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 Sunview Respiratory And Rehabilitation during CMS and state inspections, most recent first.
A minor with TBI, psychosis, ADHD, and other behavioral risks was admitted under legal guardianship and required supervision and assistance with decision-making, yet was allowed to roam freely and spend extensive unsupervised time with an adult resident with schizophrenia and other mental health diagnoses. Staff and the guardian were aware that the two residents were frequently together and expressed concern that something inappropriate might occur, but no formal care-planned supervision or separation interventions were implemented, and prior sexually inappropriate behaviors by the minor toward staff were not addressed in the care plan. One evening, an LPN entered another resident’s room and observed the adult on her knees in the bathroom in front of the minor, who had his pants down, consistent with oral sex; the residents were separated and the incident was reported. The facility’s internal investigation and report to the State Agency characterized the encounter as consensual between two cognitively intact residents and did not document it in the minor’s record as sexual abuse, and the facility did not notify child protective authorities, who only became involved after the hospital reported the incident. Surveyors found no evidence of timely protective interventions on the date of the incident, no clear documentation of the event as the reason for psychosocial monitoring and psychiatric evaluation, and no care-planned measures to supervise or discourage the relationship, leading to a finding that the facility failed to protect the minor from sexual abuse and failed to correctly identify and report the event.
A minor with TBI, ADHD, anxiety, and depression, whose healthcare decisions were made by a legal guardian and who required supervision with all decision-making, developed a close relationship with an adult resident with serious mental illness. Staff had prior concerns and had warned the adult that the other resident was a minor, and the guardian had been notified that the minor was to remain in public areas. One evening, an LPN entered another resident’s room and observed the adult on her knees in front of the minor, whose pants were down, in the bathroom; the residents were separated and the DON was notified. Both residents later acknowledged a sexual encounter, describing it as consensual and initiated by the minor, and the police classified the event as sexual assault of a minor and completed statutory rape. The facility’s 5-day investigation did not identify the younger resident as a minor in reports to the State Agency, concluded the event was between consenting individuals, omitted a statement from the nurse who discovered the incident, did not interview the room’s assigned resident or other residents about what they saw or heard, did not document protective interventions on the date of the incident, and did not report to child protective authorities at the time, despite policy requirements for prompt recognition, reporting, and thorough investigation of abuse.
The facility failed to use its QAPI processes to adequately address a sexual abuse incident between two residents. The Quality Improvement Plan focused only on the issue of admitting minors and on monitoring dates of birth, without conducting a root cause analysis of the abuse event itself. The plan did not clearly define the abuse-related problem, lacked measurable goals, timelines, and assigned responsibilities, and did not specify how effectiveness would be evaluated. It also did not identify any abuse-related policy or practice changes or provide detailed, abuse-focused staff training content, leaving the incident unaddressed from a systemic quality improvement standpoint.
The deficiency centers on the facility’s failure to recognize and report an incident of sexual abuse involving a minor resident and an adult resident in accordance with federal requirements. An LPN discovered the two residents in another resident’s bathroom in a position consistent with oral sex, and both residents later described a sexual encounter that was interrupted by staff. Although the facility knew one resident was a minor and the other an adult with serious mental illness, its initial and 5‑day reports characterized the event as a consensual encounter between cognitively intact individuals, omitted the minor’s status, and did not classify the incident as sexual abuse. The incident was reported to police nearly a day after it occurred, was not reported by the facility to child protective authorities, and the internal investigation lacked key details and documentation, leading to a cited failure to properly identify, document, and report the abuse and to assess and monitor other residents at risk.
The facility failed to recognize and thoroughly investigate a sexual encounter between a minor and an adult resident as potential sexual abuse, instead documenting it as a consensual event between cognitively intact individuals. An LPN reported finding the two in a bathroom during the act and notified a supervisor, but the facility’s internal investigation omitted a written statement from this nurse, did not interview the roommate or other residents (including other minors), and relied on interviews with staff who had not worked the shift when the incident occurred. Clinical records showed only vague references to a “reported event” and did not document timely protective interventions on the date of the incident, nor any prior supervision or measures to limit the pair’s unsupervised contact despite staff awareness that one was a minor. The facility did not identify the younger resident as a minor in reports to the State Agency, did not report the incident to DCS, and did not follow its abuse policy requiring prompt, comprehensive investigation, resident protection, and mandated external reporting.
A resident with dementia, communication deficits, and significant physical impairment, who required extensive 2-person assist and used a walker and wheelchair, was physically assaulted by a cognitively intact roommate after refusing care from a CNA. When staff returned with a male CNA, the roommate stated he had "taken care of it," and the resident was found with a forehead hematoma, lip lacerations, and blood on the floor and bed linens. The roommate, who had alcohol abuse and a behavioral care plan noting potential for physical behaviors and poor impulse control, had no prior aggressive behaviors documented in the MDS or progress notes. Despite an abuse policy stating residents’ rights to be free from abuse, the incident demonstrated a failure to protect the resident from physical abuse by another resident.
The facility provided in-house dialysis services to multiple residents without obtaining the required state-approved license modification or documentation of the contracted dialysis provider's license. Staff believed that approval of architectural plans was sufficient, but could not produce evidence of proper licensure for the dialysis center or provider when requested by surveyors.
Two residents were found with medications left at their bedside without being assessed for self-administration. One resident with moderate cognitive impairment had a vitamin left unattended, while another resident with intact cognition admitted to discarding unwanted pills. The facility's policy requires medications to be administered as per physician orders, and deviations must be documented, which was not followed in these cases.
The facility failed to ensure proper food storage and cleanliness in the kitchen, with expired and undated food items found in refrigerators, dusty ceiling vents, and an inadequately cleaned ice machine. Staff interviews revealed non-compliance with facility policies, increasing the risk of foodborne illness.
The facility failed to notify providers of a resident's change in condition, including low blood sugar and respiratory distress, leading to a family complaint. Additionally, another resident was observed without necessary leg rests for her custom wheelchair, despite therapy recommendations, resulting in improper positioning and potential risk of injury.
An LPN failed to perform hand hygiene during medication administration, as observed in two instances where items were picked up from the floor without subsequent hand sanitization. This was confirmed by interviews with the LPN and the DON, who acknowledged the facility's hand hygiene policy was not followed.
A resident with cognitive and physical impairments was observed with food caked around his mouth and on his clothing, indicating a lack of dignity and grooming care. Despite staff protocols for regular checks and meal tray removal, the resident remained in this state for over two hours, highlighting a deficiency in maintaining resident dignity and respect.
The facility failed to obtain physician orders for oxygen use for two residents, leading to potential unnecessary oxygen administration. One resident was documented as receiving oxygen without an order for nearly a month, while another had no order for increased oxygen levels despite low saturation readings. Staff interviews confirmed the facility's policy requiring physician orders for oxygen therapy, which was not followed.
The facility failed to notify a resident's representative in writing of a hospital transfer. The resident, with multiple serious diagnoses, had a critically low hemoglobin level, prompting a physician-ordered transfer. The ADON could not provide documentation of the notification, violating the facility's policy.
The facility failed to provide a bed-hold policy notice to a resident or their representative prior to or upon transfer to a hospital. The resident, with multiple serious diagnoses, was transferred due to a critically low hemoglobin level, but the bed-hold policy was not communicated, as confirmed by the ADON.
Failure to Protect Minor Resident From Sexual Abuse and Misclassification of Incident as Consensual
Penalty
Summary
The deficiency involves the facility’s failure to protect a minor resident from sexual abuse by an adult resident and to correctly identify and report the incident as sexual abuse. The minor resident had a history of traumatic brain injury (TBI) with subarachnoid hemorrhage, diffuse axonal injury, psychosis, insomnia, ADHD, anxiety, and depression, and required that decisions and consents be made by a legal guardian/parent. Care plans documented that the minor was at risk for impaired cognitive function or impaired thought processes due to recent hospitalization and TBI-induced psychosis, with interventions stating the resident needed supervision/assistance with all decision making and behavioral monitoring. Despite this, the resident was allowed to ambulate freely around the facility without direct supervision prior to the incident, and there was no care-planned intervention addressing supervision or discouraging the minor from spending time with other residents. In the days leading up to the incident, multiple staff and the minor’s legal guardian were aware that the minor and an adult resident were spending significant time together. Staff reported that the two residents were often seen together, including eating meals together and walking the halls, and that staff had warned the adult resident that the minor was underage. The unit manager reported that, prior to the incident, there was fear among staff that something inappropriate might occur between the two residents, and she called the minor’s legal guardian to report that the minor was spending time with another resident and that the facility did not want anything inappropriate to happen. The legal guardian stated that she was asked by facility staff to speak to the minor about the relationship but was unable to come to the facility, and she believed it was the facility’s responsibility to ensure the minor’s safety. There was also staff report that the minor had demonstrated sexually inappropriate behavior toward staff, yet there was no documented care plan addressing supervision or specific interventions to manage these behaviors or to prevent unsupervised interactions with other residents. On the night of the incident, an LPN entered another resident’s room and observed the adult resident on her knees in the bathroom in front of the minor, who was standing with his pants down, which the LPN interpreted as the adult performing oral sex on the minor. The residents were separated and the incident was reported to the DON. The police report later documented that both residents stated that oral sex occurred in the bathroom after the minor asked for it, and that the adult resident knew the minor’s age. The facility’s 5-day investigation report characterized the encounter as consensual between two cognitively intact residents with BIMS scores of 15 and concluded that abuse could not be substantiated, reporting to the State Agency that the incident was consensual. The clinical record for the minor did not contain documentation that the resident had been sexually abused, did not describe the incident as sexual abuse, and did not document the specific event that led to psychosocial monitoring and transfer for pediatric psychiatric evaluation. Additionally, the facility did not notify the Department of Child Services; DCS only became involved after the hospital reported the incident. Adult Protective Services later verified neglect of the adult resident as a vulnerable adult and verified that a sexual assault occurred. The surveyors found no evidence that, prior to the incident, the facility implemented supervision or preventive measures to separate or monitor the two residents despite staff concerns and knowledge of the minor’s age and vulnerabilities. The deficiency also includes the facility’s failure to implement immediate protective interventions for the minor on the date the incident occurred. Although documentation shows that the minor was placed on change-of-condition monitoring and assigned a one-to-one sitter starting the night after the incident and continuing until discharge, there was no evidence that protective interventions were put in place on the date of the incident itself. Staff interviews indicated that prior to the incident the minor was not directly supervised and had freedom to roam the facility, and that one-to-one supervision was only initiated after the event. The facility’s own investigation and reporting documents did not identify the sexual contact between an adult and a minor as sexual abuse, instead framing it as a consensual encounter, despite internal staff, APS, and DCS statements that a minor could not legally consent. The surveyors concluded that the facility failed to address the minor’s inappropriate interactions with staff, failed to provide supervision when the minor was noted to spend time with a cognitively impaired adult resident, and failed to identify and report the sexual contact between a minor and an adult as sexual abuse, resulting in a finding of Immediate Jeopardy and Substandard Quality of Care. Additional documentation in the clinical record and staff interviews further demonstrate gaps in assessment and follow-through related to the incident. Although multiple provider notes referenced plans for psychiatric consultation for both residents, there was no evidence that the minor ever received a psychiatric consult while at the facility, and the clinical record lacked clear documentation of the incident as the reason for psychosocial monitoring or hospital transfer for pediatric psychiatric evaluation. For the adult resident, psychiatric evaluation occurred after the incident and focused on anxiety and worrying about a recent event, without detailing the nature of the event in the clinical record. The facility’s care plans for both residents referenced a “reported event” and potential psychosocial well-being problems but did not specify the sexual incident or outline concrete supervision strategies to prevent recurrence. Staff interviews consistently indicated that the two residents had been spending time together, that staff were informally “keeping an eye” on the minor, and that there was concern something might happen, yet these concerns were not translated into documented, formalized interventions or timely recognition and reporting of the incident as sexual abuse of a minor by an adult resident.
Failure to Recognize and Properly Investigate Sexual Abuse of a Minor by an Adult Resident
Penalty
Summary
The deficiency involves the facility’s failure to recognize, report, and investigate non-consensual sexual acts between a minor resident and an adult resident as sexual abuse, in accordance with its own policies and regulatory requirements. A minor resident with traumatic brain injury, ADHD, anxiety, and depression was admitted with a care plan indicating impaired cognitive function or thought process due to recent hospitalization, and requiring supervision/assistance with all decision making, with all consents made by a legal guardian/parent. Despite a BIMS score of 15 and documentation of being alert and oriented, the resident’s status as a minor and need for supervision and guardian consent were known to the facility. Staff had observed the minor and an adult resident spending significant time together prior to the incident, and staff had warned the adult resident that the other resident was a minor. The unit manager reported that there was concern among staff that something inappropriate might occur between the two residents, and the legal guardian was notified in advance that the minor was spending time with another resident and had been instructed to stay in public areas. On the night of the incident, an LPN from another unit entered a resident’s room and observed the adult resident on her knees in front of the minor resident, who was standing with his pants down in the bathroom. The LPN reported that it appeared the adult resident was performing oral sex on the minor, and the residents were separated and the DON was notified. Another LPN corroborated that the nurse who discovered the incident described finding the two residents in the bathroom in this position, and that the room’s assigned resident was upset and unaware of what was happening in his bathroom. The minor later told staff that the adult resident had performed oral sex on him, and both residents separately acknowledged a sexual encounter, describing it as consensual and initiated by the minor. The police report classified the event as sexual assault of a minor, with the adult resident reporting that she performed oral sex on the minor for approximately two minutes after he asked for it, and acknowledging that she knew his age. The police report documented the offense as completed statutory rape and sexual conduct with a minor. Despite this information, the facility’s internal 5-day investigation report concluded that the incident was between two consenting individuals and that abuse could not be substantiated. The facility’s reports to the State Agency did not identify the younger resident as a minor, even though the facility knew he was under 18 and that healthcare consents were obtained from his legal guardian. The investigation did not include an interview or written statement from the nurse who discovered the incident, did not interview the resident whose room and bathroom were used, and did not document what interviewed residents had seen or heard. The facility also did not assess or monitor other residents, including other minors, for potential risk or impact, and there was no evidence of protective interventions being implemented on the date the incident occurred. The incident was reported to police nearly 24 hours after it occurred, and there was no evidence that the facility reported the incident to the Department of Child Services/Child Protective Services at the time, despite later acknowledgment by the former DON that CPS should have been notified as soon as possible. The facility’s actions and omissions were inconsistent with its abuse prevention policy, which required prompt identification of sexual abuse, immediate reporting to appropriate agencies, and thorough investigation including interviews with all relevant witnesses and review of all circumstances surrounding the event. Interviews with facility leadership and staff further demonstrated misunderstanding and misapplication of abuse definitions and consent standards as they relate to minors. The former DON stated that any alert and oriented resident, including minors, could consent to sexual activity with an adult and initially did not consider the incident to be sexual abuse because she believed it was not unwanted, although she later acknowledged that a minor cannot give consent for sexual activity and that the incident should have been reported to CPS. The former administrator stated that he viewed the incident as a crime involving an adult and a minor but did not know if it was sexual abuse. In contrast, the current DON and current administrator described sexual abuse and statutory rape as involving a minor who cannot legally consent and emphasized that it is not acceptable for an adult to sexually touch a minor. The social services supervisor and unit manager also stated that it was inappropriate and illegal for an adult resident and a pediatric/minor resident to have a sexual relationship, and that a child in the facility could not consent to sex with an adult. Despite these understandings, at the time of the incident the facility failed to apply these principles, failed to identify the event as sexual abuse of a minor, and failed to conduct and document a thorough investigation and timely reporting as required by policy and law. The APS investigative report later verified neglect of a vulnerable adult (the adult resident with serious mental illness) and confirmed that the sexual assault occurred. The DCS child safety specialist and the minor’s legal guardian both reported that the incident and its aftermath had a negative psychosocial effect on the minor. Staff interviews indicated that prior to the incident the minor was not directly supervised and was allowed to roam the facility freely, despite his minor status and TBI-related behaviors, and the social services supervisor was unsure what supervision measures were in place for pediatric/minor residents. These facts, combined with the facility’s failure to recognize the incident as sexual abuse, failure to identify and report the minor’s status in regulatory reports, failure to notify child protective authorities at the time, and failure to conduct a comprehensive investigation with all relevant witnesses and residents, formed the basis of the cited deficiency for not implementing policies and procedures to prevent abuse, neglect, and theft, specifically in relation to preventing and responding to sexual abuse of a minor by an adult resident.
Failure to Use QAPI to Address Sexual Abuse Incident Between Residents
Penalty
Summary
The deficiency involves the facility’s failure to use its QAPI and QAA processes to systematically address all care and services related to a sexual abuse incident between two residents. The facility’s Quality Improvement Plan/Action Plan dated May 20, 2025 identified the problem only as the admission of minors to the facility and cited a lack of communication to the IDT regarding admission of minors as the causal factor. The plan focused on monitoring dates of birth on admission, in-servicing admission and marketing staff on a new process for admitting minors, reviewing census in daily stand-up meetings, and conducting a full-house review of dates of birth for all current residents. However, the plan did not address the root cause of the sexual abuse incident itself or demonstrate that the facility fully investigated why the incident occurred between the two residents. The QAPI documentation did not clearly define the specific problem related to the abuse event, nor did it outline specific corrective actions tied to that event. It lacked measurable goals, timelines, and identification of who would be responsible for each step, and it did not describe how the facility would evaluate whether any interventions were effective in preventing similar incidents. The report further notes that the QAPI plan did not identify any specific changes to policies, procedures, or practices directly related to the abuse incident. Staff training described in the plan was limited to a new process for admitting minors and did not focus on the abuse-related deficiency. The plan omitted key details about the training, such as the content, who would be trained, when it would be completed, and how it would be documented and verified. Additionally, the plan did not include any system-wide changes made or planned in direct response to the sexual abuse incident, despite facility policies stating that QAPI should include systemic analysis and systemic action for high-risk, high-volume, or problem-prone issues.
Failure to Recognize and Report Sexual Abuse of a Minor Resident
Penalty
Summary
The deficiency involves the facility’s failure to recognize and report an allegation of sexual abuse involving a minor resident in accordance with federal requirements. A cognitively intact minor resident, identified as Resident #444, with diagnoses including traumatic brain injury, ADHD, anxiety, and depression, reported having received sexual acts from an adult resident, identified as Resident #3, who had diagnoses of ADHD, schizophrenia, and mood disorder. Both residents were documented as cognitively intact with BIMS scores of 15. The facility’s self-report and 5‑day investigation characterized the incident as a consensual sexual encounter between two cognitively intact residents and did not identify Resident #444 as a minor, despite the facility’s knowledge of his age. The events began when an LPN observed the two residents in another resident’s bathroom, with Resident #3 on her knees in front of Resident #444, whose pants were down, and the LPN believed oral sex was occurring. The LPN reported the incident to her supervisor and the residents were separated. Another LPN confirmed that she and the first LPN went to the room, found the assigned resident upset and unaware of the sexual encounter in his bathroom, and then separated the two residents and reported the incident to the DON. The police report later classified the event as a sexual assault of a minor and documented that Resident #3 admitted performing oral sex on Resident #444 after he asked for it, and that she knew his age. Resident #444 also reported that he asked Resident #3 for oral sex, went into the bathroom, closed the door, and that oral sex occurred until they were interrupted by staff. Despite these observations and statements, the facility’s initial and 5‑day reports to the State Agency did not identify Resident #444 as a minor and concluded that the facility was unable to substantiate that abuse occurred, describing the incident as occurring between two consenting individuals. The facility’s documentation of change‑of‑condition monitoring for both residents referenced a “reported event” but did not specify the nature of the event. The incident was reported to police nearly 24 hours after it occurred, and there was no evidence that the facility reported the incident to the Department of Child Services, even though staff and leadership acknowledged that the incident involved an adult and a minor and that the minor could not legally consent. Adult Protective Services later verified an allegation of neglect of a vulnerable adult, identified as Resident #3, and confirmed that Resident #3 sexually assaulted Resident #444 while at the facility. Interviews with the former administrator and former DON showed that they were aware the incident involved an adult and a minor and that it appeared to be a crime, yet the facility’s written investigation did not document the minor status, did not classify the event as sexual abuse, and omitted certain investigative details such as the interview with the resident whose room and bathroom were used. The current DON, who was not employed at the time of the incident, reviewed the investigation and stated she could not determine key details from the documentation, including the exact room where the incident occurred, whether anyone else was present, whether assessments were conducted for the involved residents, or whether DCS was notified. A DCS child safety specialist later reported that the incident and its aftermath had a negative psychosocial effect on Resident #444 and confirmed that, based on his age, he was not able to give consent. These documented failures to properly identify, classify, and report the incident as sexual abuse of a minor, and to notify all mandated entities, constitute the core of the deficiency. The facility also failed to take broader protective steps for other residents at risk as part of its response to the incident. The report notes that the facility did not identify the incident as sexual abuse and therefore did not implement measures such as assessment and monitoring of other residents at risk or interventions and supervision to protect other residents from possible abuse. The APS investigative report verified neglect of a vulnerable adult, Resident #3, due to serious mental illness and confirmed that the sexual assault occurred. Collectively, the record reviews, staff interviews, and external investigative findings demonstrate that the facility did not timely and accurately report the allegation of sexual abuse involving a minor to all required authorities and did not appropriately classify and respond to the event as sexual abuse, leading to the cited deficiency.
Failure to Recognize and Thoroughly Investigate Sexual Abuse Allegation Involving a Minor
Penalty
Summary
The deficiency involves the facility’s failure to recognize and investigate an allegation of sexual abuse involving a minor resident and an adult resident, and to implement required protections and notifications. A self-report submitted by the former DON stated that a staff member overheard a cognitively intact resident (BIMS 15) say he had received sexual acts from another cognitively intact resident, and that both residents later acknowledged a consensual sexual encounter that occurred the previous day. The facility’s reports to the State Agency did not identify the younger resident as a minor and characterized the incident as a consensual encounter between two residents, rather than as potential sexual abuse. The facility’s 5‑day investigation concluded that abuse could not be substantiated and that the incident occurred between consenting individuals, despite the younger resident’s minor status and the nature of the sexual act. The incident was reported in a police report as a sexual assault that occurred in the evening, with the adult resident performing oral sex on the minor in a bathroom after being asked by him, and the adult resident acknowledging she knew his age. The police report documented that an LPN entered another resident’s room, saw the adult resident on her knees with the minor in the bathroom, and reported the incident to her supervisor; the adult resident was then moved to a separate wing. However, the facility’s internal investigation did not include a written statement from this LPN and instead documented that she had only seen the two residents together watching videos with no inappropriate behavior. Staff schedules showed that none of the six staff interviewed by the facility for its investigation had worked the night shift when the incident occurred. The facility also did not document interviews with the resident whose room was used or with other residents, including other minors, who might have had information about the event. Clinical records for both residents showed they were placed on change of condition monitoring for psychosocial well-being due to a “reported event,” and care plans were initiated the day after the incident, but the documentation did not specify the nature of the event. There was no evidence in the clinical record that protective interventions were implemented on the date the incident occurred to protect the minor from further abuse or to protect other residents from the alleged perpetrator. Staff interviews indicated that prior to the incident the two residents had been “hanging out together a lot,” that staff had warned the adult resident that the younger resident was a minor, and that the minor had freedom to roam the facility without direct supervision. There was no documentation of interventions to supervise or discourage their contact, or of increased supervision or monitoring of either resident prior to the incident. The facility did not report the incident to the Department of Child Services, and DCS later confirmed it only became involved when the minor was discharged to a hospital that reported the incident. The facility’s own abuse policy required prompt, thorough investigation of all abuse allegations, interviews with all relevant staff and residents on all shifts, review of all circumstances surrounding the incident, immediate protection of the alleged victim, increased supervision, and appropriate external reporting, but the actions taken did not meet these requirements as described in the report. An APS investigation later verified neglect of the adult resident, identified as a vulnerable adult with serious mental illness, and verified that a sexual assault occurred. The former DON stated that she did not consider the incident to be sexual abuse because she believed it was not unwanted and that the minor could consent to sexual activity with an adult, and she acknowledged that the incident was not reported or investigated until the following day after a staff member overheard the minor describe the sexual act. The current DON and current administrator, interviewed later, described that a minor cannot legally consent to sexual activity with an adult, that such an incident would be considered sexual abuse or statutory rape, and that such events require immediate reporting and investigation, but they were not employed at the time of the incident and did not participate in the original response. The report concludes that because the facility failed to recognize the incident as potential abuse, it did not initiate a thorough investigation, did not take appropriate corrective actions to protect residents from possible abuse, did not assess and monitor other residents at risk, and did not notify law enforcement and DCS as required, thereby placing residents at risk for harm.
Failure to Protect a Resident From Physical Abuse by a Roommate
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident. One resident, identified as the alleged victim, had multiple diagnoses including cognitive communication deficit, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, alcohol use, dizziness, giddiness, and anxiety. Despite these conditions, a recent MDS documented a BIMS score of 15, indicating intact cognition, and noted that the resident required extensive two-person assistance with care due to upper and lower extremity impairment and used a walker and wheelchair. The resident had an active cognition care plan addressing risk for impaired cognitive function and a communication care plan addressing hearing deficit, with interventions to provide a safe environment and anticipate needs. On the date of the incident, nursing documentation recorded a change of condition related to an altercation with the resident’s roommate. According to the nursing note and the facility-reported incident (FRI), the victim had refused care from a CNA, who left the room to obtain a male CNA. When staff returned, the roommate stated that he had “taken care of it” for staff, and blood was observed on the floor and on the victim’s bed sheet. The victim was found with a raised bump (hematoma) on the forehead and small cuts to the upper and lower lips, confirmed by a skin assessment that documented small lacerations to the lips and a bump on the forehead. A psychosocial care plan was later initiated for the victim related to an assault, identifying a potential psychosocial well-being problem. The alleged perpetrator, the victim’s roommate, had diagnoses including alcohol abuse and a need for assistance with personal care. A cognition care plan identified risk for impaired cognitive function or impaired thought processes, and a behavioral care plan initiated on the date of the incident documented potential for physical behaviors toward others related to a history of harm to others and poor impulse control. However, the admission MDS for this resident also showed a BIMS score of 15, with no psychosis or behavioral symptoms documented during the assessment period, and progress notes from admission up to the incident did not indicate prior aggressive behavior. The facility’s abuse policy, last reviewed in October 2022, stated that each resident has the right to be free from abuse, including physical abuse, but the occurrence of a resident-to-resident physical assault resulting in injury to the victim demonstrated that the facility failed to protect the victim’s right to be free from physical abuse by another resident. Interviews with other residents indicated that they felt safe and would report incidents to staff, and interviews with the Administrator and DON described general procedures and expectations for preventing and responding to abuse and resident-to-resident altercations. The Administrator initially could not verify the current abuse policy until directed to the DON, who confirmed the October 2022 policy was in effect. The FRI documented that the roommate physically assaulted the victim after the victim refused care, resulting in visible injuries and blood in the room. The FRI did not indicate whether the allegation of abuse was verified or not verified, but it did document that the roommate was sent to the hospital and would not be accepted back into the facility. These documented events and injuries form the basis of the deficiency that the facility failed to ensure the resident’s right to be free from physical abuse by another resident.
Dialysis Services Provided Without Required State License Modification
Penalty
Summary
The facility failed to ensure that a request for modification of its health care institution license was approved by the state agency prior to establishing and providing in-house dialysis services. Despite submitting building plans and receiving approval for architectural plans and specifications, the facility did not obtain the required modified license to operate a dialysis center within the premises. The administrator believed that the approval of the architectural plans was sufficient to begin providing dialysis services, but was unable to provide documentation of a modified facility license or the license of the contracted dialysis provider when requested by surveyors. From March 1, 2024 through March 7, 2025, dialysis treatments were provided to nine residents within the facility, utilizing a multipurpose room and bedside services. The facility assessment indicated an average of 16 residents receiving dialysis services daily, with a total of approximately 55 residents having end stage renal disease. Observations during the survey revealed the presence of six dialysis machines and residents actively receiving dialysis treatments in-house, managed by a contracted dialysis provider whose licensure could not be produced by the facility. Interviews with staff confirmed that the in-house dialysis program had been operating under the assumption that the architectural approval sufficed for licensure modification. The facility was unable to provide evidence of the required state approval for the modification of its license to include dialysis services, nor could it provide the license for the contracted dialysis provider. This resulted in the facility operating and providing dialysis services without compliance with all applicable federal, state, and local laws and regulations.
Failure to Ensure Proper Medication Administration
Penalty
Summary
The facility failed to ensure that medications were not left at the bedside for two residents who were not assessed to be clinically appropriate for self-administration of medications. Resident #62, who was readmitted with acute respiratory failure, pleural effusion, and pneumonia, had a BIMS score indicating moderate cognitive impairment. Despite this, a medication cup with a large capsule was found on the resident's bedside table. The resident expressed a preference to take the vitamin later, but there was no evidence of an assessment for self-administration. The RN involved was unaware of any residents permitted to self-administer medications and acknowledged the risks of leaving medications unattended. Resident #71, diagnosed with end-stage renal disease, had a BIMS score indicating intact cognition. However, there was no evidence of a self-administration assessment or physician orders for self-administration. During an observation, a medication cup with five tablets was found on the resident's bedside table, and the resident admitted to discarding unwanted pills. The RN responsible did not observe the resident taking the medications and was unaware of the resident's actions. The facility's protocol requires documentation of medication refusal and proper disposal, which was not followed in this case. Interviews with the Director of Nursing confirmed that medications should not be left at the bedside unless there is an order for self-administration. The facility's policy mandates that medications be administered according to physician orders and that any deviations be documented. The failure to adhere to these policies resulted in medications being left unattended, posing risks of incorrect administration or non-administration.
Deficiencies in Food Storage and Kitchen Cleanliness
Penalty
Summary
The facility failed to ensure proper food storage and handling practices, as observed during a kitchen inspection. Several food items in the refrigerator were found to be beyond their use-by dates, including grated parmesan cheese, lettuce salad bags, and milk cartons. Additionally, opened food items such as orange juice, turkey deli meat, and pizza were not dated, posing a risk of foodborne illness. Interviews with staff revealed a lack of adherence to the facility's policy, which mandates that potentially hazardous foods be covered, labeled, and dated. The facility also neglected to maintain cleanliness in the kitchen, particularly concerning the ceiling vents and the ice machine. The ceiling vent above the food tray line was coated with dust and debris, which extended to the surrounding ceiling and light fixture. The Dietary Manager admitted that the vent cleaning schedule was overlooked, and the Maintenance Director confirmed that the vents had not been cleaned since a previous date. This oversight contradicts the facility's policy requiring monthly cleaning of vent fans. Furthermore, the ice machine was found to be inadequately cleaned, with a black-brown discoloration on the interior plastic shroud. The cleaning log indicated a lack of regular maintenance, with no entries for several weeks. The Dietary Manager and Maintenance Director acknowledged that the ice machine had not been cleaned since a contracted deep clean, despite the facility's policy requiring monthly cleaning. This failure to maintain sanitary conditions in the kitchen increases the risk of contamination and foodborne illness.
Failure to Address Change in Condition and Ensure Proper Wheelchair Positioning
Penalty
Summary
The facility failed to provide appropriate care and services for a resident who experienced a change in condition. The resident, admitted with multiple diagnoses including diabetes mellitus and pneumonia, had physician orders for insulin and glucose monitoring. Despite documented low blood sugar levels and symptoms such as lethargy and labored breathing, there was no evidence that the provider was notified of these changes. The resident's condition worsened, leading to a complaint from the family about inadequate response to the resident's health decline. Another deficiency involved a resident who required a custom tilt-in-space wheelchair with leg rests for proper positioning due to mobility impairments. Observations revealed that the resident was frequently without leg rests, causing her legs to dangle unsupported. Despite therapy recommendations and the resident's care plan, the leg rests were missing for an extended period, and staff failed to ensure the resident was properly positioned, increasing the risk of injury and discomfort. Interviews with staff highlighted a lack of communication and documentation regarding the residents' conditions and needs. Nursing staff did not consistently notify providers of significant changes in residents' health status, and there was inadequate follow-up on missing equipment necessary for resident care. These deficiencies indicate a failure to adhere to facility policies on change of condition reporting and the provision of necessary mobility aids.
Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to ensure proper hand hygiene during medication administration, as observed during a survey. On September 17, 2024, an LPN was seen dropping a used plastic vial of normal saline on the floor. The LPN picked up the vial with bare hands and disposed of it in the sharps container without sanitizing her hands. She then proceeded to open medication cart drawers and prepare medications for administration without performing hand hygiene. In another instance, the same LPN dropped a packet from her pocket onto the floor, picked it up with bare hands, and placed it back in her pocket. She did not sanitize her hands before locking the medication cart, picking up prepared medications, and entering a resident's room. Interviews with the LPN and the DON confirmed that the facility's hand hygiene policy requires sanitizing hands after picking items up off the floor, which was not followed in these instances.
Failure to Maintain Resident Dignity and Grooming
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect, as evidenced by observations and interviews. The resident, who was admitted with diagnoses including muscle disuse atrophy, dysphagia, and cognitive communication deficit, required assistance with personal care and had a care plan that emphasized promoting dignity and ensuring privacy. Despite this, an observation revealed the resident lying supine in bed with pureed-like substance caked around his mouth and beard, wearing a shirt saturated with the same substance, and with one sock on and the other off. The resident's bed was in the lowest position with a visibly soiled fall mat on the floor, and the meal tray was placed on the side table. Interviews with staff indicated that breakfast trays were typically picked up around 9:30 a.m., and resident rounds were conducted every two hours or more frequently if needed. However, a subsequent observation approximately two and a half hours later found the resident still in the same condition, with the pureed-like substance still present around his mouth and beard, and his shirt still saturated. This indicates a failure to provide necessary services to maintain good nutrition and grooming, as outlined in the facility's policy for activities of daily living.
Lack of Physician Orders for Oxygen Use
Penalty
Summary
The facility failed to ensure there was a physician order for the use of oxygen for two residents, which could result in unnecessary oxygen use. Resident #219 was readmitted with diagnoses including end-stage renal disease, respiratory failure, and type 2 diabetes mellitus. Despite being documented as receiving oxygen via nasal cannula on multiple occasions between February 17 and March 15, 2023, there was no physician order for oxygen use during this period. The care plan was updated on March 17, 2023, to include oxygen therapy, but the lack of a physician order prior to this date was confirmed by the Assistant Director of Nursing and the Respiratory Therapy Director. Resident #168 was admitted with diagnoses of urinary tract infection, pneumonia, and type 2 diabetes mellitus. The resident's oxygen saturation levels were recorded as low on several occasions, and the resident was documented as receiving oxygen via nasal cannula. However, there was no evidence of a physician order for oxygen use from February 9 through February 12, 2023. The care plan was revised on February 13, 2023, to include oxygen therapy, but there was no documentation of a physician order for the increased oxygen levels administered to the resident. Interviews with staff, including a Licensed Practical Nurse and the Director of Nursing, revealed that the facility's policy required a physician order for oxygen administration. The Director of Nursing stated that any change in a resident's condition, such as increased oxygen needs, should be documented and reported to the provider. The facility's policy on oxygen administration, revised in July 2013, also required a physician order for oxygen therapy, highlighting the deficiency in following established protocols.
Failure to Notify Resident Representative of Hospital Transfer
Penalty
Summary
The facility failed to ensure that the resident representative (RR) was notified in writing of a transfer to the hospital for one resident. Resident #6, who had diagnoses including respiratory failure, diabetes mellitus, quadriplegia, and seizure disorder, was found to have a critically low hemoglobin level of 5.7 grams per deciliter on October 23, 2023. Following this finding, the physician ordered the resident to be transferred to the hospital. However, there was no evidence in the clinical record that the RR was provided with a written notice of this transfer. During an interview conducted on November 9, 2023, the assistant director of nursing (ADON) was unable to provide documentation of the notification to the RR regarding the transfer of Resident #6 on October 23, 2023. The facility's policy on Admission, Transfer, and Discharge, dated May 2022, requires that the transfer or discharge be documented in the resident's medical record and that appropriate information be communicated to the receiving healthcare institution or provider. This policy was not followed in this instance, leading to the deficiency.
Failure to Provide Bed-Hold Notification
Penalty
Summary
The facility failed to ensure that the bed-hold policy or notice was provided to a resident or their representative prior to or upon transfer to a hospital. Resident #6, who had diagnoses including respiratory failure, diabetes mellitus, quadriplegia, and seizure disorder, was found to have a critically low hemoglobin level of 5.7 g/dl on October 23, 2023. Following this finding, the physician ordered the resident to be discharged to the hospital. However, there was no evidence in the clinical record that the bed-hold policy was communicated to the resident or their representative before or during the transfer. During an interview conducted on November 9, 2023, the assistant director of nursing (ADON) confirmed that the bed-hold notification was not provided to the resident or their representative. The facility's policy on Admission/Discharge/Transfer did not include a requirement for notifying residents or their representatives about the bed-hold policy. This oversight could result in residents and their representatives being unaware of their ability to return to the facility after hospitalization.
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.
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What surveyors actually found near you
We read the 233 citations issued within 25 miles in the last 12 months — 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 Youngtown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Boswell Transitional Care Of Cascadia | 0.8 mi | ★★★★★ | 0 | 0 |
| Immanuel Campus Of Care | 2.3 mi | ★★★★★ | 3 | 0 |
| Az - Rio Vista Post Acute And Rehabilitation | 2.3 mi | ★★★★★ | 0 | 0 |
| Peoria Post Acute And Rehabilitation | 2.4 mi | ★★★★★ | 5 | 0 |
| Freedom Plaza Care Center | 2.5 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.