Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Water's Edge Center For Health & Rehab during CMS and state inspections, most recent first.
A resident with chronic respiratory failure and pain was ordered a Fentanyl 12 mcg transdermal patch every 72 hours. After an LPN removed a patch early, an RN supervisor obtained a verbal order to replace it but mistakenly entered Fentanyl 75 mcg into the eMAR and co‑signed the order alone. Nursing staff continued to administer 12 mcg patches while documenting 75 mcg on the MAR, without fully verifying the order against the medication packaging. Later, an APRN, not recognizing the erroneous increase in the record, refilled the prescription at 75 mcg, the pharmacy dispensed that strength, and a 75 mcg patch was applied. The resident subsequently developed decreased respirations and low oxygen saturation, and the discrepancy between the intended 12 mcg dose and the administered 75 mcg patch was identified as a clinically significant medication error.
A resident with osteoarthritis, anxiety, Alzheimer’s dementia, impaired cognition, incontinence, and unsteady gait was identified as a fall risk and care planned for supervise/touching assist with toileting and personal hygiene, use of a cane, and non-skid socks, but had no documented scheduled toileting or prompted voiding program. During one bathroom assist, a NA partially closed the door and turned away to provide privacy, after which the resident sustained an unwitnessed fall with head strike and a right distal humerus fracture. Documentation later described the resident as noncompliant with transfers and frequently ambulating without assistance or using the call light. The resident was subsequently found on the bathroom floor again after attempting to use the toilet, this time with severe left upper extremity pain and a left displaced comminuted distal humerus fracture, demonstrating that supervision and fall-prevention interventions were not effectively implemented for this high-risk, cognitively impaired resident.
A cognitively impaired resident with osteoarthritis, anxiety, and Alzheimer’s dementia, who was frequently incontinent and not on a toileting program, did not have a comprehensive, person-centered care plan that included scheduled toileting or prompted voiding despite documented fall risk and self-care deficits. The care plan called for supervised/touching assist with toileting and personal hygiene and general fall-prevention measures, but lacked a structured toileting program. The resident was assisted to the bathroom by a NA, who partially closed the door and turned away, then found the resident on the floor after an unwitnessed fall that resulted in a distal humerus fracture. Later documentation noted ongoing issues with transfers, unassisted ambulation without using the call light, and another bathroom fall causing a second distal humerus fracture, while facility policies required ADL assistance and fall-prevention interventions to be based on a person-centered evaluation and incorporated into the care plan.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
A resident with atrial fibrillation was given Aspirin 81 mg daily instead of the prescribed twice-weekly dose due to a transcription error by a nurse, which was not caught by the orienting nurse or through the facility's required second-check process. The error resulted in the resident receiving the medication more frequently than ordered until the mistake was discovered after discharge.
A resident with severe cognitive impairment sustained a facial injury during care, and a nursing assistant later alleged that another staff member may have struck the resident. The allegation was not reported to a supervisor or the state agency until five days after the incident, contrary to facility policy requiring immediate reporting of abuse allegations.
A resident with severe cognitive impairment and total dependence for ADLs did not receive care according to their plan, which required two staff for assistance. Instead, a nurse aide provided care alone while the resident was agitated, resulting in the resident sustaining a left eye bruise and cut from a Hoyer lift sling attachment. Documentation and interviews confirmed the aide was aware of the two-person requirement but proceeded alone due to delays in obtaining help.
A resident with dementia experienced an unwitnessed fall, resulting in a minor head contusion. Despite facility policy requiring neurological monitoring, the medical record lacked documentation of completed assessments. The DNS confirmed monitoring was done but could not provide the records, indicating a failure to maintain accurate documentation.
A resident with dementia and traumatic brain injury, at high risk for elopement, was able to exit a secured unit unsupervised due to an expired wander guard. Despite weekly checks, the device was not replaced, allowing the resident to access the elevator and leave the facility. Staff failed to document elopement behaviors or conduct required monitoring, and the facility's policies on wander guard usage and elopement prevention were not followed.
The facility failed to maintain a clean, sanitary, and homelike environment across all units, with issues such as damaged and stained floors, walls, and ceilings observed. The Director of Maintenance was aware of some issues but did not document findings, while the ADNS and DNS were unaware of the extent of the problems. The facility's infection prevention program requires monthly rounds, but documentation was lacking.
A resident with dementia and other medical conditions experienced a significant delay in receiving dentures due to poor communication and follow-up by the facility. Despite initial steps taken in 2021 and 2022, the resident did not receive dentures for over two years, even though dental services were available. The facility failed to adhere to its policy of providing necessary dental care and documenting delays.
The facility failed to serve food at a safe temperature, as observed during a test tray evaluation. The main entree and peas were found to be below the required temperature of 140 degrees Fahrenheit. The FSD could not explain the temperature drop, despite meals being plated on a warming tray and delivered quickly. Facility policy requires action if food temperatures fall below 135 degrees Fahrenheit.
The facility failed to maintain sanitary conditions in the kitchen, with surveyors observing unsanitary conditions such as empty trash bags and boxes on countertops, opened and undated food items, and improperly stored non-resident items. The FSD cited short staffing as a challenge in adhering to cleaning schedules and storage expectations. The facility's policies on food storage and sanitation were not met, as confirmed by the DNS and Administrator.
The facility failed to notify resident representatives and physicians of significant changes in condition for two residents. One resident, at high risk for elopement, left a secured unit twice without proper notification or documentation. Another resident experienced eye discomfort and a rash, but the physician and representative were not promptly informed. Interviews revealed lapses in communication and adherence to facility policies.
The facility failed to monitor and document care for two residents, one with itchy skin and another with edema. The first resident did not receive prescribed anti-itch medication, and there was no behavior monitoring. The second resident was not assessed by an RN for eye discomfort and did not consistently receive compression stockings as ordered. Lack of policies and adherence to physician orders contributed to these deficiencies.
A resident with multiple diagnoses, including a fractured kneecap and gout, experienced inadequate pain management over a weekend due to a lack of prn medication orders and failure of staff to contact the physician for additional pain relief. Despite expressing significant pain, the resident was not provided further Acetaminophen, resulting in a sleepless night. The facility's Pain Management Policy, which requires prompt evaluation and treatment, was not adhered to, leading to unmanaged pain.
A facility failed to provide a bed hold notice to a resident with intact cognition during four hospital transfers, despite policy requirements. The resident, admitted with bowel obstruction and anemia, only signed the notice at admission. Interviews revealed that the RN Supervisor did not follow the procedure to send the notice with the resident, contrary to facility policy.
Significant Fentanyl Patch Dosing Error and Transcription Failures
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from a significant medication error related to Fentanyl transdermal patches. The resident had diagnoses including nontraumatic intracerebral hemorrhage in the brain stem, chronic respiratory failure, and congestive heart failure, and had severely impaired cognition. Physician orders from early November through late February directed application of a Fentanyl 12 mcg patch every 72 hours for pain, and controlled substance disposition records showed that 12 mcg patches were dispensed and applied on that schedule. The resident’s care plan identified actual pain related to disease process and altered respiratory status related to chronic respiratory failure, with interventions to administer medications as ordered and monitor for effectiveness and side effects. On one shift, an agency LPN removed the resident’s Fentanyl patch a day earlier than scheduled and then realized there was no order to replace it. The LPN notified the RN supervisor, who contacted the APRN and obtained a verbal order to replace the patch and continue the 72‑hour cycle. When entering the new order into the electronic MAR, the RN supervisor inadvertently selected Fentanyl 75 mcg instead of 12 mcg and co‑signed the order herself rather than obtaining a second nurse verification. Subsequent review of controlled substance disposition records showed that no 75 mcg patches were dispensed at that time and that 12 mcg patches continued to be applied on multiple dates, while the February MAR reflected that staff were documenting administration of a 75 mcg patch on those same dates. Nursing staff continued to sign for Fentanyl 75 mcg on the MAR even though only 12 mcg patches were being dispensed and applied, and they did not fully read and verify the physician’s order against the medication packaging. Later, the APRN refilled the Fentanyl prescription and, not recognizing that the dose in the record had been erroneously increased, accidentally refilled the prescription for Fentanyl 75 mcg instead of 12 mcg. The pharmacy then dispensed 75 mcg patches, and the first 75 mcg patch was applied to the resident. After application of the 75 mcg patch, the resident experienced a change in condition characterized by a decreased respiratory rate and low oxygen saturation on room air, which improved with repositioning and supplemental oxygen. The event was identified as a clinically significant medication dose discrepancy, with the patch in place being Fentanyl 75 mcg while the intended dose was 12 mcg. Interviews with the DNS, APRN, RN supervisor, and pharmacist confirmed that the incorrect 75 mcg order had been entered into the eMAR, that the APRN later refilled the higher dose in error, and that nursing staff failed to follow the facility’s medication administration policy and the six rights of medication administration, resulting in the resident receiving a Fentanyl 75 mcg patch instead of the ordered 12 mcg dose.
Failure to Adequately Supervise High-Risk Resident During Toileting Leading to Recurrent Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and effective fall prevention interventions for a cognitively impaired resident with incontinence and a known fall risk, resulting in two unwitnessed falls with major injuries. The resident had osteoarthritis of the knee, anxiety, and Alzheimer’s dementia, with a BIMS score of 5, was frequently incontinent of bowel and bladder, and was not on a toileting program. The resident’s care plan identified a self-care deficit related to weakness and deconditioning, with interventions including toileting and personal hygiene using a straight point cane with supervise/touching assist of one staff, and dementia-related interventions to anticipate and meet needs. The care plan also identified potential for falls due to unsteady gait, with interventions such as non-skid socks, monitoring for gait changes, and offering diversional activities including toileting and ambulating. However, the clinical record did not show a scheduled toileting or prompted voiding program to address incontinence and toileting needs. On one occasion, the resident was assisted to the bathroom by a nursing assistant, who opened the bathroom door and observed the resident place the cane in the sink. The nursing assistant, aware that the resident liked privacy, partially closed the door and turned away, after which a sound was heard and the resident was found on the floor with a head strike and painful right forearm, later diagnosed as a bicondylar intra-articular fracture of the distal humerus. The DNS stated that at the time of this first fall, the resident was care planned as a supervised assist of one for toileting and personal hygiene, meaning staff were to supervise the ADL to allow for cueing and assistance, and acknowledged that the nursing assistant did not provide constant supervision because his back was turned. Subsequent documentation noted the resident was noncompliant with transfers and was observed multiple times ambulating without assistance and not using the call light. Later, the resident was found lying on the bathroom floor on the left side after using the bathroom, complaining of severe left upper extremity pain and inability to move the arm, and was diagnosed with a left displaced comminuted fracture of the distal humerus. These events occurred despite the resident’s known cognitive impairment, incontinence, unsteady gait, and identified fall risk.
Failure to Develop Comprehensive Toileting and Fall-Risk Care Plan for Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to develop a comprehensive, person-centered care plan addressing a cognitively impaired resident’s toileting needs and fall risk, including the absence of a scheduled toileting or prompted voiding program. The resident had osteoarthritis of the knee, anxiety, and Alzheimer’s dementia, with a BIMS score of 5 indicating impaired cognition, and was frequently incontinent of bowel and bladder without being on a toileting program. The Resident Care Plan identified self-care deficits related to weakness and deconditioning, dementia with an intervention to anticipate and meet needs, and potential for falls due to unsteady gait, with interventions such as supervised/touching assist for toileting and personal hygiene, use of non-skid socks, monitoring gait changes, and offering diversional activities including toileting and ambulating. However, the care plan did not include a structured toileting schedule or prompted voiding program despite the resident’s incontinence and cognitive impairment. The resident experienced an unwitnessed fall in the bathroom with a head strike, resulting in a frontal head hematoma and a painful right forearm, and was later diagnosed in the ED with a bicondylar intra-articular fracture of the distal humerus. At the time of this fall, the resident was assisted to the bathroom by a NA, who opened the bathroom door, observed the resident place a cane in the sink, then partially closed the door to provide privacy and turned away, subsequently hearing a sound and finding the resident on the floor. The DNS stated that the resident was care planned as a supervised assist of one for toileting and personal hygiene, meaning staff were to supervise the ADL to allow for cueing and assistance, and acknowledged that the NA did not have constant supervision because his back was turned. Subsequent nursing notes documented the resident being noncompliant with transfers, being found in the bathroom after asking to lie down, ambulating multiple times without assistance and not using the call light, and later being found lying on the bathroom floor again after using the bathroom, with severe pain and inability to move the left upper arm, and an ED diagnosis of a left displaced comminuted fracture of the distal humerus. The facility’s ADL policy and Fall Prevention Program required assistance per the person-centered care plan and incorporation of risk-based interventions into the care plan, which were not fully implemented regarding scheduled toileting and fall prevention for this resident.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Medication Order Transcription Error Leads to Incorrect Aspirin Administration
Penalty
Summary
A deficiency occurred when a physician's order for Aspirin 81 mg to be administered twice a week was incorrectly transcribed as a daily order for a resident with atrial fibrillation. The hospital discharge summary specified the correct dosing frequency, but during the admission process, a registered nurse transcribed the order into the electronic medical record as a daily dose. The medication was then administered daily for five consecutive days, rather than the intended twice-weekly schedule. The error was not identified until after the resident was discharged, when a medication incident report was completed. Interviews revealed that the nurse responsible for transcribing the order did not re-check the order before confirming it in the EMR and assumed her preceptor would review her work. The preceptor, who was orienting the nurse, did not verify the accuracy of the transcribed order. The Director of Nursing Services confirmed that the facility's process requires a second nurse to review and confirm new orders in the EMR, but this second check was not completed, resulting in the medication error.
Failure to Timely Report Alleged Abuse
Penalty
Summary
Staff failed to report an allegation of abuse in a timely manner for a resident with dementia and severe cognitive impairment. The resident, who was dependent for activities of daily living and required assistance with mobility and transfers, sustained a left eye bruise and cut during care involving a mechanical lift. A nursing note documented the injury and indicated the resident was agitated and had banged their head, but later, a nursing assistant alleged that another staff member could have struck the resident during care. The allegation was not reported to a supervisor until five days after the incident, despite facility policy requiring immediate reporting of abuse allegations. Documentation and interviews confirmed that the delay in reporting occurred because the nursing assistant who heard the resident's accusation did not notify a supervisor until several days later. The incident was subsequently reported to the state agency five days after it occurred. The director of nursing acknowledged that the incident should have been reported immediately, in accordance with facility policy. The failure to promptly report the suspected abuse resulted in a deficiency finding during the survey.
Failure to Follow Two-Person Assist Plan Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, dependent for activities of daily living (ADLs), and frequently incontinent, did not receive care in accordance with their plan of care. The resident's care plan and aide care card both directed that two staff members were required to assist with care, including bed mobility, repositioning, and transfers using a mechanical lift. Despite these directives, a nurse aide provided care alone while the resident was agitated, and only called for assistance when it was time to use the Hoyer lift for transfer. During this episode, the resident sustained a left eye bruise and cut, reportedly from the Hoyer lift sling attachment, after expressing pain and agitation. Interviews and documentation confirmed that the nurse aide was aware of the requirement for two-person assistance but proceeded alone due to delays in obtaining help. The Director of Nursing confirmed that the resident was care planned for two-person assistance and that care should not have been provided while the resident was agitated. The incident was identified through clinical record review, staff interviews, and facility documentation, which showed that care was not provided according to the resident's plan of care.
Incomplete Neurological Monitoring Documentation After Resident Fall
Penalty
Summary
The facility failed to ensure the medical record for a resident was complete and accurate, specifically regarding documentation of neurological monitoring following an unwitnessed fall. The resident, who had a diagnosis of dementia and was severely cognitively impaired, experienced a fall resulting in a minor contusion to the head. Despite the facility's policy requiring neurological evaluations and monitoring after such incidents, the record review did not identify completed neurological assessments. The Director of Nursing Services (DNS) confirmed that neurological monitoring was conducted but was unable to provide documentation of the assessments, indicating a lapse in maintaining accurate medical records. The facility's Neurological Assessment/Evaluation Policy mandates that licensed nurses perform neurological evaluations and monitoring for residents who have experienced unwitnessed falls, especially those on anticoagulant therapy. The policy outlines a specific schedule for neurological checks, which was not documented in the resident's medical record. Additionally, the facility's Documentation Guidelines policy requires that services provided to residents be documented in the electronic medical record, with provisions for adding late notes if documentation is omitted. The absence of documented neurological assessments suggests non-compliance with these policies, leading to the identified deficiency.
Resident Elopement Due to Expired Wander Guard and Inadequate Supervision
Penalty
Summary
The facility failed to ensure the safety of a resident with dementia and traumatic brain injury, who was at high risk for elopement and falls. The resident, who was on a secured locked unit and wore a wander guard, was able to exit the unit unsupervised on two occasions. The wander guard had expired eight months prior, and despite being checked weekly, it was not replaced. The resident was able to access the elevator and leave the secured unit without the alarm system locking the elevator doors, allowing the resident to reach the first floor and exit the building. The facility's documentation and staff interviews revealed a lack of adequate supervision and failure to implement necessary interventions after the resident's initial elopement. The resident's care plan included the use of a wander guard and behavior monitoring for elopement, but these measures were not effectively executed. Staff failed to document the resident's elopement behaviors and did not conduct the required 15-minute checks or 1:1 monitoring after the incidents. Additionally, there was a lack of communication among staff regarding the malfunctioning wander guard and the resident's elopement risk. The facility's policies on wander guard usage and elopement prevention were not followed, contributing to the resident's ability to leave the secured unit and the facility. The wander guard system was supposed to lock doors when a monitored resident approached, but it failed to do so due to the expired device. The facility's failure to adhere to its own policies and procedures resulted in the resident being unsupervised and at risk in unsecured areas of the facility and outside the building.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, sanitary, and homelike environment across all five units, as observed during a survey. The maintenance repair log from April to June 2024 did not document the condition of resident rooms, and environmental rounds conducted by RN #1 also lacked documentation regarding room conditions. Observations on July 2, 2024, revealed numerous issues, including damaged and stained floor tiles, walls, and ceilings, as well as dirty and debris-laden floors in various rooms and common areas across multiple floors. The Director of Maintenance, who has been employed since November 2023, acknowledged awareness of some issues and mentioned ongoing efforts to repair damaged walls, but did not document his rounds or findings. The Assistant Director of Nursing Services (ADNS) was unaware of the stained and dirty conditions of the floors and curtains and planned to discuss these issues with relevant staff. The Director of Nursing Services (DNS) was also unaware of the issues and intended to hold a meeting with key personnel to address the expectations for a homelike environment. Interviews with RN #1 and the Director of Housekeeping were not obtained. The facility's Infection Preventionist position description outlines responsibilities for maintaining a safe environment, and the facility's infection prevention rounds program requires monthly rounds by the Infection Prevention Committee and department heads. The janitor, housekeeper, and maintenance worker position descriptions emphasize routine tasks to ensure cleanliness and maintenance of the facility.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to provide timely dental services to a resident, identified as Resident #57, who was admitted with diagnoses including dementia, stroke, hemiplegia, and diabetes. A physician's order was made in July 2021 to obtain a dental consult for dentures, and consent was given by the resident later that month. However, despite the initial steps taken, including dental evaluations and impressions made in early 2022, the process was delayed significantly. The resident was informed of the need for removal of dental roots before denture fabrication, but due to various reasons, including the resident's medical appointments and surgeries, the dentures were not provided. Throughout 2023 and into 2024, the resident expressed a desire to proceed with the denture process after completing hip surgeries. Despite being seen by dental services multiple times, the resident did not receive the dentures. Interviews with facility staff revealed a lack of communication and follow-up regarding the resident's dental needs. The resident repeatedly requested to be seen by dental services, but there was no effective system in place to ensure these requests were addressed promptly. The facility's policy required them to provide necessary dental services and document any delays, but this was not adhered to. The dental services were available in the facility on numerous occasions, yet the resident's needs were not prioritized. Interviews with the dental hygienist and dentist indicated that they were waiting for the resident to request further action, but the facility staff did not facilitate this communication effectively. As a result, the resident remained without dentures for over two years, impacting their ability to chew food.
Failure to Serve Food at Safe Temperature
Penalty
Summary
The facility failed to serve food at a safe and palatable temperature, as observed during a test tray evaluation. On the specified date, the Surveyor and Food Service Director (FSD) followed a meal cart to the 4th floor dining room and measured the temperature of the last meal on the cart. The main entree, turkey, was found to be at 124 degrees Fahrenheit, and the peas were at 127 degrees Fahrenheit. These temperatures were below the facility's guidelines, which require hot foods to be held at 140 degrees Fahrenheit or higher. The FSD was unable to explain the temperature drop, despite indicating that meals were plated on a warming tray and delivered relatively quickly by nurse aides. The facility policy states that foods are in the danger zone when below 135 degrees Fahrenheit and requires action to be taken if temperatures are not within the acceptable range.
Sanitation and Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen and ensure meals were distributed at a palatable temperature. During an initial walkthrough, surveyors observed several unsanitary conditions, including empty trash bags and boxes on countertops near food, opened and undated food items, and a discarded latex glove near a food mixer. Additionally, a rack with unused disposable lids was found near unused garbage bags, and a soiled orange safety cone was partially underneath the rack. The freezer contained opened, undated, and uncovered food items with signs of freezer burn, and non-resident items such as ice cream and a bottle of spring water were improperly stored. The refrigerator had undated sandwiches and a sleeve of turkey meat with a tear in the plastic wrapping. The Food Service Director (FSD) acknowledged the kitchen was short-staffed, making it difficult to adhere to the cleaning schedule and storage expectations. The facility's policy requires food from non-approved sources to be stored separately and mandates proper labeling and storage of refrigerated foods. Damaged food products should be kept away from usable stock, and the storeroom should be clean and rodent-proof. The policy also emphasizes the importance of cleaning and sanitizing food service equipment and surfaces to minimize contamination risks. Despite these policies, the facility did not meet the expected standards, as confirmed by interviews with the Director of Nursing Services (DNS) and the Administrator.
Failure to Notify Resident Representatives and Physicians of Changes in Condition
Penalty
Summary
The facility failed to notify the resident representative and physician in two separate incidents involving residents with significant changes in their conditions. Resident #78, who was admitted with dementia and a traumatic brain injury, was at high risk for elopement and had a wander guard device in place. Despite these precautions, the resident managed to leave a secured locked unit on two occasions, on 6/25/24 and 6/28/24, without the knowledge of the resident's representative or physician. The facility's documentation and interviews revealed discrepancies in the timing and handling of these incidents, including a lack of immediate notification to the appropriate parties and failure to document the elopement behaviors adequately. In the case of Resident #101, who was admitted with dementia, hypertension, and a stroke, the facility did not promptly notify the resident's representative or physician of a change in condition involving eye discomfort and a rash on the hands. The resident complained of eye discomfort on 6/22/24, but the physician was not notified until 6/25/24, and the resident's representative was only left a message without further follow-up. The facility's policy required immediate notification and documentation of such changes, which was not adhered to in this case. Interviews with facility staff, including the DNS and various nurses, highlighted lapses in communication and documentation. The DNS acknowledged that the facility's policies on change of condition and elopement were not followed, as the responsible parties were not notified in a timely manner, and documentation of attempts to reach the resident's representative was insufficient. These deficiencies indicate a failure to adhere to established protocols for resident safety and communication.
Deficiencies in Monitoring and Documentation of Resident Care
Penalty
Summary
The facility failed to adequately monitor and document the care of Resident #91, who had a history of dry, itchy skin and was prescribed Triamcinolone Acetonide lotion for itchiness. Despite the physician's order to apply the lotion as needed, the treatment administration records did not show any documentation of its application throughout June 2024. Observations revealed that Resident #91 had multiple areas of skin at various stages of healing, indicating ongoing scratching behavior. Interviews with staff indicated a lack of behavior monitoring and documentation, and the facility did not provide a policy for behavior monitoring or nursing documentation. Resident #101, who had diagnoses including dementia and edema, was not assessed by a registered nurse when complaints of eye discomfort were noted. The resident was also not consistently provided with compression stockings as per the physician's order. Observations showed that the resident was often without the prescribed stockings, leading to visible edema. Interviews with staff revealed confusion and lack of adherence to the physician's orders regarding the application of compression stockings, and there was no facility policy provided for the use of compression stockings. The facility's failure to monitor and document the care of these residents, as well as the lack of adherence to physician orders, highlights deficiencies in the facility's care processes. The absence of policies for behavior monitoring, nursing documentation, and compression stocking application contributed to these deficiencies, impacting the residents' care and treatment.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to meet the pain management needs of a resident, identified as Resident #289, who was admitted with multiple diagnoses including a fractured kneecap, polymyalgia rheumatica, fibromyalgia, and gout. The baseline care plan highlighted the need for pain management related to arthritis, with interventions such as administering medications per physician orders and responding immediately to complaints of pain. However, the facility did not adhere to these interventions, as evidenced by the resident's experience over a weekend when pain management was inadequate. On 6/29/24, Resident #289 received a one-time dose of Acetaminophen 650 mg for pain, as per a physician's order. Despite this, the resident reported a pain level of 6 out of 10 later that day and was unable to receive additional pain relief due to the absence of a prn pain medication order. The resident expressed frustration at not receiving further Acetaminophen, which resulted in a sleepless night due to pain. LPN #10, who was on duty, acknowledged the resident's pain but did not contact the physician for additional orders, instead placing a note in the APRN communication book without documenting the resident's pain or need for medication. Interviews with the APRN and MD revealed that the physician was not contacted over the weekend for additional pain management orders, although he was available and willing to provide them. The DNS confirmed that the charge nurse should have informed the supervisor and APRN of the resident's need for pain medication immediately. The facility's Pain Management Policy emphasizes prompt evaluation and treatment of pain, which was not followed in this instance, leading to the resident experiencing unmanaged pain over the weekend.
Failure to Provide Bed Hold Notice During Hospital Transfers
Penalty
Summary
The facility failed to provide a bed hold notice to a resident or their representative prior to the resident's transfer to the hospital on four separate occasions. The resident, who had intact cognition, was admitted with diagnoses including bowel obstruction and anemia. Despite the facility's policy requiring a written bed hold notice to be given at the time of transfer, the resident only signed the notice at admission, and it was not provided during subsequent hospitalizations. Interviews with facility staff revealed that the RN Supervisor was responsible for sending the bed hold notice with residents during hospital transfers. However, this procedure was not followed for the resident's hospitalizations. The facility's policy mandates that a copy of the bed hold notice be given to the resident, maintained in their medical record, and provided to the business office, but these steps were not completed for the resident's transfers.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Middletown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Apple Rehab Middletown | 1.3 mi | — | 0 | 0 |
| Wadsworth Glen Health Care And Rehabilitation Cent | 1.3 mi | — | 0 | 0 |
| Portland Care & Rehab Centre, Inc | 1.8 mi | — | 0 | 0 |
| Autumn Lake Healthcare At Cromwell | 3.1 mi | — | 0 | 0 |
| Pilgrim Manor | 3.2 mi | — | 0 | 0 |
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