Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cordova Health And Rehabilitation, Llc during CMS and state inspections, most recent first.
A resident with a history of manipulative romantic behaviors and entering other residents' rooms was not adequately supervised, leading to a serious incident of sexual abuse by another resident. Despite being aware of the behaviors, the facility failed to implement effective interventions, resulting in immediate jeopardy for the resident.
A facility failed to thoroughly investigate an incident of abuse involving two residents, leading to a citation for non-compliance. Staff witnessed a compromising situation between the residents, but the investigation did not include interviews or identify the facility's failure to supervise a resident with a history of inappropriate behaviors. The lack of a comprehensive investigation and protective measures resulted in Immediate Jeopardy due to the risk of serious harm.
The facility failed to prevent potential cross-contamination in its food service areas. Staff were observed chewing gum while assisting residents with meals, posing a contamination risk. Additionally, clean pots and pans were stored on rusty shelves, and the storeroom for supplements had a dirty floor and uncleanable wooden shelving. The food preparation sink lacked proper backflow prevention, further risking contamination.
The facility failed to maintain the Three-compartment Pot and Pan Sink in good repair, as two of its drain levers were not functioning, preventing proper use. This issue persisted since the kitchen floor renovation, leading to deviations from standard procedures for washing and sanitizing pans. The deficiency had the potential to affect all 108 residents receiving meals from the kitchen.
The facility failed to maintain a clean and homelike environment, with deficiencies including a corroded and dusty vent in the Dining Room, dusty ceiling vents in hallways, a non-functional clock, and torn vinyl chairs. These issues were confirmed by staff and could lead to cross-contamination and respiratory issues.
The facility failed to report abuse allegations within the required two-hour timeframe on multiple occasions. One incident involved a resident reporting verbal abuse by another resident, and another involved a CNA allegedly cursing at a resident. Delays in reporting were attributed to administrative oversights and lack of access to necessary resources.
A facility failed to transmit a completed MDS assessment for a resident to CMS within the required timeframe. The assessment, completed by the MDS Coordinator, was not sent after its completion, as confirmed during an interview. This oversight was discovered during a record review, highlighting non-compliance with federal transmission requirements.
The facility failed to accurately code the MDS assessments for two residents, affecting their PASRR Level II status. One resident with PTSD and a Developmental Disorder and another with Depression were incorrectly marked as not having a PASRR Level II status, despite documentation indicating otherwise. The MDS Coordinator confirmed these errors during interviews.
The facility did not adhere to its Enhanced Dining policy, serving meals on transport trays in the dining room, affecting 40 residents. Staff interviews revealed a lack of awareness about the policy's intent to eliminate trays for a more homelike dining experience. The Resident Council President confirmed the issue was never discussed with residents.
Inadequate Supervision Leads to Resident Abuse
Penalty
Summary
The facility failed to provide adequate supervision and appropriate interventions to prevent sexual abuse perpetrated by one resident against another. The incident involved a resident with known manipulative romantic behaviors and a history of entering male residents' rooms. Despite being aware of these behaviors, the facility did not develop or implement interventions to address the resident's repeated behaviors and ensure their protection. On the day of the incident, staff heard a resident yelling for help and found the resident on the floor beside another resident's bed, with the latter attempting to force the former into a non-consensual sexual act. The resident who was victimized had a history of hemiplegia, aphasia, and depression, and was unable to complete a mental status interview due to memory problems. The facility's social services department had documented the resident's behaviors over time, including entering other residents' rooms and engaging in manipulative romantic behaviors. However, the facility's care plan did not include the necessary level of supervision to ensure the resident's safety or specify when and how the resident should be monitored. Interviews with staff revealed that the facility's approach to managing the resident's behaviors was limited to redirection and monitoring, without any formal documentation or specific interventions. Staff members were aware of the resident's behaviors but did not have clear guidance on how to manage them effectively. The lack of adequate supervision and intervention led to a situation where the resident was placed in immediate jeopardy, resulting in a serious incident of abuse.
Removal Plan
- RI #82 was placed back on 1:1 observation. RI #82 will not be left unsupervised until deemed safe by facility medical director. The facility will communicate to the medical director after there is no behaviors that increase her vulnerability for sexual abuse.
- RI #82 care plans were reviewed and revised by MDS coordinator to include 1:1 supervision.
- RI #325 was placed on 1:1 supervision until discharged to hospital then discharged home to family. Resident has not returned to the facility.
- RI #82 was assessed by RN Unit Manager and noted to have right ankle pain.
- Management nursing staff completed a facility audit to identify any other residents with known manipulative romantic behaviors, history of consenting to sexual relationships with other residents and history of entering male residents' rooms without supervision. None were identified.
- The Regional Administrator provided 1:1 in-service education to Administrator and DON regarding the abuse policy, distressed behavior management program and identification and notification of new or worsening behaviors that increase residents' vulnerability to sexual abuse.
- Education was initiated by Staff Development Nurse with facility staff regarding abuse policy to include protecting residents from sexual abuse and identifying behaviors that increase residents vulnerability to sexual abuse, by use of notification of new or worsening behaviors from NM.II-24B (exhibit 2) the form will be reviewed in the morning to reduce the risk of abuse. No staff will be allowed to work unless they have been in serviced. CNA's will communicate behaviors to the nurse, the nurse will implement immediate appropriate intervention will document on the electronic medication administration (EMAR) record under resident task. The Director of Nursing or the assistant director of nursing will review resident task history each business day during morning meeting to ensure the appropriate intervention to maintain the safety of the resident. MDS coordinator will then update resident care plans to reflect the new behavior of the resident with the appropriate care plan.
- Emergency QAPI meeting was held with all key personnel (Administrator, Director of Nursing, Department Heads, Regional Administrator and Regional Nurse Consultant). QAPI meeting discussed residents are kept safe from all types of abuse/sexual abuse and neglect. This was done by educating staff on who to report abuse to, when to report abuse and what to report.
- There are no residents known to the facility to be demonstrating with known manipulative romantic behaviors, history of consenting to sexual relationships with other resident, and history of entering male residents' rooms without supervision besides resident RI #82. Any sexually inappropriate behavior will be reported immediately to the Administrator or DON. The facility will immediately initiate the abuse protocol to include immediate protection of residents, notification of local police, MD/CRNP, ADPH and responsible parties followed by complete investigation.
Failure to Investigate and Prevent Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate an incident of abuse involving two residents, which led to a citation for non-compliance with federal regulations. On the date of the incident, staff members witnessed a situation in which one resident was found in a compromising position with another resident. Despite the severity of the situation, the facility's investigation did not include interviews with the residents involved, nor did it identify the facility's failure to provide adequate supervision to one of the residents, who had a known history of inappropriate behaviors. The investigation was incomplete as it did not explore potential contributing factors, such as the resident's history of entering other residents' rooms without supervision. The facility's policies required a thorough investigation to determine the cause of the incident and to implement measures to prevent recurrence. However, the investigation lacked critical elements, such as obtaining witness statements and identifying causal factors, which hindered the development of effective interventions. The deficiency was cited as Immediate Jeopardy due to the facility's non-compliance with the requirement to protect residents from abuse, neglect, and exploitation. The failure to conduct a comprehensive investigation and implement corrective actions put residents at risk of serious harm. The facility's inability to address the repeated behaviors of one resident and the lack of protective measures contributed to the deficiency.
Removal Plan
- Regional Administrator and Regional Nurse Consultant provided 1:1 in-service education to Administrator, DON and ADON regarding Abuse/Sexual Abuse policies implemented, including conducting a thorough investigation, to include contributing factors to the occurrence and take appropriate corrective action based on investigation results and contributing factors, completion of Abuse Questionnaire NM.II-20exh.A and collecting and retaining resident statements to determine a clear time of occurrence of events and that all staff responding appropriately per the abuse policy; identification of prospective residents who may pose a risk of sexual abuse to other residents due to their behaviors and planning for management of those behaviors.
- Director of Nursing re-interviewed RI #82.
- Regional nurse consultant and Regional Administrator reviewed for all previous investigations. None were identified that the Regional Administrator or Regional Nurse Consultant disagreed with the investigation outcome.
- QAPI completed with administrator for understanding the administrator's responsibility regarding facility policies being implemented and followed. Regional Administrator will sign off on facility reportable investigations to include sexual abuse investigations for compliance to the facilities abuse/sexual abuse policy, QAPI policy, behavior monitoring policy and notification policy are implemented/conducted according to the policy.
- The Administrator was educated by the regional nurse consultant to utilize the Verification of Investigation (VOI) form to conduct a consistent and thorough investigation of alleged abuse. The VOI includes detained description of events/allegation, BIMS score, Resident interview summary, immediate resident protection initiated, and the related.
Sanitation and Cross-Contamination Issues in Food Service
Penalty
Summary
The facility failed to adhere to proper food safety and sanitation standards, leading to potential cross-contamination risks. During dining observations, several staff members, including CNAs and a Restorative Nurse, were seen chewing gum while assisting residents with their meals. This behavior was noted to occur directly over residents' food, which could lead to contamination. Interviews with the staff revealed a lack of awareness regarding the prohibition of gum chewing during meal assistance, highlighting a gap in training or policy enforcement. Additionally, the facility's kitchen had several sanitation issues. Clean pots and pans were stored on rusty wire shelving, which could lead to contamination from rust and dirt. The storeroom for thickened liquids and nutritional supplements had a dirty floor, with a delivery of supplements placed directly on it. The wooden shelving in the storeroom had gaps along the floor line, making it difficult to clean and potentially attracting pests. These conditions were acknowledged by the Dietary Manager and Registered Dietitian, who recognized the contamination risks posed by these deficiencies. Furthermore, the food preparation area had a double sink with a direct connection to the sewer, lacking an air gap or backflow prevention device. This setup could allow for contamination of food preparation areas. The Director of Maintenance was unaware of any backflow prevention measures in place and indicated the need to consult with a plumber. These findings indicate significant lapses in maintaining a sanitary environment in the facility's food service areas, as required by the U.S. FDA 2022 Food Code.
Failure to Maintain Kitchen Equipment in Good Repair
Penalty
Summary
The facility failed to maintain the Three-compartment Pot and Pan Sink in good repair, as required by their Sanitation Principles policy and the U.S. FDA 2022 Food Code. During an initial kitchen tour, it was observed that the sink was not set up for use because two of the three drain levers were not functioning, preventing the rinse and sanitizing sinks from holding water. The Dietary Manager confirmed that the sink had been out of order since March or April 2024, following the kitchen floor renovation. As a result, the facility had been using the dishroom to wash and sanitize pans, which deviated from the standard procedure. Interviews with the Dietary Manager and the Registered Dietitian revealed that the sink is considered a basic piece of kitchen equipment and should not have been out of service for such an extended period. The facility uses a maintenance system called TELS, which should have addressed the issue. The Director of Maintenance was unaware of why the sink had not been repaired, despite being informed about the problem when the sink was reinstalled after the floor renovation. This deficiency had the potential to affect all 108 residents receiving meals from the kitchen.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment, as evidenced by several deficiencies observed during the survey. In the Dining Room, a large return vent was found to be heavily corroded with rust and covered in dust, which could be easily removed by touch. This vent was located near the emergency exit door and was observed to be in this condition over multiple days while residents were present for meals. Interviews with the Director of Maintenance, Dietary Manager, and Registered Dietitian confirmed the presence of rust, dirt, and dust, and acknowledged that this did not contribute to a homelike environment and could potentially lead to cross-contamination. In the hallways, several ceiling vents on C and D Halls were observed to have a build-up of a dark black substance, identified as dust by the Director of Maintenance. This accumulation of dust was noted to potentially affect residents by exacerbating allergies and respiratory issues. Additionally, a clock in the front hallway on C Hall was found to be non-functional, displaying an incorrect time, which could mislead residents relying on it to attend activities on time. The facility also failed to maintain the condition of vinyl upholstered chairs in the front lobby and hallway. Several chairs were observed with torn or cracked upholstery, making them difficult to clean and potentially leading to injury or cross-contamination. The Director of Maintenance acknowledged that the condition of these chairs was not homelike and could pose a risk of fluid transfer and contamination. These deficiencies were identified as part of a complaint investigation.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse within the required two-hour timeframe to the state agency on three separate occasions, affecting three residents. On April 9, 2024, a resident reported verbal abuse involving another resident, but the incident was not reported to the state agency until the following day. The facility's administrator acknowledged the delay, stating that the incident should have been reported on the day it occurred. This incident was part of a complaint investigation. Another incident occurred on October 27, 2024, when a resident reported verbal abuse by a CNA. The assistant director of nursing (ADON) was informed of the incident shortly after it occurred but did not report it to the state agency until the next day, citing a lack of access to necessary resources as the reason for the delay. The ADON admitted that the report was late and should have been made within the required timeframe. The administrator confirmed the late reporting, which was also part of a separate complaint investigation.
Failure to Transmit MDS Assessment
Penalty
Summary
The facility failed to ensure the timely transmission of a completed Minimum Data Set (MDS) assessment for a resident, identified as RI #2, to the Centers for Medicare & Medicaid Services (CMS) system. According to the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date. In this case, RI #2's annual MDS assessment was completed on October 7, 2024, but was not transmitted to CMS as required. The MDS Coordinator confirmed during an interview that the assessment for RI #2 was started on September 23, 2024, and completed on October 7, 2024. However, the coordinator acknowledged that the assessment was not transmitted to CMS after its completion. The failure to transmit the MDS assessment was identified during a record review on November 14, 2024, indicating a lapse in the facility's compliance with federal transmission requirements.
Inaccurate MDS Coding for PASRR Level II Status
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) assessments for two residents, which affected the accuracy of their Preadmission Screening and Resident Review (PASRR) Level II status. Resident Identified (RI) #60 was admitted with diagnoses including Generalized Anxiety Disorder, Post-Traumatic Stress Disorder (PTSD), and a Developmental Disorder. Despite having a PASRR Level II Service Determination indicating serious mental illness and a related condition, the MDS assessment incorrectly marked the PASRR status as 'No'. This discrepancy was confirmed during an interview with the MDS Coordinator, who acknowledged the error and emphasized the importance of accurate MDS data. Similarly, RI #82, who was admitted with a diagnosis of Depression, also had an incorrect MDS assessment. The PASRR Level II Service Determination for this resident indicated a serious mental illness, yet the MDS was marked as 'No' for PASRR Level II status. The MDS Coordinator confirmed this was an error during a follow-up interview, acknowledging that the MDS should have been marked to reflect the resident's Level II status. These inaccuracies in the MDS assessments were identified during a review of 22 sampled residents.
Deficiency in Dining Experience Due to Use of Meal Trays
Penalty
Summary
The facility failed to ensure a dignified dining experience for residents during lunch meals on two consecutive days. Observations revealed that meals were served on transport trays directly placed on tables in the dining room, contrary to the facility's Enhanced Dining policy, which aims to eliminate food trays for a more homelike environment. This practice affected all 40 residents present in the dining room. The dining room was set with green linen tablecloths and seasonal decorations, yet the meal service did not align with the policy's standard of providing a non-institutional dining experience. Interviews with staff, including the Registered Dietitian, Dietary Manager, and Restorative Nurse, indicated a lack of awareness and discussion regarding the appropriateness of serving meals on trays in the dining room. The Resident Council President confirmed that the topic had never been discussed with residents. Staff acknowledged that serving meals on trays could detract from the homelike atmosphere intended by the facility's dining policy. The deficiency highlights a disconnect between the facility's policy and its implementation, impacting the residents' right to a dignified dining experience.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 8 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Cordova
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Shadescrest Health Care Center | 6.9 mi | ★★★★★ | 0 | 0 |
| Ridgeview Health Services, Inc | 8.2 mi | ★★★★★ | 0 | 0 |
| Ridgewood Health Services, Inc. | 8.6 mi | ★★★★★ | 0 | 0 |
| Walker Rehabilitation Center, Inc | 21.2 mi | ★★★★★ | 0 | 0 |
| Cherry Hill Rehabilitation & Healthcare Center | 21.3 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Cordova Health And Rehabilitation, Llc.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.