that resident-to-resident altercations, whether verbal or physical, should be reported within 2 hours, but no HCFRS report was found. Resident #55, who had intact cognition, reported that another resident had jumped into bed and grabbed her breast on multiple occasions; the DON later acknowledged the allegation should have been reported, but the HCFRS report was initiated about 14 hours after the allegation was brought to the DON's attention. Resident #10, who had moderately impaired cognition and daily verbal behaviors toward others, was documented as throwing water on a roommate after alleging the roommate was trying to climb into the bed; the DON said this was a resident-to-resident altercation that should have been investigated and reported, but it was not reported to the state agency. Resident #45, who had severe cognitive impairment, alleged that a staff member grabbed and handled her roughly, causing bruising to her arm; the DON did not report the allegation because he felt it could not be substantiated, and the HCFRS record did not show a report within the required 2-hour time frame.

Penalty

Fine: $327,700

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to investigate multiple allegations of abuse involving five residents. The report states that allegations included sexual abuse, resident-to-resident altercations, and physical abuse by staff, and that the facility did not complete the required investigations for these events. Facility leadership, including the DON and NHA, acknowledged during interviews that these allegations should have been investigated but were not. Resident #36, who was admitted in April 2025 and had diagnoses including anxiety disorder, paraplegia, and depression, had intact cognition on the most recent MDS and was dependent on staff for care and transfers. The resident reported that another resident repeatedly made sexually explicit comments, exposed genitals, and engaged in ongoing inappropriate behavior. The resident stated that the incident was reported to the DON and NHA by email and that police were called. The report notes that the allegation was not reported in the HCFRS as required, and the DON and NHA both stated that the sexual abuse allegation and the related resident-to-resident altercation should have been investigated but were not. Resident #47, who had dementia with behavioral disturbance, wandering, and traumatic brain injury, had severely impaired cognition on the most recent MDS. Clinical notes described provocative hypersexual behavior toward peers, including exposing self and making sexually explicit statements. Other residents also reported that this resident approached them with vulgar sexual comments and exposed genitals. The DON later stated that the allegation of sexual abuse involving Resident #47 should have been investigated but had not. The report also states that the NHA agreed the event should have been investigated and that a thorough investigation would include interviews with the residents involved and staff who may have witnessed the event. Resident #25, who had bipolar disorder and Alzheimer’s disease and was assessed as severely cognitively impaired, had progress notes documenting a resident altercation on multiple dates in January 2026. Notes described the resident as confused, unable to explain what happened, and involved in a brief altercation with another resident. The DON stated he was unaware of the notes at the time and that no investigation had been completed, although one should have been. Resident #45, who had Alzheimer’s disease and schizophrenia and severe cognitive impairment, reported being grabbed roughly by a staff member and having bruises on an arm. The DON’s incident report documented the resident’s statement but did not show further investigation such as staff interviews, resident interviews, skin checks, or other assessments. The DON stated that the incident report was the only investigation completed and that no further investigation was done because no bruises were visible and the resident could not recall full details. Resident #10, who had Alzheimer’s disease with late onset and anxiety disorder and was moderately cognitively impaired, was involved in an incident in which water was spilled on a roommate and the resident reported that the roommate was trying to climb into the resident’s bed. The social work note documented the incident as a resident-to-resident altercation and noted that the DON and physician were notified. The health care reporting system did not show that the facility reported the altercation to the state agency. The DON later stated that the incident should have been investigated and reported, and the Administrator stated that it should have been investigated and filed with the state agency.

Penalty

Fine: $327,700

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to store drugs and biologicals in accordance with State and Federal requirements. In the [NAME] Wing medication room, an unopened Lantus Solostar insulin pen was found at room temperature even though the manufacturer’s label indicated it should be refrigerated until opened. In the [NAME] Wing medication cart, multiple opened medications with shortened expiry dates were undated, including fluticasone propionate and salmeterol inhalers, an Airsupra inhaler, a Symbicort inhaler, latanoprost eye drops, and artificial tears. The surveyor also observed loose, unlabeled pills, one bottle of artificial tears not labeled with a resident name and stored outside its box, and medications stored touching a sticky brown substance in a drawer. Similar findings were observed in the Central Wing medication cart, including undated latanoprost eye drops, inhalers, liquid protein, artificial tears, loose unlabeled pills, and medications stored in contact with a sticky brown substance. The facility also failed to keep medication carts and the medication room secured when unattended. On one unit, the medication cart was observed unlocked and unattended in the hallway, with the nurse not within sight of it. On another occasion, the same cart was again observed unlocked and unattended in the hallway, and the assigned nurse could not be located. The medication room on the [NAME] Wing was observed ajar with no nurse in view, while two residents were wandering around the desk in front of the open room. Staff interviews confirmed that carts should be locked when unattended and that the medication room should never be left unlocked when unattended. The facility further failed to restrict access to the medication room and to separately secure a controlled drug. A nurse gave keys to a person who was not wearing a facility badge or uniform, and that person used the keys to enter the medication room out of the nurse’s sight. Staff identified the person as an off-duty nurse retrieving personal belongings. In the North/Central medication room, two bottles of lorazepam were stored in the shared medication refrigerator with non-controlled medications rather than in a separately locked, permanently affixed compartment for controlled drugs. Staff stated the facility did not have such a compartment, and the DON confirmed lorazepam should always be locked separately.

Penalty

Fine: $327,700

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to store and prepare food in accordance with professional standards for food service safety. During an initial kitchen walkthrough on 2/5/26, the surveyor observed a case of acorn squash with significant signs of decomposition, a case of sweet potatoes with textural changes and a blueish-white wispy growth, an undated bag of shredded cabbage with brown discoloration and textural changes, and a container of oranges with color changes, textural changes, and a blueish-white wispy growth. The surveyor also observed black wispy growth on shelving in the walk-in refrigerator, two undated bags of shredded mozzarella cheese with irregular blue coloring consistent with mold, a container of salsa dated opened 8/26 with blueish-white wispy growth on the outside and a slimy white substance inside, raw fish fillets stored above opened ready-to-eat ham, a box of chicken stored directly on the freezer floor, two bottles of juice opened but undated, sliced deli turkey opened but undated, salami dated 1/10/26, a fan covered in brownish stringy debris with food stored below it, and undated brownies in the reach-in refrigerator. During interview, the FSD stated he had noticed the acorn squash the day before and should have thrown it out, that kitchen staff were supposed to label and date all prepared and opened foods and discard them after seven days, and that the shredded cabbage should have been dated. He also stated the sweet potatoes should have been gone through and the ones showing signs of decomposition discarded, the black wispy growth on the shelving could be mold and food should not be stored on top of or below it, raw fish should not have been stored above opened ready-to-eat ham, the salsa should have been thrown away, the chicken should not have been stored on the freezer floor, the open juice should have been dated when opened, the deli turkey and salami should have been discarded, and food should not be stored below the fan because debris could fall and contaminate the food. The facility also failed to practice proper food handling during meals in the [NAME] Unit dining room. Staff were observed touching toast, muffins, dinner rolls, and bananas with bare hands while serving residents, including spreading jelly and buttering rolls without gloves and without washing hands between tasks. The COD was observed putting a finger inside a milk container spout to open it without gloves, and multiple CNAs and a nurse handled ready-to-eat food with bare hands. One resident took a glass of juice from a tablemate’s tray and drank it, then took food from another resident’s plate with her bare hands and ate it, and the nurse did not stop the resident from eating the food from another resident’s plate. The DON stated that food should not be touched by staff and that staff assisting with meals should wear gloves when touching food.

Penalty

Fine: $327,700

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a dignified existence for one resident when staff did not pull the privacy curtain during morning bathing care, leaving the resident naked in bed and visible to two roommates. The resident was dependent on staff for all activities of daily living, had diagnoses including dysphagia, unspecified dementia, and seizures, and had a BIMS score of 8 out of 15 indicating moderate cognitive impairment. The resident’s care plan directed staff to assist with bathing, dressing, and grooming, and the facility policy stated that staff shall promote, maintain, and protect resident privacy, including bodily privacy during personal care and treatment. During observation, CNA #4 provided care with the curtain open, and both roommates were able to see the resident receiving personal care. The CNA stated that residents should be provided privacy during care, and the DON stated that staff should pull privacy curtains when providing personal care.

Penalty

Fine: $327,700

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to inform residents or their representatives of charges for services available in the facility that were not covered under Medicare/Medicaid or by the facility's per diem rate for two of two applicable records reviewed. The deficiency involved two residents who came off their Medicare Part A benefit, still had benefit days remaining, and remained at the facility. Review of the notices provided to these residents showed that the SNF ABN (CMS-10055) forms did not include an estimated cost of services if they chose to pay privately. During interview, the Social Worker stated she was responsible for giving the SNF ABN notices and said she left the cost breakdown sections blank because she did not know the individual costs, although she acknowledged that the resident or representative should have been given a cost breakdown if they assumed financial responsibility for skilled services. The Operations Director also stated she was unsure of the cost breakdown for skilled services, but said it should be listed on the SNF ABN.

Penalty

Fine: $327,700

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a home-like environment on the [NAME] Wing because the hallway repeatedly had a strong odor of stale urine during multiple survey observations. The facility policy titled "Home-like Environment Policy" stated its purpose was to provide a safe, comfortable, and dignified environment that reflects a home-like atmosphere and promotes resident choice, independence, and well-being. During the resident group meeting, 4 of 8 residents reported unpleasant odors in the facility, including comments about a poor bathroom-like odor and a constant smell of feces, and one resident stated housekeeping did not stay on top of the odors. Staff interviews confirmed the odor problem was ongoing and not resolved. A nurse said staff frequently used deodorizing spray to cover odors on the [NAME] Wing, and the primary housekeeper said she had to wash the floors 3 to 4 times a day because urine had soaked into the flooring in two resident rooms, but the cleaning only covered up the smell. A CNA said there were often strong urine odors on the wing, especially in the morning before housekeeping arrived, and carried room spray to use when needed. The Administrator stated the wing smelled of urine because a resident urinated on the floor and the urine may have soaked into the floor. Another nurse said the wing often smelled of urine and that it was expected because it was a dementia unit. The housekeeper reported she had been telling administration for over a year that she could not get the smell out of the floor, and the DOF later confirmed the urine had soaked into the flooring and said it should have been fixed promptly but was not.

Penalty

Fine: $327,700

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that staff completed a quarterly MDS assessment in a timely manner for Resident #27. Review of the CMS RAI Manual showed that a quarterly MDS is due every quarter, with no more than 92 days between OBRA assessments, and must be completed no later than 14 calendar days after the ARD. Resident #27, who was admitted in April 2022, had a most recent quarterly MDS with an ARD of 10/2/25, and no further MDS assessments were completed or transmitted to CMS after that assessment. During interview, the MDS Coordinator stated that Resident #27 was supposed to have a quarterly MDS completed on 12/26/25 but it was missed and acknowledged that the assessment was overdue. The DON stated that he expected the MDS Coordinator to complete all MDS assessments following the RAI manual instructions.

Penalty

Fine: $327,700

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A care plan for suicidal ideation was not developed for one resident out of a sample of 34. The resident was admitted in December 2025 with diagnoses including schizoaffective disorder and schizophrenia. The most recent MDS indicated a BIMS score of 14 out of 15, showing the resident was cognitively intact, and also showed the resident required substantial assistance with ADLs. Review of the psychiatrist note from 12/29/25 showed the resident had experienced suicidal ideation earlier that day, but no longer expressed suicidal ideation at the time of the visit. A medical provider note dated 1/25/25 stated the resident called police at the facility requesting to leave, expressed suicidal ideation with a plan, and was placed on 1:1 monitoring for safety; the note also stated there was no suicidal ideation on assessment that day. Review of the interdisciplinary care plans showed no care plan was created to address suicidal ideation after the 12/29/25 event. During interviews, the DON stated any resident who has expressed suicidal ideation should have a care plan developed to address the concern, and the Social Worker stated any resident who expresses suicidal ideation in the present or past should have a suicidal ideation care plan developed.

Penalty

Fine: $327,700

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to review and revise the comprehensive care plan after quarterly MDS assessments for 2 residents. The record review and interviews showed that the interdisciplinary team did not keep the care plans aligned with the residents’ current needs and interventions, despite the facility policy stating that the IDT develops and implements a comprehensive, person-centered care plan based on the comprehensive assessment. For one resident admitted in March 2025 with diagnoses including dementia with behavioral disturbance, wandering, and traumatic brain injury, the most recent MDS showed severely impaired cognition and wandering but no behaviors other than wandering 1-3 days a week. The resident’s active physician orders and care plan still included 15-minute checks, yet the MAR and TAR did not show those checks were performed from July 2025 until they were later implemented in February 2026. The DON stated the 15-minute checks were an outdated intervention that should have been identified during quarterly care plan meetings, and the care plan should have been revised to reflect the current plan of care. For another resident admitted in March 2025 with Alzheimer’s dementia and failure to thrive, the most recent MDS indicated the resident spoke Swahili and needed or wanted an interpreter to communicate with staff. The care plan identified a communication problem related to a language barrier, but it did not include interventions such as a communication board or translator services. Interviews with CNA, nursing, social work, MDS, and DON staff confirmed that staff could not communicate with the resident when Swahili-speaking staff were unavailable and that the expected communication supports were not included in the care plan after the MDS review.

Penalty

Fine: $327,700

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide care in accordance with professional standards of practice for one resident. Resident #74 was admitted in January 2026 with diagnoses including seizure and epilepsy, had a BIMS score of 13 out of 15 indicating intact cognition, and was dependent on staff for activities of daily living. The medical record included an active physician order for padded side rails while in bed secondary to seizure activity, dated 2/28/23. During multiple observations on 2/5/26, 2/6/26, and 2/9/26, the resident was seen lying in bed with two quarter side rails up, and the side rails were not padded. During interview, a nurse stated the resident should have padded side rails based on the physician orders. A CNA stated he had not seen the resident's bed with padded side rails and said nurses would be the ones to place them if required. The DON stated physician orders should be followed as ordered and that the resident was ordered to have padded side rails, which should have been in place.

Penalty

Fine: $327,700

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide assistance with activities of daily living for three residents, including two residents who were dependent on staff for toileting and one resident who required help with grooming. The report states that the facility did not provide incontinence care for two residents and did not assist one resident with grooming tasks and removal of unwanted facial hair. Resident #69 had diagnoses including Alzheimer's disease, a BIMS score of 00, severe cognitive impairment, and was dependent on staff for toileting tasks with frequent incontinence of both bowel and bladder. The resident's bowel and bladder assessment indicated the resident never voided appropriately without incontinence, had daily stool incontinence, and was never mentally aware of the need to toilet. The care plan directed staff to check and change the resident every 2 hours and as needed, provide incontinent care after each episode, and toilet every 2 hours. On multiple observations, the resident remained in a wheelchair in the dining room for more than four hours at a time without being assisted to the bathroom or checked for incontinence. On one occasion, when toileting assistance was finally provided, the resident's brief was observed to be saturated with urine. Resident #67 had diagnoses including Alzheimer's disease, severe cognitive impairment, and was dependent on staff for all functional tasks and always incontinent of both bowel and bladder. The resident's bowel and bladder assessment indicated the resident never voided without incontinence, had daily stool incontinence, and was not usually aware of the need to toilet. The care plan directed staff to check and change every 2 hours, assist to toilet every 2 hours and as needed, and provide incontinent care after each episode. On multiple observations, the resident remained in the dining room in the same position for over four hours at a time without being assisted to the bathroom or checked for incontinence. When toileting assistance was eventually provided, the resident's brief was observed to be saturated with urine. Resident #45 had diagnoses including Alzheimer's disease and schizophrenia and a BIMS score of 3, indicating severe cognitive impairment. The MDS indicated the resident required moderate assistance with grooming tasks. The resident was observed with significant long chin hair and stated a desire to have the chin hair removed and to have a smooth chin without hair. On a later observation, the chin hair was still present, and the resident again stated that staff had not offered to remove it and that the resident wanted it removed. The care plan identified the resident as needing assistance with bathing, dressing, and grooming, and a CNA stated that removing unwanted facial hair is part of daily care and that the resident does not refuse grooming assistance, including chin hair removal. The DON stated that all unwanted facial hair should be removed as part of daily grooming, and the record did not indicate that the resident refused grooming assistance.

Penalty

Fine: $327,700

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Provide activities to meet all residents' needs. The facility failed to provide an activities program for residents on the [NAME] Unit. The facility policy stated that activities must be appropriate to each resident's needs and interests, provided in individual and group settings for ambulatory and non-ambulatory residents, and include a variety of planned activities. It also stated that a staff member must be assigned responsibility for developing, documenting, and maintaining the activities program, and that sufficient support staff must be available to meet residents' activity needs. On 2/5/26, 2/6/26, and 2/10/26, the activities listed on the activity calendar for the [NAME] Unit did not take place during the morning hours between breakfast and lunch. Surveyors observed that only three residents were given individual activities at the table while the remaining residents were lined up in front of the television, several were sleeping, and CNAs supervising the room did not engage with residents. No activity staff member was present during these observations. During interview, the Activity Director stated she was the only activity staff member, the activity assistant was on medical leave, she primarily spent time on other units, and she had not trained CNAs to run activities while supervising the room. She also stated that the [NAME] Unit residents were not having their activity needs met.

Penalty

Fine: $327,700

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that Resident #48, who had a diagnosis of unspecified bilateral hearing loss and severe cognitive impairment, received proper treatment and assistive devices to maintain hearing abilities. The resident’s most recent MDS indicated highly impaired hearing with an absence of useful hearing and that hearing aids were not used during the assessment. The resident’s record also showed a request for audiology services, and physician orders existed for dental, ophthalmology, optometry, and podiatry consults, but the audiology order was not initiated until after survey concerns were raised. Survey observations showed the resident repeatedly without any hearing assistive devices while dressed and sitting in the room, walking with staff, and participating in activities. During one observation, the resident stated he/she could not hear the surveyor and that the hearing aids were not present. The resident’s record contained a DON note stating staff would check to make sure the resident had hearing aids in place because the resident was very hard of hearing and did not hear without them. The record also included a nurse practitioner note stating the resident had hearing loss and used hearing aids, but there was no documentation that the resident had ever been seen by audiology services or that the resident had refused hearing aids. Interviews with the HCP, nursing staff, the Unit Manager, the DON, and the Social Worker showed that the resident had hearing aids when admitted, that they later went missing, and that staff did not notify the HCP or arrange audiology follow-up. The HCP said the resident could not hear without an assistive device and had not been seen by audiology while in the facility. Staff stated that hearing aid loss should have been reported and that the resident should have been referred to audiology, but the resident was not on the upcoming audiology schedule and had never been seen by audiology during the admission. The DON also found hearing aid batteries in the resident’s drawer, but no hearing aids were present.

Penalty

Fine: $327,700

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a safe environment for one resident by not following the resident’s fall-related plan of care. Resident #38 was admitted with diagnoses including dementia and hemiplegia, and the most recent MDS indicated the resident was rarely or never understood and had severe cognitive impairment. The resident’s care plan, revised 2/2/26, identified the resident as high risk for falls related to right-side paralysis and included the intervention: do not leave the resident unattended in the room by himself/herself. Surveyors observed Resident #38 in bed without staff present in the room or visible from the hallway on multiple occasions. On one observation, a nurse later entered the room and stated she was checking on the resident because he/she should never be left alone in the room, explaining that staff must stay with the resident because he/she is a fall risk and is always trying to get out of bed. During interviews, a CNA said staff often leave the resident unattended in the room and was unaware of the care plan requirement, and a nurse said she was also unaware of the intervention. The DON stated that fall interventions in the care plan should be implemented and that Resident #38 should not have been left unattended if the care plan indicated this was an intervention.

Penalty

Fine: $327,700

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to identify and address a significant weight loss for a resident with dementia, adult failure to thrive, and schizoaffective disorder. The resident was cognitively intact on the most recent MDS and required setup assistance for self-feeding and maximal assistance for other ADLs. During observations and interviews, the resident stated he/she was not eating because the food was being poisoned and described refusing meals, while staff reported the resident would eat preferred foods when they were obtained from the kitchen. The resident’s weights showed a decline from 149 pounds to 145.6 pounds, then to 132.6 pounds, which reflected an 8.93% loss in one month and 11% loss in three months, followed by a further drop to 122.6 pounds, a 7.54% loss in one month and a total 17.72% loss over five months. The facility policy required nursing to report weight loss to the dietitian within 24 hours, and if weight loss was verified, the dietitian was to seek care plan adjustments including snacks and supplements, with a full assessment required for weight loss over CMS guidelines. The medical record did not show that the resident was referred to the dietitian after the weight loss occurred, and the resident had not been seen by the facility dietitian since before the documented decline. The nurse practitioner noted weight loss and documented encouraging oral intake and supplements, but the record did not show that supplements were trialed, initiated, or encouraged by nursing staff. Interviews with the nurse practitioner, nursing staff, the RD, and the DON confirmed that the significant weight loss had been identified, but an assessment was not completed and nutritional interventions were not added to the resident’s plan of care.

Penalty

Fine: $327,700

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide oxygen as ordered for two residents with severe cognitive impairment and chronic respiratory conditions. Resident #21 had diagnoses including COPD, dementia, and heart failure, and was ordered oxygen at 2 liters continuous via nasal cannula to keep oxygen saturation at or above 90%. Resident #9 had diagnoses including COPD, a pulmonary nodule, and heart failure, and was ordered oxygen at 2 to 3 liters per minute with oxygen saturation checks each shift and as necessary. Both residents were dependent on staff for care and mobility, and both had care plans directing staff to provide oxygen as ordered and monitor for respiratory distress. During observation, Resident #21 was seen in bed with oxygen at 1 liter via nasal cannula, then later was brought to the dining room without oxygen properly in place. The portable oxygen tubing was wrapped around the tank instead of being placed on the resident’s nose, and later the nasal cannula was on the resident while the portable tank was empty. The resident remained with an empty tank for an extended period while compliant with wearing the cannula. When the nurse checked the resident’s oxygen saturation, it was 85%, then later the DON obtained readings of 74%, 80%, and 80% after repeated checks. The nurse stated he did not know the ordered oxygen level and had not assessed the resident’s oxygen that day, and the CNA stated that CNAs fill tanks before the shift but do not check whether they remain full. Resident #9 was observed sleeping in the dining room with a nasal cannula in place and a portable oxygen tank attached to the recliner, but the tank was empty. The nurse checked the tank and confirmed it was empty, and stated he did not know the ordered oxygen level and had not assessed the resident’s oxygen yet that day. A working oximeter was not available on the unit, so the nurse left to obtain one from another unit. When oxygen saturation was finally obtained, the reading was 74%, and later the DON obtained a reading of 80% after repeating the check. The DON stated that CNAs should be filling portable oxygen tanks and that both CNAs and nurses should be monitoring the tanks and ensuring oxygen is provided at the physician-ordered level.

Penalty

Fine: $327,700

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure safe, appropriate pain management for a resident with chronic pain by not completing a pain management consult ordered by the Nurse Practitioner. Resident #3 was admitted with diagnoses including osteoarthritis, left shoulder pain, fatigue, and major depressive disorder, and the most recent MDS showed the resident was cognitively intact and required moderate to maximum assistance with ADLs. The resident reported ongoing pain in both shoulders that ranged in severity and limited arm movement, stated the current pain regimen was not working, and said staff told him/her to take more medication. The resident also said the pain was causing depression and frustration because of the inability to use his/her arms. The resident’s pain care plan included administering pain medication as ordered and PRN breakthrough medication with effectiveness noted, and the physician order dated 12/9/25 directed a pain management consult and orthopedic follow-up for pain in multiple joints. The medical record did not show that the pain management consult was completed. The Unit Manager stated the facility emails the pain doctor when a consult is ordered and believed the DON had done so, while the NP said the consult was still pending and that the resident’s pain could not be managed by medication alone. The DON acknowledged the consult had not been completed and said there was a two-month delay in communicating the consult to the pain doctor, providing an email request dated 2/9/26. The resident’s activated HCP said the pain regimen was not effective, the pain had worsened over the last one to two years, and the resident had declined and stayed in bed more.

Penalty

Fine: $327,700

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure one resident was provided a trauma informed plan of care after the resident reported sexual abuse by a peer. The resident was admitted in April 2025 with diagnoses including anxiety disorder, paraplegia, and depression, and the most recent MDS indicated intact cognition with a Brief Interview for Mental Status score of 15 out of 15, no behaviors, and dependence on staff for care and transfers. The resident’s trauma care plan, last updated on 4/28/25, addressed a history of trauma related to an accident and paraplegia, with interventions such as encouraging the resident to identify trauma triggers, verbalize feelings, and providing support for loud noises or aggressive behavior from others. The resident reported that another resident repeatedly made sexually explicit and threatening comments, including an incident in which the other resident approached the resident in the hall and made vulgar sexual statements. The resident stated that the issue had been reported to the facility multiple times, that an email was sent to the DON and NHA, and that police were called. The resident also stated that the other resident’s behavior continued after the police response and that the resident lived in fear because he/she could not protect himself/herself or get up and run. Review of the medical record showed the trauma care plan was not updated after the sexual threats and abuse report to include resident-specific triggers and interventions related to the incident. Interviews with staff confirmed the need for an updated trauma care plan: the CNA said the resident became scared and uncomfortable when hearing the accused resident nearby during care, the SW said the resident should have a trauma care plan addressing support needs, the DON said the plan should have been updated after the incident, and the NHA said safeguards should have been put in place and the trauma care plan updated following the event.

Penalty

Fine: $327,700

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide appropriate treatment and services for a resident diagnosed with dementia, traumatic brain injury, wandering, and other behavioral disturbance. The resident had severely impaired cognition on the most recent MDS assessment and was documented as wandering, entering other residents’ rooms, disrobing in hallways and common areas, and making sexually inappropriate remarks and gestures toward other residents. Nursing progress notes repeatedly described the resident as disruptive, difficult to redirect, and continuing the same behaviors after redirection attempts. The resident’s record showed multiple behavior-related care plans, including plans for cognitive impairment, psychotropic medication use, aggression, and inappropriate sexual behavior. Those plans included interventions such as monitoring target behaviors, documenting episodes, protecting other residents, and closely monitoring the resident to prevent recurrence of aggression. The record review found that the care plans and interventions were not reviewed after the resident’s sexual abuse of a peer, and they were not revised when the documented interventions were ineffective. Survey findings and interviews showed that staff were aware of the resident’s ongoing behaviors and that the behaviors continued despite repeated redirection. A DON note documented that police were called after residents reported the resident exposing himself/herself and making sexually explicit statements. During interviews, residents reported feeling unsafe and described repeated sexual comments and exposure. Staff, including CNAs, the SW, the DON, and the psychiatrist, stated that the resident was not appropriate for the facility, that the resident should be on a dementia specialty care unit, and that the resident’s behaviors were not being adequately managed within the facility.

Penalty

Fine: $327,700

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide medically-related social services to support the highest practicable mental and psychological well-being for one resident. Resident #36, who had diagnoses including anxiety disorder, paraplegia, and depression, was cognitively intact on the most recent MDS and was dependent on staff for self-care and transfers. The resident reported that another resident repeatedly made sexually explicit threats and inappropriate comments, including an incident in which the other resident allegedly exposed his/her genitals and made vulgar sexual statements while the resident was seated in the hall with other residents. Resident #36 stated that the incident was reported to the DON and NHA by email and that police were called the same day. The resident said the accused resident was taken to the hospital by responding police officers but returned the next day, and the behaviors continued. Resident #36 also stated that he/she lived in fear that the other resident would take the abuse further and that the facility SW never followed up in person or offered emotional support. Emails in the record showed the resident repeatedly asked that the residents be removed from the area because they were out of control and sexually inappropriate, while the SW responded by email that staff would try to redirect wandering residents and supervise them more closely. The medical record did not show that the abuse was addressed by the SW, and the care plan did not include resolved or current care plans related to the sexual abuse incident or the resident’s report of ongoing abuse. During interviews, the psychiatrist, DON, NHA, and medical director each stated that the resident should have received support and follow-up from the SW after the sexual abuse and threats. The SW stated she was not informed about the initial incident, did not meet with the resident in person, and did not provide talk therapy in the facility because the psychotherapist had left and had not been replaced.

Penalty

Fine: $327,700

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to address and implement the Consultant Pharmacist’s medication regimen review recommendation in a timely manner for one resident. The resident was admitted in September 2022 with diagnoses including glaucoma, dementia, and bipolar disorder, and had physician orders for Latanoprost 0.005% ophthalmic solution in both eyes in the evening for glaucoma and Artificial Tears ophthalmic solution 1% in both eyes three times a day for dry eye. The Consultant Pharmacist’s medication regimen review repeatedly noted that the resident was ordered multiple eye drops and that the eye drops should be separated by at least 5 minutes during administration. The recommendation was documented in December 2025 and again in February 2026, but the resident’s clinical record did not show that the December 2025 recommendation was reviewed or responded to by the provider. During interview, the DON stated the Consultant Pharmacist sends recommendations to him, he gives them to the provider for agreement or disagreement, and nursing enters the orders into the EHR; he also stated that a two-month delay in implementing recommendations would be considered a delay in care.

Penalty

Fine: $327,700

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that four residents were free from unnecessary psychotropic medication use. For one resident with diagnoses including anxiety, dementia with psychotic disorder, unspecified psychosis, major depression, generalized anxiety, and restlessness/agitation, the psychiatrist recommended decreasing Seroquel and discontinuing the morning dose, but the resident’s record did not show that nursing notified the physician or that the recommendation was implemented. The resident’s orders still reflected Seroquel in the morning and at other times, and staff interviews showed the recommendation had been reviewed but not acted on. For two residents receiving antipsychotic medications, the facility did not complete AIMS assessments as expected. One resident with schizophrenia, unspecified mood disorder, and anxiety disorder was ordered ziprasidone, but the record did not show an AIMS assessment since the psychiatrist noted no AIMS symptoms. Another resident with schizoaffective disorder bipolar type and schizophrenia was ordered clozapine, and the record did not show an AIMS assessment completed upon admission. Staff interviews showed uncertainty about who completed AIMS assessments and when they were required, while the DON stated they should be completed upon admission and quarterly. A third resident with dementia, bipolar disorder, unspecified psychosis, anxiety, and major depressive disorder was receiving risperidone 0.5 mg daily and 2 mg in the evening. The resident’s psychotropic care plan included monitoring for side effects and adverse reactions, but the medical record did not show an AIMS assessment since the prior year. Interviews with nursing, social work, and the DON showed inconsistent understanding of responsibility for completing AIMS assessments, and the DON stated the assessment should have been completed for this resident.

Penalty

Fine: $327,700

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide dental services and replace missing dentures for one resident with severe cognitive impairment and dependence on staff for activities of daily living. The resident was admitted with diagnoses including unspecified dementia, mood disturbance, anxiety, and major depression. The resident’s daughter and health care proxy reported that the resident’s dentures had been missing for about a year and said she had not seen the resident wearing them in a long time. She also believed the resident may have lost weight because of not wearing the dentures. During the survey, the resident was observed in the dining room for breakfast and lunch without dentures in place. The resident’s medical record included a dental consult order and a signed consent for dental services, but the record did not show that the resident was ever seen by a dentist or dental hygienist. An email from the resident’s daughter to the social worker stated that staff had tried to locate the missing lower dentures and could not find them, and that a request had been made for the resident to be seen by the dentist. The resident’s care plan included oral hygiene and brushing three times daily and noted that the resident had dentures that should be washed daily and ensured clean in the mouth. When the unit manager and surveyor searched the resident’s room and treatment cart, they found a container labeled with the resident’s name containing a pair of lower dentures, but the upper dentures could not be found. The unit manager said she was unaware the resident had dentures and did not know why the resident had not been seen by the dentist. The CNA said she was unaware whether the resident had dentures and did not assist with placing dentures in. The social worker said she was unaware of the missing dentures and did not recall the email about the lost dentures and dental appointment. The DON said he was unaware the dentures were missing and was unaware the resident had not been seen by the dentist while at the facility.

Penalty

Fine: $327,700

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop, implement, and maintain a QAPI program that addressed the full range of care and services and used a systematic, data-driven approach to identify underlying causes of problems, develop corrective actions, and monitor whether performance improvement activities were effective. The facility policy stated that QAPI should cover clinical care, quality of life, resident choice, care transitions, feedback, data monitoring, performance improvement projects, and system analysis, but the facility's QAPI plan did not show that a QAPI had been developed for the systemic concerns identified by surveyors in rehabilitation services, contracture management, or abuse reporting, investigation, and prevention. During interview, the Administrator said he oversaw QAPI, that the facility had recently moved from quarterly to monthly meetings, and that recent projects had focused on environmental improvements and dietary menu accuracy. When asked about clinical areas, he could not name any recent QAPI work. He stated that QAPI projects should be triggered by adverse events, including events related to contracture management, rehabilitation services, and abuse allegations, but the facility did not complete QAPI projects for those concerns even though they were known issues. The DON said he identified issues by talking with nursing staff and was responsible for the clinical part of QAPI, but QAPI projects were not developed for contracture management or rehabilitation services; he also stated that he recognized concerns when therapy staff were not available for necessary treatments earlier in the fall.

Penalty

Fine: $327,700

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain an infection prevention and control program on the North Unit for two residents who were on Enhanced Barrier Precautions (EBP). Resident #74 was admitted with dysphagia and a gastrostomy tube, and physician orders included enteral feeding every shift and daily tube site care. On 2/5/26 and again on 2/6/26, a CNA was observed providing morning care to Resident #74 without wearing a gown, despite an EBP sign posted at the room entrance and a PPE bin located in the hallway outside the room. During interview, the CNA stated the resident was not on precautions and believed the signage and PPE bin belonged to a previous resident. A nurse later stated that residents with wounds and medical devices should be on EBP and that the CNA should have worn PPE when providing care. Resident #6 was admitted with dementia and a pressure ulcer, and had an order dated 2/11/26 for daily wound care to a stage 4 full-thickness right heel wound. On 2/6/26, a nurse brought the entire treatment cart into Resident #6's room to perform the dressing change and was observed multiple times removing soiled gloves without performing hand hygiene before putting on new gloves. During interview, the nurse stated the resident was on EBP, that the treatment cart should not have been brought into the room, and that hand hygiene should have been performed between glove changes. The DON stated that EBP should be followed for residents with medical devices or wounds and that nurses are expected to perform hand hygiene when changing gloves.

Penalty

Fine: $327,700

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to educate residents and staff on COVID-19 vaccination, offer the vaccine to eligible residents and staff after education, and properly document vaccination status when it administered the COVID-19 vaccine to one resident without consent from the resident or the resident’s health care proxy. The resident was admitted in October 2022 with diagnoses including unspecified dementia, mood disturbance, anxiety, and major depression, and the most recent MDS showed a BIMS score of 1, indicating severe cognitive impairment. The resident was dependent on staff for activities of daily living and required supervision for mobility tasks, and was not able to participate in an interview during the survey period because of cognitive status. The resident’s daughter and health care proxy told surveyors that she had informed the facility she did not want the resident to receive the COVID-19 vaccine and that the resident would not have agreed to it if cognitively able. The medical record contained an email from the daughter stating she did not want the resident getting the vaccine. Despite this, the physician record included an order for Comirnaty COVID-19 vaccine, and the November 2025 MAR and nursing note documented the vaccine as administered. The DON initially stated he believed the resident had not received the vaccine because he only saw the nursing note, but after re-reviewing the record he stated that because there was an order and the nurse documented administration, the vaccine must have been given without the health care proxy’s consent.

Penalty

Fine: $327,700

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Resident #1’s MDS assessment dated 12/23/25 inaccurately coded the use of restraints as less than daily. The resident was admitted in September 2025 with diagnoses including Alzheimer’s dementia and had a BIMS score of 3 out of 15, indicating severe cognitive impairment. Survey observations on multiple dates found the resident seated without restraints, and review of the physician’s orders, plan of care, and nursing progress notes for the assessment period did not show restraint use. A nurse who worked with the resident in December 2025 stated the facility was restraint free and that the resident was never restrained, and the MDS Coordinator confirmed the assessment was coded inaccurately. Resident #50’s MDS assessment dated 12/11/25 inaccurately coded the resident as rarely/never understood and did not complete the BIMS and Mood interviews. The resident was admitted in March 2025 with diagnoses including Alzheimer’s dementia and preferred to speak Swahili, with an interpreter needed or wanted to communicate with staff. A CNA stated the resident speaks Swahili, can understand English enough to answer basic questions, and communicates other needs with Swahili-speaking staff. The MDS Coordinator and Social Worker both stated the resident was usually able to understand and make needs known in Swahili, that the resident should not have been coded as rarely/never understood, and that the interviews should have been attempted and completed in the resident’s preferred language. Resident #24’s discharge MDS dated 12/16/25 and annual MDS dated 12/19/25 failed to indicate a pressure ulcer despite documentation of an unstageable necrosis wound on the left hand. The resident was admitted in December 2024 with diagnoses including osteoarthritis, heart failure, and hypertension. Records showed a weekly skin assessment identifying unstageable necrosis on the left hand, a dietitian note describing an unstageable necrosis left hand wound, ongoing treatment orders for soaking and dressing the left hand throughout December 2025, and a hospital discharge summary stating the patient had a pressure ulcer with wound care recommendations. A nurse confirmed the resident had a known unstageable pressure ulcer in the contracted left hand at discharge, and the MDS Coordinator stated both MDS assessments were coded inaccurately.

Penalty

Fine: $322,660

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect three residents from neglect, specifically in the implementation of wound care treatments as recommended by the Consultant Wound Physician. For Resident #20, the facility neglected to implement wound treatments, resulting in the deterioration of a pressure injury from a closed unstageable to a Stage 4 pressure injury. The facility also failed to follow up on a progress note indicating right hip redness and did not implement the use of an air mattress. Observations revealed that care-planned interventions, such as the use of prevalon boots and an air mattress, were not implemented, and there was a lack of documentation and follow-up on new skin issues. Resident #23 was also neglected as the facility failed to implement treatment recommendations for a stage two pressure wound on the left heel. The resident was observed with heels directly on the mattress and without the necessary dressing, despite the wound physician's recommendations. The nursing staff did not communicate the wound recommendations to the medical doctor, and there was no treatment order in place for the resident's pressure ulcer. For Resident #26, the facility neglected to implement the treatments as recommended by the Consultant Wound Physician, resulting in undocumented wound treatment and failure to implement treatment orders for newly identified pressure ulcers. The resident had multiple pressure ulcers and non-pressure wounds, and the facility did not follow the wound physician's dressing treatment plans. Interviews with staff revealed a lack of awareness and communication regarding the residents' wound care needs and treatment recommendations.

Penalty

Fine: $322,660

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate care and treatment to prevent the development and worsening of pressure injuries for three residents. For one resident, the facility did not implement the treatments and physician orders recommended by the Consultant Wound Physician, resulting in the deterioration of an unstageable pressure wound to a Stage 4 pressure injury. The facility also failed to use an air mattress and did not follow up on a progress note indicating right hip redness, leading to the development of a right hip wound. Another resident did not receive the treatment recommendations by the Wound Consultant Physician for wound care. The facility's policy on pressure injury risk assessment and decubitus prevention was not followed, as evidenced by the lack of timely risk assessments, skin inspections, and implementation of care plans based on identified risk factors. The facility also failed to notify the attending providers of the wound consultant's recommendations and did not implement the recommended wound treatments in a timely manner. The facility's lack of communication and documentation contributed to the deficiencies. Nursing staff did not have access to wound recommendations and visit notes, and there was no unit manager or Director of Nurses to oversee the implementation of wound care. The Medical Director and Nurse Practitioner were not made aware of the resident's condition and treatment orders, leading to inconsistencies in care and documentation. The facility's failure to follow the wound consultant's recommendations and implement preventative measures resulted in the worsening of pressure injuries for the residents.

Penalty

Fine: $322,660

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that nursing staff were adequately trained and demonstrated the necessary competencies to provide appropriate care for residents, particularly in the area of pressure injury and wound care. This deficiency was highlighted by the case of a resident who was admitted with several medical conditions, including Alzheimer's disease and a cognitive communication deficit. The resident developed an unstageable deep tissue injury (DTI) on the right heel, which deteriorated into a Stage 4 pressure injury due to the staff's failure to implement recommended treatments and notify the physician of the wound's progression. The survey revealed that the facility did not conduct proper training or competency evaluations for its nursing staff. Personnel files of 13 nursing staff members, including licensed nurses and certified nursing assistants, lacked documentation of competencies necessary for wound care and other specialized care areas. Interviews with nurses indicated that they had not received adequate training or competency evaluations related to wound care, and some nurses admitted to not documenting wound assessments or notifying physicians of changes in wound conditions. Additionally, the facility's policy on wound care was not effectively implemented, as evidenced by the incomplete wound care competency checklists for licensed nurses. Observations during the survey showed that some nurses did not follow proper infection control protocols during wound dressing changes. The facility's lack of a structured training curriculum and reliance on verbal confirmations for staff training further contributed to the deficiency, as there was no formal process to ensure that nursing staff were competent in providing the necessary care for residents.

Removal Plan

• The MDS/Educator Nurse has developed nursing competencies specific to wound care to be provided to all clinical team members to ensure that this practice does not recur.
• Wound Care competencies will be completed.
• The nursing competencies evaluate the nurse on identifying, assessing and treating wounds, wound care testing regarding sterile dressing changes, Decubitus care, knowledge of and review of each nurse's documentation, evaluations of careplan knowledge, lifting and positioning knowledge, transfer technique, incontinent skin relation to skin integrity, medication evaluations and many other skilled nursing techniques.

Penalty

Fine: $322,660

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure effective and efficient use of its resources to provide appropriate wound care, resulting in the development of an infected Stage 4 pressure injury for a resident. The administration did not provide necessary education and training for nursing staff to manage wound care competently. This lack of training led to a failure in performing skin checks, wound evaluations, implementing physician orders, and updating the physician and care plan when significant changes occurred. The resident, who was admitted with diagnoses including Alzheimer's disease and was at risk for pressure injuries, developed a new unstageable deep tissue injury that deteriorated into a Stage 4 pressure injury. The medical records revealed that the nursing staff did not implement the treatment and physician orders recommended by the Consultant Wound Physician. There was a lack of documentation indicating that the physician was notified of the wound's progression. Interviews with nursing staff indicated that they had not received any training or competencies related to wound care, and their education files lacked documentation of necessary skills to evaluate and manage the resident's wound properly. The absence of a Director of Nursing (DON) and other clinical oversight roles further exacerbated the situation, as there was no effective system in place for pressure injury prevention and care. The facility's administration did not assign a competent individual to oversee clinical decisions in the absence of the DON. Interviews with staff revealed confusion about roles and responsibilities, with some staff unaware of their designation as charge nurses or lacking access to wound care recommendations. The Medical Director and other senior members were not informed of the DON's absence, and there was no tracking system for wound care recommendations. This lack of clinical oversight and communication contributed to the failure in providing adequate wound care for the resident.

Penalty

Fine: $322,660

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to notify the physician or nurse practitioner of the treatment recommendations made by the consulting wound physician for two residents, resulting in the wound treatments not being implemented. Resident #23, who was admitted with diagnoses including traumatic brain injury and major depressive disorder, had a stage two pressure wound on the left heel. Despite the wound doctor's recommendations for treatment, the facility did not implement these orders, and the physician was not informed. Similarly, Resident #26, admitted with multiple pressure ulcers and dementia, did not have the wound doctor's treatment recommendations communicated to the physician, leading to a lack of implementation of necessary wound care. Additionally, the facility failed to notify the physician or nurse practitioner of a change in condition for two residents. Resident #6, who has chronic obstructive pulmonary disease and requires oxygen therapy, was found without proper oxygen administration, leading to a significant drop in oxygen saturation and respiratory distress. The staff did not notify the physician or nurse practitioner of this critical change in condition. Furthermore, Resident #6 experienced a significant weight loss of 12% in one month, yet the facility did not report this to the physician as required by their policy. Resident #7 also experienced a failure in communication regarding changes in their condition. The facility did not report to the nurse practitioner or physician that the resident had open, discolored, and weeping skin on the right lower extremity, as well as scabs and swelling on the left lower extremity. This lack of communication and failure to implement treatment recommendations highlights significant deficiencies in the facility's processes for managing changes in residents' conditions and ensuring appropriate medical interventions are in place.

Penalty

Fine: $322,660

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to address the nutritional status of a resident in a timely manner, resulting in a significant weight loss of 12% over one month. The resident, who was admitted with diagnoses including dysphagia, vitamin deficiencies, and dementia, was observed not eating meals on multiple occasions. Despite being on a planned weight gain program with dietary supplements, the resident experienced unplanned weight loss, which was not promptly addressed by the facility. The facility's policy required re-weighing residents with significant weight changes and notifying the dietitian and physician. However, the resident's weight loss was not consistently monitored, and re-weights were delayed. The dietitian requested re-weights on several occasions, but these were not completed within the expected timeframe. Additionally, there was a lack of communication and documentation regarding the resident's weight loss, and no new dietary orders were implemented to address the issue. Interviews with staff revealed a lack of awareness and communication regarding the resident's weight loss. The nurse practitioner and medical director were not informed of the significant weight loss, and the registered dietitian noted delays in re-weighting and communication due to the absence of a Director of Nursing. The facility's failure to adhere to its weight management policy and ensure timely interventions contributed to the resident's continued weight loss.

Penalty

Fine: $322,660

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide consistent oxygen therapy to a resident with chronic obstructive pulmonary disease (COPD) and other respiratory conditions, leading to a significant drop in the resident's oxygen saturation levels. The resident, who was cognitively intact and required continuous oxygen therapy, was observed multiple times without the nasal cannula properly placed, resulting in oxygen saturation levels as low as 77%, causing respiratory distress. Despite the presence of staff in the dining room, the resident's oxygen needs were not adequately monitored or addressed. Observations revealed that the resident's portable oxygen concentrator was empty, and the nasal cannula was not correctly positioned in the resident's nostrils. Nurse #1, who was responsible for the resident's care, failed to recognize the improper placement of the nasal cannula and the empty oxygen tank, leading to the resident experiencing difficulty breathing and using accessory muscles to breathe. The nurse initially dismissed the resident's condition as stable and only took corrective action after being prompted by the surveyor. Interviews with facility staff, including the Nurse Practitioner and Medical Director, indicated a lack of communication and adherence to physician orders regarding the resident's oxygen therapy. The staff failed to notify the Nurse Practitioner of the resident's respiratory distress, and there was a general lack of awareness and competence in managing the resident's oxygen needs. The facility's failure to ensure proper respiratory care and treatment according to professional standards and physician orders resulted in the resident's hospitalization due to a change in mental status and low oxygen levels.

Penalty

Fine: $322,660

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure sufficient staffing to meet the needs of residents, particularly on weekends, as evidenced by the Payroll-Based Journal (PBJ) Staffing Data Report for Fiscal Year Quarter 2, 2024. The report indicated excessively low weekend staffing, which triggered a follow-up during the survey. The facility's 'Facility Assessment Tool' outlined a staffing plan that required 11.5 licensed nurses and 26 nurse aides, but did not specify hours per resident day. Resident Council Meeting Minutes revealed complaints from residents about longer wait times and insufficient staff on weekends, with staff acknowledging the shortages and the use of temporary agencies to fill gaps. Interviews with the Administrator confirmed that staffing was a challenge at the beginning of 2024, with a target of 3.56 to 3.60 hours per patient day (PPD) for a census of 60-70 residents. However, the PPD data for January, February, and March 2024 showed that weekend staffing consistently fell below this target, with all weekends in January and March, and most in February, not meeting the required PPD. This deficiency in staffing levels directly impacted the facility's ability to provide adequate care and maintain the highest practicable physical, mental, and psychosocial well-being of the residents.

Penalty

Fine: $322,660

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a Registered Nurse (RN) was serving as the Director of Nurses (DON) on a full-time basis. The deficiency was identified through multiple interviews conducted with facility staff. The Administrator confirmed that there has not been a DON working at the facility since August 22, 2024, and efforts are ongoing to fill the position. The Project Manager indicated that extra nursing staff are providing oversight by working overtime in the absence of a DON. The MDS Coordinator, who recently started working, was informed that the DON was on medical leave. Several nurses and the Scheduler expressed uncertainty about who was currently in charge of the nursing department, confirming that the DON had been absent for weeks.

Penalty

Fine: $322,660

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a Certified Nurse Assistant (CNA) was not employed for more than four months without passing the CNA exam and obtaining a CNA license. CNA #6 was hired on March 4, 2024, and was not registered as a CNA in the state of Massachusetts. Despite being aware of this issue on July 4, 2024, the Director of Nursing did not remove CNA #6 from the schedule, allowing them to continue providing direct resident care. The Administrator's Assistant confirmed that CNAs need an active license to perform duties and removed CNA #6 from the schedule only after being informed by the surveyor during the survey period.

Penalty

Fine: $322,660

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to conduct performance evaluations for three Certified Nursing Assistants (CNAs) as required by their policy. The policy mandates performance evaluations to be conducted approximately 90 days after hire or job change, and annually thereafter. However, a review of employee files revealed that three CNAs, hired on 6/26/06, 7/14/24, and 12/5/22, did not have documented performance reviews. During an interview, the Consultant Nurse confirmed that all facility employees, including CNAs, should receive yearly performance evaluations.

Penalty

Fine: $322,660

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to conduct and document a comprehensive facility-wide assessment that accurately reflected the resources necessary to care for its residents. Specifically, the facility did not ensure that licensed nursing staff were competent in wound care, which is a critical service offered based on the residents' needs. The facility's assessment tool, dated April 5, 2024, outlined various common diagnoses among residents, including skin ulcers and other conditions requiring wound care. Despite this, the review of seven licensed nurse personnel files active during the survey period showed a lack of documented competency assessments in wound care. During an interview, the Consulting Nurse confirmed that all licensed clinical staff should have documented clinical competencies, indicating a gap in the facility's training and competency verification processes. The facility's documentation stated that staff training and inservices were provided throughout the year, including wound care, but the absence of competency assessments in the personnel files suggests a failure to ensure that staff were adequately prepared to meet the residents' wound care needs.

Penalty

Fine: $322,660

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement an effective infection control program, as evidenced by several deficiencies. Firstly, the facility did not have a water management program in place to prevent water-borne illnesses, such as Legionella. The Maintenance Worker admitted to not knowing the risk assessment for the building and was in the process of contacting a water management company. This indicates a lack of preparedness and proactive measures in managing potential water-borne infections. Secondly, the facility did not implement enhanced barrier precautions for residents at risk of or colonized with multi-drug resistant organisms (MDROs). Staff members, including nurses and certified nurse aides, were unaware of the need for personal protective equipment (PPE) during high-contact care activities for residents with wounds or indwelling medical devices. Observations revealed that staff did not use PPE during wound care, and there were no signs or PPE available for residents requiring enhanced barrier precautions. Additionally, the facility failed to maintain infection control standards for respiratory equipment, as a nasal cannula that had fallen on the floor was placed back on a resident without being cleaned or replaced. This resident, who had severe cognitive impairment and was dependent on staff for care, was at risk due to the improper handling of their oxygen therapy equipment.

Penalty

Fine: $322,660

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement an effective antibiotic stewardship program as required by the Centers for Disease Control and Prevention (CDC) guidelines. The facility's policy, dated 10/11/23, outlined the need for an Antibiotic Stewardship Program (ASP) to promote appropriate antibiotic use and optimize infection treatment. However, the facility did not track antibiotics for the month of July 2024 and only tracked one of three units in August 2024. Additionally, there was no evidence of an antibiotic time-out process to reassess the need for antibiotics prescribed to residents. Interviews with facility staff revealed a lack of awareness and education regarding the antibiotic stewardship program. Nurse #3 and CNA #2 were unfamiliar with the program, and Nurse #3 did not notify providers about antibiotic time-outs. Nurse #6 also confirmed she had not received education on the program and only recorded resident names on line listings. The Consulting Nurse emphasized that the program should involve more than just line listings and that nursing staff should be knowledgeable about initiating the program when a resident starts an antibiotic.

Penalty

Fine: $322,660

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to designate a qualified infection preventionist responsible for the infection prevention and control program. The Director of Nurses (DON) was identified as the Infection Control Preventionist, but she has been on leave since August 22, 2024. The review of the DON's training course modules revealed that she did not complete the post-test required to receive the certificate of completion for the Infection Preventionist training. Interviews conducted with various staff members, including nurses and a certified nurse aide, indicated a lack of awareness regarding the current infection preventionist in the building. The Consulting Nurse also confirmed the absence of a designated backup for the infection preventionist role and emphasized the necessity of completing the training modules and post-test to qualify as an Infection Preventionist. This lack of designation and training completion led to the deficiency in the facility's infection prevention and control plan.

Penalty

Fine: $322,660

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement and maintain an effective training program for both new and existing staff members, as required by their Facility Assessment. The assessment outlined the need for staff training on various clinical competencies, including infection control, resident assessments, and specialized care procedures. However, a review of personnel files for clinical nursing staff, including licensed nurses and CNAs, revealed a lack of documented training and competencies. None of the reviewed files showed evidence of completed clinical training or competencies upon hire, and there was no documentation of yearly competencies as required by the Facility Assessment. Interviews with facility administrators and staff further highlighted the deficiency. The Administrator and Assistant Administrator admitted that new employees only received a brief orientation focused on policies and procedures, without any clinical training. They also acknowledged the absence of a formal training curriculum, relying instead on verbal confirmation and word of mouth to track training status. A consulting nurse confirmed that all licensed clinical staff should have documented clinical competencies, which were missing in the reviewed files. No additional educational documents were provided during the survey to address these deficiencies.

Penalty

Fine: $322,660

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement mandatory infection control training for all direct care staff, as evidenced by a review of personnel files and interviews. The Facility Assessment, reviewed in April 2024, outlined the need for staff training and competencies in various areas, including infection control. However, upon review of 10 personnel files of actively working clinical nursing staff, including 4 Licensed Nurses and 6 Certified Nursing Assistants (CNAs), it was found that the facility did not conduct training that included an evaluation of demonstrated competencies necessary for the resident population, particularly in infection control. None of the 10 direct care staff had documentation of completed infection control training or competencies upon hire. Interviews with staff further highlighted the deficiency. Nurse #6 mentioned that during orientation, the focus was primarily on administrative topics, sensitivity training, abuse training, and HIPAA, with minimal emphasis on clinical aspects such as infection control. The Consulting Nurse confirmed that all licensed clinical staff should have documented clinical competencies, which were lacking in this case. The absence of documented infection control training and competencies for the staff indicates a significant oversight in the facility's infection prevention and control program.