Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Barton Hospital D/p Snf during CMS and state inspections, most recent first.
Failure to Protect PHI: The facility failed to maintain an ongoing educational program on confidentiality of patient information after a staff member admitted using the facility computer to access her ex-husband's hospital records for personal reasons. The breach involved PHI including the patient's name, MRN, DOB, phone number, and clinical notes, while the DON stated staff are expected to access only files related to residents the facility is planning to care for.
Wheelchair Armrests Found Cracked and Exposed: Three residents who used wheelchairs were observed with cracked arm pads and exposed foam on their wheelchair armrests. The PT, CNA, IP nurse, and DON confirmed the arm pads were not in good repair, could be uncomfortable, and were expected to be reported or replaced; the facility policy stated equipment should be routinely monitored for damage that could hinder function or create uncleanable surfaces.
Morphine administration times did not match between the MAR and the CDR for a resident receiving scheduled morphine for chronic pain. The MAR showed the narcotic was given at 9 p.m., while the CDR documented it was administered 1 hour and 10 minutes early on two occasions. The DON and PSQN stated the MAR and CDR times are supposed to match for narcotic oversight and that giving a narcotic more than an hour early was not acceptable.
Medication Storage and Labeling Deficiencies: An expired eye drop medication was still being administered to a resident with dry eyes, an open hydrocortisone cream lacked an open date, and another resident’s vitamin C bottle had an illegible expiration date. In addition, a treatment cart was left unlocked and unattended in the hall with multiple prescription creams and ointments that were unlabeled, undated, or expired, making them accessible to residents and visitors.
Food Storage and Kitchen Sanitation Deficiencies: A resident's refrigerator contained expired butter, opened juice without proper dating or labeling, and an opened jar of mayonnaise without dates or labels. In the kitchen, food prep utensils were stored in a bin with crumbs and debris. The DM, IP, and DON all confirmed the items and areas were not maintained as expected, and facility policy required opened food to be dated or discarded and kitchen items to be kept clean.
Failure to maintain dryer lint compartment cleanliness: Surveyors observed a thick layer of lint in the dryer lint trap compartment during a laundry room tour. The IP Nurse and DES both confirmed the lint buildup and could not provide documentation of routine lint removal. The facility had no formal schedule for inspecting or cleaning the dryer lint compartment, and the linen room cleaning policy did not include specific guidance for dryer maintenance.
A resident with Alzheimer's disease and no decision-making capacity had a POLST indicating DNR status, but the form was not signed by the court-appointed Public Guardian and required sections were left blank. The DON and DPSQ confirmed the POLST was incomplete, and staff stated the guardian participated by phone in a care conference but did not want to sign the DNR POLST. Physician notes referenced the resident as full code on the POLST before later documenting review with the ethics committee and public guardian.
A resident’s private medical information was displayed on an unattended medication cart computer screen in a hallway, including MAR details such as code status and medications. The LPN stated she had only partially closed the screen flap and acknowledged it was a breach of privacy, while the DON stated staff are expected to lock the screen when leaving the cart so the information is not visible to visitors or other residents.
Failure to obtain ordered monthly weights for a resident with Alzheimer’s disease and Crohn’s disease. The resident was at risk for weight loss and had an order for monthly weights, but the WVS showed missed weights in two months and documented weight declines. During observation, the resident had a partially eaten pureed meal at the bedside, and staff confirmed the expectation was to weigh the resident monthly using a Hoyer lift.
A resident with a urinary catheter returned from the hospital after treatment for a UTI, but the catheter was not included in the care plan, there were no provider orders for catheter care, no TAR documentation for catheter cleaning, and no urine output amounts were charted. An LN and the DON both confirmed the missing documentation, and the DON stated staff would not be aware the resident had a catheter and needed catheter care.
Unnecessary Psychotropic Medication Use Without Documented Diagnosis: A resident received Citalopram for depression even though the clinical record, MDS assessments, and psychotropic medication reviews did not document depression or related symptoms. The resident was cognitively intact, denied feeling depressed or hopeless, and staff described her as calm and pleasant. The DON and pharmacy consultant confirmed the diagnosis was not reflected in the resident’s profile.
A resident with dementia, a history of frequent falls, and recent hip arthroplasty aftercare was assessed as high fall risk and had orders for a bed pad alarm and chair clip alarm, along with a care plan for staff-assisted ambulation and transfers. The care plan did not address the resident’s poor safety awareness or specify hourly checks, even though the resident could not reliably use a call light. On the day of the incident, the resident, who required one-person assistance for all walking and transfers, was found by an LPN ambulating unassisted in the hallway without a walker, became unsteady, and fell, striking his head and right side. Staff reported that the bed pad alarm, which had been activated earlier by a CNA, did not sound when the resident got up. The resident sustained a displaced right femur fracture with intramuscular hemorrhage and was transferred to the ED and then airlifted for further care, later being placed on comfort care and dying a few days after the fall. The DON stated that pad alarms were assumed to function for 30 days without routine checks and could not explain why this alarm failed, and surveyors also observed another high-risk resident’s bed alarm sounding without staff present in the hall or at the nurses’ station.
Two residents with dementia were involved in a witnessed altercation, resulting in one being hit on the head and the other sustaining bleeding skin tears. Although staff provided first aid, required assessments and documentation of the injuries were not completed in the clinical record, contrary to facility policy. Interviews and record reviews confirmed the lack of proper documentation and assessment following the incident.
A resident with Alzheimer's disease and dementia, identified as high risk for falls and requiring supervision, was left unattended by a CNA who did not inform other staff. The resident subsequently experienced an unwitnessed fall, resulting in a hip fracture that required surgery and skilled nursing care. Staff interviews and documentation confirmed the need for continuous supervision, which was not provided.
A resident with moderate memory impairment was struck in the face by her roommate, who had a documented history of behavioral disturbances and was under one-on-one supervision by a Patient Safety Technician. Despite this supervision, the aggressive resident was able to approach and hit the other resident, who was sitting at the foot of her bed. The incident was witnessed by staff and met the facility's definition of abuse.
Failure to Protect PHI
Penalty
Summary
The facility failed to meet State licensure requirements for Staff Development - Confidentiality of patient information when it did not effectively provide an ongoing educational program to ensure staff had the necessary skills and knowledge regarding the confidentiality and appropriate use of PHI. An investigation into a facility-reported incident confirmed that a staff member admitted to using the facility computer to access her ex-husband's hospital records for personal reasons rather than for patient care purposes. The facility report titled Notice of Breach of Protected Health Information (PHI) indicated that the breach occurred on multiple dates and involved access to a patient's name, medical record, date of birth, phone number, and clinical notes, including hospital notes, labs, and patient status. During interview, the DON stated staff are expected not to access patient files that do not apply to the facility and that staff had annual HIPAA training, but the staff member still accessed the PHI for personal use. The DON stated staff should only access files for residents the facility is planning on caring for.
Wheelchair Armrests Found Cracked and Exposed
Penalty
Summary
The facility failed to ensure that wheelchairs were maintained in safe condition when three sampled residents were found with cracked and exposed wheelchair armrests. Resident 13 was admitted with diagnoses including a right artificial hip joint, polymyalgia rheumatica, and chronic pain, and was dependent on a wheelchair and walker; her care guide stated she frequently used her wheelchair for short distances. During observation, her wheelchair arm handles were found cracked with exposed foam inside the cushion, and she confirmed the wheelchair was uncomfortable and wanted it changed. Resident 30 was admitted with diagnoses including a history of falling and failure to thrive and was dependent on a wheelchair and walker; his care guide stated he was often found propelling his wheelchair around the facility. During observation and interview, his wheelchair arm handles were found cracked with exposed foam, and he stated he preferred the arm handles not be cracked to avoid his arm being pinched. Resident 43 was admitted with diagnoses including pain in the right knee, a right artificial knee joint, and chronic pain, and was dependent on a wheelchair and walker; her care guide stated she used a wheelchair for mobility and should be encouraged to use it instead of a walker due to severe knee pain. Her wheelchair arm handles were also observed cracked with exposed foam, and she and a family member agreed the condition could cause discomfort or skin issues and should be replaced. The PT, CNA, IP nurse, and DON all confirmed the cracked and exposed arm pads were not in good repair and were expected to be reported or replaced, and the facility policy stated equipment should be routinely monitored for damage that could hinder function or result in uncleanable surfaces.
Morphine administration times did not match between MAR and controlled drug record
Penalty
Summary
The facility failed to ensure the administration time for morphine on the MAR matched the Controlled Drug Record for one sampled resident. Resident 5 was admitted in 2022 with diagnoses including chronic pain and osteomyelitis. Her order summary dated 3/27/25 showed morphine sulfate extended release 15 mg, two tablets by mouth at bedtime for chronic pain, and her March 2026 MAR showed the morphine was scheduled for 9 p.m. The MAR documented that two tablets of morphine were given at 9 p.m. on 3/29/26 and 3/31/26, but the CDR for those same dates showed the morphine was administered at 7:50 p.m., 1 hour and 10 minutes before the scheduled time. During interview, the DON and PSQN stated the administration window was one hour before or after the MAR time, that the MAR and CDR times are supposed to match for oversight of narcotic medications, and that it was not acceptable to administer a narcotic more than an hour early.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Medications and biologicals were not stored and labeled in accordance with accepted professional principles. During observation and interview, Resident 17’s artificial tears eye drops were found with an expiration date of 4/5/26 written on the box, and the LN confirmed the drops were expired because the facility considered eye drops expired 30 days after opening. The MAR showed the resident continued to receive the eye drops through the morning of 4/8/26. Resident 17 had been admitted in 2024 and had an order for artificial tears, 2 drops twice daily for dry eyes. Resident 20, also admitted in 2024, had an order for vitamin C 500 mg daily, and the bottle of ascorbic acid had a smudged, illegible expiration date. An open tube of hydrocortisone cream 1% for general resident use was found without an open date, and the LN confirmed it had been opened but not dated. The LN stated the medication was available for resident use if ordered by the physician, and the facility’s posted guide on the cart stated that all items were to be dated and initialed when opened. During interview, the DON stated that hydrocortisone creams were to be labeled upon opening and that if they were not labeled, they should be discarded because no one would know whether the medication was expired. A treatment cart containing prescription ointments and creams was left unlocked and unattended in the hall, accessible to residents and visitors. Treatment Cart 1 contained multiple items in an unlocked drawer, including a tube of mupirocin 2% ointment without a resident name, an unlabeled and undated tube of Premarin 0.625 mg cream, an unlabeled and undated tube of permethrin 5% cream with an expiration date of 5/2025, a tube of betamethasone dipropionate ointment with an expiration date of 5/31/25, and three tubes of lubricating jelly with an open date of 10/8/2024. The LN acknowledged the cart was unlocked and accessible, and the DON stated treatment carts containing medicated ointments and creams should never be left unlocked.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
Food was not stored and prepared in accordance with professional standards for food service safety in a facility with a census of 45. During an observation of a resident's refrigerator, surveyors found a one-gallon plastic bag of expired individual butters with an expiration date of 3/20/26, a bottle of cranberry cocktail juice with an open date of 12/10/25, an opened bottle of cranberry juice that was undated and unlabeled, and an opened jar of mayonnaise that was also undated. During a concurrent interview, LN 4 confirmed the unlabeled and outdated items and stated resident food from home was expected to be labeled so residents would be safe. LN 3, CNA 1, the DM, DA 1, and the DON each stated food should be labeled, dated, and not expired, and that expired items should be removed from the refrigerator. The facility policy titled Food handling and storage from outside SNF stated opened food would remain in the refrigerator for no more than 7 days and anything without a name and/or date would be immediately discarded. During a kitchen inspection tour, food preparation utensils were found stored in a metal bin with crumbs and debris. The DM confirmed the utensils were lying in debris and stated the bin was expected to be clean and free of debris. The IP stated crumbs and debris in clean and sanitized areas were not safe and could harbor bacteria that could make a resident sick. The DON stated crumbs and debris should not be inside a clean area to avoid illness to residents. The facility policy titled Departmental Safety: Food Service stated dishes should be kept clean and serviceable and stored properly in the kitchen service area.
Failure to Maintain Dryer Lint Compartment
Penalty
Summary
The facility failed to maintain electrical equipment in a safe condition when it did not routinely remove lint buildup from the dryer in the laundry room. During a tour of the laundry room on 4/9/26 at 2:45 p.m., accompanied by the Infection Prevention Nurse, surveyors observed a thick layer of lint accumulation in the lint trap compartment of the dryer. The Infection Prevention Nurse stated the lint trap was to be cleaned on a regular basis to remove lint accumulation, but she was unable to provide documentation or a log confirming routine lint removal. She also stated she did not inspect the laundry room for cleanliness and that the laundry room was managed by the Director of Environmental Services. During a concurrent observation and interview with the Director of Environmental Services on 4/9/26 at 3:02 p.m., the Director acknowledged the lint compartment had lint accumulation and stated it looked like it had not been cleaned that day. The Director stated the dryer needed to be inspected and cleaned of lint accumulation every day, but was unable to provide documentation or a log confirming routine lint removal. The Director confirmed the facility did not have a formalized schedule requiring routine inspection and cleaning of the dryer lint compartment, and stated there were no documents available showing when the last inspection of the dryer lint compartment was done. Review of the facility policy titled, Clean Linen Room Cleaning Procedure, dated 11/5/21, showed the purpose was to maintain the linen room in a clean, safe, sanitary and outstanding condition, but it did not include specific procedures or guidance for routine cleaning and maintenance of laundry equipment, including dryers, to prevent lint accumulation.
Incomplete POLST for Resident Lacking Capacity
Penalty
Summary
The facility failed to ensure the POLST for a resident with Alzheimer's disease and hearing loss was properly completed with the signature of the resident's Public Conservator. The resident had been admitted in 2019 and was documented by physician order on 9/23/19 as lacking capacity to make decisions, with the [County] Public Guardian listed as the surrogate decision maker. A Letter of Conservatorship dated 1/2/2020 identified the Public Guardian as the court-appointed conservator with exclusive authority to consent for medical treatment. The resident's clinical record contained a POLST indicating DNR status, signed by two physicians on 12/20/22. However, Section D did not list the required name, did not indicate whether the DNR status was discussed with the legally recognized decisionmaker, and did not contain the signature of the resident's legally recognized decisionmaker. The POLST instructions stated that a legally recognized decisionmaker may include a court-appointed conservator or guardian and that the POLST must be signed by a physician and the patient or decisionmaker to be valid. During interviews, LN 3 stated the POLST must be signed by the physician and public guardian when the resident lacks capacity and has no identified family members. The DON and DPSQ reviewed the form and validated that it was not completed properly and was not signed by the appointed Public Guardian. The DON stated the code status was changed to DNR after a care conference in which the Public Guardian participated by phone, but the Public Guardian did not want to sign the POLST and did not want to take responsibility. Physician progress notes referenced the resident as currently full code on the POLST and later noted review with ethics committee and the public guardian, after which the resident was changed from full code to DNR.
Unattended Medication Cart Screen Exposed Resident Medical Information
Penalty
Summary
The facility failed to maintain confidentiality for one resident when an unattended medication cart computer screen was left open in the hallway and displayed private medical information. During a concurrent observation and interview, the screen showed a section of the resident’s MAR, including his code status and medications. The resident had been admitted with diagnoses including chronic kidney disease and gangrene of the left foot, and his MDS indicated a BIMS score of 14 out of 15, showing intact cognition. His admission packet, signed on 4/6/26, included resident rights related to the confidentiality of information, including medical records. During the observation, the LPN who had been administering medications returned to the cart and stated she had partially closed the computer screen flap to conceal the resident’s medical information. She stated she should not have left the unattended computer screen open and that it was a breach of privacy because visitors or other residents could view the resident’s medications. The DON stated nurses are expected to lock the computer screen each time they leave the cart to administer medications, which blanks out the screen, and stated the LPN violated HIPAA by exposing the resident’s private health information to anyone walking down the hallway. The facility policy stated staff are expected to secure patient records containing individually identifiable health information so they are not readily available to those who do not need them.
Failure to Obtain Ordered Monthly Weights
Penalty
Summary
The facility failed to ensure a physician’s order was followed for one sampled resident who was ordered to be weighed monthly. The resident was admitted in Fall 2024 with diagnoses including Alzheimer’s disease and Crohn’s disease, and the MDS dated 3/12/26 indicated the resident did not have the capacity to make decisions and was at risk for weight loss. The order summary dated 4/10/26 directed staff to weigh the resident monthly and have CNAs document the weights in the plan of care. The Weight and Vital Summary dated 4/10/26 showed the resident was not weighed in December 2025 or February 2026, and it also reflected a 13 lb. 4 oz. decline in December 2025 and a 3 lb. 4 oz. decline in February 2026. During observation, the resident was found with a partially eaten pureed diet at the bedside, and a CNA stated the resident was on a pureed diet and had not been eating that day. Staff interviews confirmed the expectation was to obtain monthly weights using a Hoyer lift, and the DON stated monthly weights were expected when ordered and were important for monitoring weight changes.
Missing Catheter Orders, Care Plan, and Output Documentation
Penalty
Summary
Appropriate care for a resident with an indwelling urinary catheter was not provided when catheter placement and catheter care were not included in the resident’s care plan, orders, treatment record, or urine output log. The resident was admitted with diagnoses including removal of the left cancerous kidney and acute right kidney failure, and had been hospitalized for a UTI before returning to the facility with a urinary catheter inserted by the hospital to monitor exact urine output. The interim care plan noted only that the resident had an indwelling urinary catheter, with no further information, and the care plan report later showed no goal for catheter care. Record review also showed no medical orders for catheter care, no catheter care documentation in the TAR, and no urine output amounts entered in the urinary output log from the resident’s return through the date of review. During interview, an LN stated the catheter order was not in the record and that there was nowhere to document catheter care in the TAR, and the DON confirmed the order, care, and urine output amounts were missing. The DON stated the orders should have been entered soon after the resident’s readmission and that staff would not be aware the resident had a catheter and needed catheter care because it was not in the care plan.
Unnecessary Psychotropic Medication Use Without Documented Diagnosis
Penalty
Summary
The facility failed to ensure that psychotropic medication use was supported by a documented, clinically appropriate indication for one resident who was receiving Citalopram. Resident 6 was admitted in 2024 with diagnoses including high blood pressure, diabetes mellitus, and a right upper arm fracture. The resident’s record showed an order for Citalopram 10 mg daily for depression as manifested by hopelessness and lack of interest, and the medication had previously been started at 40 mg daily and then gradually reduced to 30 mg, 20 mg, and 10 mg. A review of the resident’s clinical record, physician admission history, and multiple physician progress notes did not show depression listed as a diagnosis. The resident’s MDS assessments also did not identify depression, and the mood assessments indicated a depression score of 00 with no reported symptoms such as little interest in doing things or feeling down, depressed, or hopeless. Psychotropic Medication Evaluations from June 2025 through December 2025 likewise documented 0 episodes of hopelessness and lack of interest and did not include depression as the diagnosis or required indication for Citalopram. During observation and interview, Resident 6 was pleasant, cognitively intact, and stated she did not think she had depression. She explained that she preferred staying in her room, doing puzzles and crosswords, listening to the news, and sometimes attending activities, and she denied feeling hopeless or lacking interest in life. Nursing staff described her as calm, pleasant, quiet, and not observed crying or expressing depression. The DON confirmed that the resident’s records did not include a diagnosis of depression, that depression was not listed on the MDS assessments, and that residents receiving antidepressants were required to have a documented diagnosis of depression reflected in the clinical profile; the pharmacy consultant also stated that any resident receiving antidepressant therapy was required to have a documented diagnosis of depression listed in the profile.
Failure to Adequately Supervise High-Risk Resident and Reliance on Non-Functioning Bed Alarm
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and assistance to prevent an avoidable fall for a resident identified as high risk for falls. The resident was admitted with multiple diagnoses including aftercare following right hip arthroplasty, dementia, and a history of frequent falls. The resident’s fall risk evaluation showed a high fall risk score, and the admission MDS documented severely impaired cognitive status. Physician orders included use of a bed pad alarm every shift and a clip alarm while in a wheelchair. The fall risk care plan identified the resident as at risk for falls, with goals to reduce falls and injuries and interventions such as staff assistance with ambulation and transfers, use of bed pad and clip alarms, and environmental evaluation for fall risks. However, the care plan did not address the resident’s poor safety awareness and did not include hourly checking and monitoring, despite the resident’s inability to use a call light and impaired cognition. On the day of the incident, the resident was observed by staff ambulating in the hallway directly outside his room without an assistive device or staff assistance, despite having poor balance and requiring one-person assistance for all walking and transfers. According to the post-fall evaluation, the resident was unsteady, not using his walker, lost his balance, and fell to the right, landing on his right side and hitting the back of his head. Staff reported that the bed pad alarm, which was intended to alert them when the resident attempted to get out of bed, did not sound when the resident got up unassisted. The DON and LN stated that the resident’s bed pad alarm did not go off, and the DON acknowledged that staff were supposed to round on residents every hour, especially those at high risk for falls, but these visual checks were not documented. A CNA reported that earlier that day the resident had been up in a wheelchair for a long time, appeared very tired, and was transferred to bed with the bed pad alarm activated, as indicated by two short beeps. Following the fall, the resident was noted to be in significant pain, unable to move his lower extremities, and was transferred to the ED. ED documentation and CT imaging revealed a displaced fracture of the right femur with associated intramuscular hemorrhage and severe deformity of the right femur. The resident was subsequently airlifted to another hospital for further evaluation and treatment and was later placed on comfort care and died three days after the fall. Interviews with the PT indicated that, although the resident had become stronger with therapy, he still required staff assistance with transfers and had poor balance, with difficulty standing and a tendency to fall backward earlier the same day. The DON stated that pad alarms did not require routine functionality checks and were assumed to work for 30 days, and the facility was unable to determine why the alarm did not activate when the resident got up. During a tour of another hall, surveyors also observed another high fall risk resident with a bed pad alarm sounding and a call light blinking without staff present in the hallway or at the nursing station, demonstrating reliance on alarms without immediate staff response. A requested policy addressing resident safety, supervision, and accident prevention was not provided.
Failure to Protect Residents from Abuse and Inadequate Documentation of Injuries
Penalty
Summary
The facility failed to protect two residents from abuse during an altercation in which one resident hit another on the head, and the second resident responded by grabbing the first resident's forearm, causing skin tears. Both residents had a history of dementia and moderate cognitive impairment, as indicated by their BIMS scores and care plans, which included interventions for resident-to-resident altercations. Staff witnessed the incident in the dining room, and it was documented that first aid was administered to the resident who sustained skin injuries. Despite the incident and the facility's policy requiring a full head-to-toe assessment and documentation of any injuries following abuse, there was no evidence in the clinical record that the resident's skin injuries were assessed or documented. The nursing staff did not record the location, measurements, or description of the injuries, nor did they document the treatment provided, as required by facility protocol. The DON and a licensed nurse confirmed that the assessment and documentation were missing from the resident's clinical record, despite expectations and policy. Observations and interviews with both residents confirmed the occurrence of the altercation and the resulting injuries. The resident who sustained the skin tears described the incident and the resulting pain and bleeding, while the other resident was unable to recall the event due to memory impairment. Staff interviews corroborated the sequence of events and the lack of proper documentation following the incident.
Failure to Provide Adequate Supervision Resulting in Resident Fall and Injury
Penalty
Summary
Staff failed to provide adequate supervision to a resident with Alzheimer's disease and dementia, who was identified as high risk for falls. The resident's care plan specifically instructed staff not to leave her unattended due to her tendency to attempt self-transfers. Despite these instructions, a CNA left the resident alone at the nurse's station while responding to another call light, without notifying other staff members. At the time, all other staff were occupied in other rooms, leaving the resident unsupervised. As a result of being left unattended, the resident experienced an unwitnessed fall, which led to a left hip fracture. The resident required surgical intervention and subsequent skilled nursing care for pain management and rehabilitation. Facility records, including the resident's MDS, fall risk assessment, and care guide, all indicated the need for supervision and highlighted the resident's history of multiple falls. Interviews with staff and the interim DON confirmed that the resident should have been supervised at all times, especially during meals, and acknowledged that the fall could have been prevented with proper supervision.
Resident Struck by Roommate Despite One-on-One Supervision
Penalty
Summary
A deficiency occurred when a resident with moderate memory impairment was struck in the face by her roommate, who had a history of behavioral disturbances, including physical aggression toward staff and other residents. At the time of the incident, the aggressor was under one-on-one supervision by a Patient Safety Technician (PST), yet was able to approach and hit the other resident, who was sitting at the foot of her bed near the doorway. The PST witnessed the event but was positioned behind and to the side of the aggressor, which did not prevent the physical contact. The aggressor's medical history included dementia with behavioral disturbances, psychosis, and Alzheimer's disease, and prior documentation noted multiple instances of striking staff. The facility's policy required an environment free from abuse, but the incident was confirmed by the Interim Director of Nursing to meet the facility's definition of abuse. The resident who was struck reported pain and frustration, noting that the one-on-one supervision in place did not prevent the incident.
What surveyors are citing around you — mapped
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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 114 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 South Lake Tahoe
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Gardnerville Health & Rehabilitation Center | 13.1 mi | ★★★★★ | 3 | 0 |
| Mountain View Health And Rehabilitation | 19.7 mi | ★★★★★ | 22 | 0 |
| Sierra Basin Post Acute | 21.6 mi | ★★★★★ | 13 | 0 |
| Ormsby Post Acute Rehabilitation | 22.4 mi | — | 34 | 0 |
| Northstar Post Acute | 22.9 mi | ★★★★★ | 42 | 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 August 2026) and official state health department websites.