Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fairmont Rehabilitation Hospital during CMS and state inspections, most recent first.
Food handling and sanitation deficiencies were observed in the kitchen and storage areas for meals served to 53 residents. Debris was found in a clean utensils drawer, mold was present in a bag of cherries, multiple food containers and spice items were loose or improperly sealed, and several opened seasonings and sweeteners lacked required dating. Staff also observed wet snack containers stacked in a cabinet, debris on the food prep table, heavy grease buildup on the oven/range, cracked and peeling wall surfaces above the dishwashing sink, one cutting board used for raw and ready-to-eat foods, and fish thawing in still water instead of under running water.
Failure to Protect Resident Dignity and Privacy During Care: A resident who required moderate assistance with bathing was exposed from the hallway when a CNA did not fully close the privacy curtain during a bed bath. The resident also had a nephrostomy drainage bag that was not covered with a dignity bag, and an LN, IP, and DON all confirmed the cover was needed to protect privacy and dignity.
Call Light Left Out of Reach: A resident with hemiplegia, hemiparesis, aphasia, dysphagia, and muscle weakness had a call light observed off to the side of the bed instead of within reach. A CNA confirmed it should have been placed on the bed or overbed table, and the resident’s family member stated the resident was not verbal, had difficulty moving, and should have the call light near the right hand. The IP, DSD, and DON stated call lights should be within residents’ reach, and facility policy required personal items and call lights to be kept within easy reach.
Resident Council concerns were not addressed in a timely manner, including long call light wait times, call lights wrapped around bed rails, staff speaking another language, and staff leaving before completing ADL care or asking if anything else was needed. Residents reported that issues raised in prior council meetings had not changed, and several declined to attend because they felt nothing was being done. Interviews with the AD, DSD, AA, and residents, along with Resident Council minutes, showed repeated complaints about call light response, communication, and ADL care that remained unresolved.
A resident with COPD, schizophrenia, anxiety disorder, and severe cognitive impairment had repeated falls and was documented as being on hospice care. After a fall, the care plan included fall mats at bedside, but during observation the LN, DSD, and DON confirmed no fall mat was present at the resident’s bedside even though the intervention was active.
A resident’s allergy profile continued to list Levaquin as an allergy, yet the resident received Levaquin for a UTI. The MAR showed multiple doses were administered, but there was no documented provider clarification, no IDT documentation about the allergy, and no record of monitoring for adverse reactions or side effects. Staff interviews confirmed the allergy remained active in the chart and that the required documentation was missing.
Unlabeled Urinal: A resident's urinal was observed without identifying information, and CNA confirmed it should have been labeled. The IP, DSD, and DON stated urinals were expected to be labeled with resident identifiers to prevent cross-contamination and infection control issues, and the facility's policies required equipment to be clearly labeled before use.
Inaccurate MDS Oxygen Therapy Assessment: A resident with pleural effusion and acute respiratory distress was observed receiving O2 via nasal cannula at 2.5 LPM, but the MDS Section O entries stated the resident was not on oxygen therapy. An LN confirmed the resident had been on O2 since November and had an order for 2 to 3 LPM to keep O2 sat above 90%, while the DON stated the MDS should have reflected the resident’s oxygen use.
The facility failed to submit a required 5‑day written investigation summary to the state after a resident‑to‑resident altercation in which one resident blocked a bathroom door, preventing another resident with dementia from exiting. The initial abuse report was completed and sent, and both residents’ care plans were updated to reflect risk for psychosocial and mood changes related to the incident. However, the SSD acknowledged not submitting the 5‑day investigation report, and the DON confirmed there was no documentation or confirmation of submission, despite facility policy requiring a written report of investigation findings to be provided to the appropriate agencies within five working days.
A resident with dementia and moderate cognitive impairment frequently used a shared bathroom for extended periods, limiting timely access for other residents and contributing to a prior resident-to-resident altercation over bathroom use. Several residents reported having to wait, hold urine, or seek staff help or alternate toileting locations due to the resident’s prolonged bathroom occupancy. Staff, including a CNA and an LN, acknowledged the resident’s forgetfulness, lack of call light use, removal of a personal alarm, and need for supervision, yet no individualized care plan was developed to address bathroom use behaviors or to prevent further conflict, despite facility policy requiring comprehensive, person-centered care plans.
A facility failed to implement a comprehensive water safety management program to minimize the risk of Legionella and other waterborne pathogens. After a resident tested positive for Legionella, it was found that the facility lacked a detailed risk assessment, a mapped water system, adequate monitoring protocols, and a contract with a certified water testing company. The existing policy was insufficient and did not meet CDC or public health standards, leaving gaps in prevention and response measures.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
Two residents with physician-ordered small portion diets were served full meal portions instead of the prescribed reduced portions. Despite clear dietary orders and care plans, dietary staff did not follow portion control guidelines, and both residents received the same amount of food as others without such orders. Staff interviews indicated that the correct portion sizes were not called out or served, and the Food and Nutrition Services director confirmed the error.
The facility failed to label open food packages with use by dates and improperly stacked wet plate covers, risking food quality and safety for 56 residents. The Dietary Manager and Director of Nursing confirmed these practices could lead to bacterial growth and illness. Facility policies on dishwashing and food labeling were not followed.
The facility failed to ensure the safe use of facility-owned smartphones for communication with medical providers, compromising residents' Protected Health Information (PHI). Smartphones were used to send sensitive information, including residents' names and medical conditions, without secure messaging software, violating HIPAA regulations. The facility's policy required secure messaging, but this was not followed, leading to a significant breach of residents' privacy.
The facility failed to ensure safe medication storage practices, including undated and improperly stored medications on a medication cart, expired test tubes in a medication closet, and an opened, undated vial of Aplisol in a medication refrigerator. These deficiencies were acknowledged by the DON, who confirmed the potential for ineffective treatments due to these lapses.
A resident received a daily dose of Vitamin D3 at 50,000 units for two months due to a medication error. The pharmacy consultant did not identify the error during routine medication regimen reviews. The MD was unaware of the daily dosage, which could lead to adverse effects. The DON confirmed the error and expected the pharmacy to ensure medication safety.
A resident was found with three unlabeled medications at their bedside, including an inhaler and nasal sprays, without a doctor's order or facility awareness. The resident claimed these were prescribed by their allergy doctor, but the facility's policies require medications to be assessed and authorized for self-administration. The facility failed to ensure safe storage and use, leading to unauthorized medication use.
The facility failed to properly clean and sanitize a shared glucometer between uses for two residents, as observed during medication administration. An LPN used a Sani-Cloth-Bleach wipe for less than 10 seconds, not meeting the required 4-minute wet time. Interviews revealed that staff were educated on the correct procedure, which involves a two-step cleaning and disinfecting process using two wipes, as per the manufacturer's instructions. The observed practice did not align with these guidelines, posing a risk of infection spread.
The facility failed to ensure that prescription medication delivery manifests, including narcotic controlled medications, were consistently signed by licensed staff upon delivery. During an inspection, it was found that delivery sheets were not consistently signed, which may contribute to unsafe medication handling and risk of drug diversion. The Director of Nursing stated that staff signed a copy for the driver but not the facility copy, contrary to the facility's policies.
A facility failed to ensure the safe use of psychotropic medications for a resident due to an unsupported diagnosis of bipolar disorder and inadequate communication of mental health consults and medication adjustments. The resident's medical records did not reflect the bipolar disorder diagnosis used to justify aripiprazole administration, and the primary psychiatrist confirmed the absence of such a diagnosis. Additionally, the facility's process for handling mental health consults hindered the continuity of care, as critical information was not included in the resident's medical record.
The facility exceeded the acceptable medication error rate with two incidents involving medication administration errors. A nurse documented medications as given despite a resident's refusal, and another nurse administered insulin after a resident began eating, contrary to the prescribed timing. The facility's policies lacked guidance on medication refusal and nursing responsibilities.
A facility failed to ensure nursing staff followed infection prevention practices and Enhanced Barrier Precaution (EBP) guidelines during IV antibiotic administration to a resident. A nurse entered the resident's EBP-marked room without a gown and with her mask below her nose, accessing the mid-line without the required protective gown. Despite being aware of EBP requirements, the nurse admitted to forgetting to wear the gown, potentially exposing the resident to infection. Interviews confirmed staff were educated on EBP importance, and facility policy required gown and gloves during high-contact care activities.
Food Sanitation, Storage, and Preparation Deficiencies
Penalty
Summary
Sanitary conditions were not maintained in the kitchen and food storage areas for meals served to 53 residents. During observation with the Certified Dietary Manager (CDM), debris was found inside the clean utensils drawer, and the CDM stated the drawer had last been cleaned several days earlier and that the debris may have come from the wooden surface above it. The Registered Dietician (RD) stated the drawer needed repair because it could lead to food contamination. The facility policy required utensils, counters, shelves, and equipment to be kept clean, maintained in good repair, and free from breaks, corrosion, open seams, cracks, and chipped areas. Food storage practices were inconsistent and several items were found improperly stored or labeled. A bag of cherries in the refrigerator contained visible mold and was not labeled with a use-by date. Cereal container lids were loose, an opened box of iced tea bags contained a plastic bag with a hole, four spice containers had lids that could not be closed, two large spice containers with screw-top lids were not tightly sealed, and a casserole scalloped potatoes box was not properly sealed. Multiple opened liquid seasonings and sweeteners also lacked open-by, received-by, or use-by dates, and the CDM stated staff from different facilities were following different labeling practices. Wet snack containers were stacked in a cabinet. The facility policies required food items to be labeled and dated according to established procedures, and the FDA Food Code cited in the report required ready-to-eat time/temperature control for safety food to be discarded if it was in a container or package without a date or day. Food preparation and kitchen sanitation issues were also observed. The food preparation table had debris and dust accumulation, and the CDM stated that anything contacting food must be clean. The kitchen used only one cutting board for meat, poultry, vegetables, and ready-to-eat foods, with staff washing and sanitizing it continuously throughout the day; the CDM acknowledged this practice could present a risk for cross-contamination and foodborne illness. The oven/range had significant grease buildup on non-food contact surfaces, and the wall directly above the manual dishwashing sink had cracked, chipped, peeling, and flaking paint. Two pieces of fish were also observed thawing in a bowl of still water rather than under running water, and the AS stated the thawing procedure was not followed. The facility policies required separate cleaned and sanitized cutting boards, clean equipment surfaces, walls free of chipped or peeling paint, and proper thawing methods.
Failure to Protect Resident Dignity and Privacy During Care
Penalty
Summary
The facility failed to promote, maintain, and protect the dignity and privacy of one resident during personal care and with a urinary drainage device. The resident had diagnoses including hydronephrosis with renal and ureteral calculous obstruction and, on the MDS dated 4/30/26, required moderate assistance with bathing. During a concurrent observation and interview on 5/5/26 at 9:08 AM, a CNA was providing a bed bath but did not fully close the privacy curtain, leaving the resident's body exposed and visible from the hallway. The CNA later stated she did not realize the curtain was not fully closed until after the observation, and another CNA and the DON stated that curtains must be fully closed during a bed bath to prevent exposure and protect dignity. The resident also had a nephrostomy drainage bag that was not covered with a dignity bag. During a concurrent observation and interview on 5/5/26 at 1:25 PM, an LN confirmed the nephrostomy bag did not have a dignity cover and stated it posed a risk to the resident's privacy. The IP and DON both stated that the nephrostomy bag should have a cover to protect the resident's dignity and privacy. The facility's dignity policy stated that staff promote, maintain, and protect resident privacy, including bodily privacy during personal care, and that staff are expected to help keep a urinary catheter bag covered.
Call Light Left Out of Reach
Penalty
Summary
The facility failed to accommodate the needs of Resident 68 when the resident’s call light was not within reach. Resident 68’s clinical record showed diagnoses including need for assistance with personal care, hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, muscle weakness, aphasia, and dysphagia. The care plan identified the resident as at risk for falls related to muscle weakness and included the intervention to be sure the call light was within reach and to encourage use of it to call for assistance as needed. During a concurrent observation and interview, Resident 68’s call light was observed off to the left side of the bed. A CNA confirmed it should have been placed on the bed or overbed table and not off the bed, and stated the resident would have been unable to call for help with it out of reach. The resident’s family member stated the resident had difficulty moving, was not verbal, was right-handed, and should have the call light close to the right hand as much as possible. The IP, DSD, and DON each stated that call lights should be within residents’ reach, and the facility’s policies stated that personal items and call lights should be kept within easy reach of residents.
Resident Council Concerns Not Addressed in a Timely Manner
Penalty
Summary
The facility failed to act upon concerns raised by the Resident Council regarding call lights not being answered in a timely manner, call lights being wrapped around bed rails, staff speaking another language, and staff not completing ADL care before leaving residents' rooms. Resident Council minutes from 1/27/26 and 2/24/26 documented repeated concerns about long wait times for call lights on all shifts, staff not communicating when leaving for showers or breaks, call lights not being left within reach, staff leaving after assisting residents without asking if anything else was needed, staff checking only one bed in a room, and staff speaking another language on the floor and in resident rooms. Resident 23 was admitted in 2025 with diagnoses including muscle weakness, type 2 DM, and essential HTN. Resident 53 was admitted in 2025 with diagnoses including major depressive disorder, cardiogenic shock, and hypovolemic shock. Resident 56 was admitted in 2024 with diagnoses including hemiplegia and hemiparesis, functional quadriplegia, major depressive disorder, and dysphagia. During interviews, Resident 53 stated some staff still wrapped the call light around the bed rail, some staff spoke another language she could not understand, and she sometimes waited more than 20 minutes for a call light to be answered. Resident 23 stated some staff still did not knock before entering and left her room after ADL care without asking if she needed anything else. Resident 56 stated staff left her room without finishing requested ADL care and still did not ask if she needed anything else. The Activities Director stated the facility held monthly Resident Council meetings and that resident concerns were documented and reported to the Director of Staff Development. She stated that residents had raised concerns at prior meetings about call light response times, communication, staff introductions, staff asking if residents needed anything else before leaving, checking both beds in a room, staff speaking another language, and honoring resident preferences. The 3/24/26 Resident Council minutes documented that residents declined to attend because they felt nothing had been done or changed, and the Activities Assistant confirmed that only 4 residents attended the meeting she invited them to. The DSD stated she was not aware residents had declined to attend and said better internal communication was needed to address Resident Council issues faster. The facility policy stated it was the facility's policy to assist residents in establishing and maintaining a Resident Council and to provide an opportunity for residents to express concerns, contribute ideas, and make recommendations, and that Resident Council concerns were to be addressed and resolved when possible.
Failure to Place Ordered Fall Mat at Bedside
Penalty
Summary
The facility failed to implement a fall intervention for one resident when a fall mat was not placed at the bedside. The resident had been admitted in 2025 with diagnoses including COPD, schizophrenia, and anxiety disorder, and the MDS dated 1/12/26 showed a BIMS score of 0 out of 15, indicating severe cognitive impairment. After a fall on 2/21/26, the resident was found on the floor beside the bed in a sitting position holding the handrail, and staff assisted the resident back to bed with no visible injuries noted. Interdisciplinary notes dated 2/24/26 documented another fall event in which staff heard the resident calling for help and found the resident on the floor beside the bed in a sitting position holding the handrail. The notes stated the resident was on hospice care and included the intervention of fall mats at bedside. During observation and interview on 5/6/26, the licensed nurse, DSD, and DON all confirmed there was no fall mat at the resident’s bedside, even though the fall mat intervention was active and should have been in place.
Incomplete Allergy Documentation and Medication Monitoring
Penalty
Summary
Resident 5’s medical record was not maintained accurately and completely when the resident’s allergy profile continued to list Levaquin as an allergy, yet Levaquin was ordered and administered for a urinary tract infection. The record review showed the resident was admitted with a diagnosis that included UTI, and the MAR documented administration of Levaquin 500 mg on multiple days. A progress note also showed the allergy list included Levaquin, but there was no documented physician clarification addressing the allergy before the medication was given. The record contained no documentation of communication with the ordering provider to clarify the allergy status, no documentation of an IDT meeting discussing the medication allergy, and no documentation that the resident was monitored for adverse reactions or side effects after receiving Levaquin. During interviews, LN 3, the IP, the DON, and the Pharmacist confirmed the allergy remained listed, the medication was administered, and documentation of clarification and monitoring was absent. The discharge summary stated the documented Levaquin allergy was on the allergy profile, but it did not appear the resident actually had one, and the allergy remained active in the facility medical record without being updated.
Unlabeled Urinal
Penalty
Summary
The facility failed to practice appropriate infection prevention and control measures when Resident 67's urinal was observed without identifying information. Resident 67's clinical record showed diagnoses including need for assistance with personal care, hemiplegia, and hemiparesis following a cerebral infarction affecting the right dominant side. During observation and interview, CNA 3 confirmed the urinal was not labeled and stated it should have been labeled, noting that another resident could have accidentally used it. During interviews, the IP stated staff were expected to label urinals for each resident by room number or initials and that unlabeled urinals would not identify ownership. The IP stated that infections such as MDROs could occur if urinals were not properly labeled. The DSD stated each resident using a urinal should have labels and individual identifiers to prevent cross-contamination and infection control issues. The DON stated staff were expected to label urinals before giving them to residents and that unlabeled urinals created a cross-contamination risk, especially when residents shared the same restroom. The facility's Infection Prevention and Control Program policy stated it was intended to decrease the risk of infection to residents and personnel, and the Equipment Labeling Policy stated all equipment must be clearly labeled and equipment without proper labeling must not be used until corrected.
Inaccurate MDS Oxygen Therapy Assessment
Penalty
Summary
The facility failed to ensure an accurate MDS assessment for one sampled resident when the oxygen therapy section was documented incorrectly. The resident was admitted in 2025 with diagnoses including pleural effusion, and the care plan initiated in November 2025 addressed acute respiratory distress with interventions that included administering oxygen as ordered, elevating the head of the bed for shortness of breath when lying flat, and monitoring for shortness of breath. The resident’s MDS Section O dated 1/23/26 and 4/29/26 indicated that the resident was not on oxygen therapy, but observation on 5/4/26 showed the resident receiving supplemental oxygen via nasal cannula at 2.5 LPM. During record review and interviews, an LN confirmed the resident had been receiving oxygen via nasal cannula since November 2025 and had an order for 2 to 3 LPM to keep oxygen saturation above 90%. The LN stated the MDS should have reflected that the resident received oxygen therapy, and the DON stated the MDS staff could have reviewed the physician’s order, oxygen documentation, vital signs, and asked nursing staff to verify oxygen use.
Failure to Submit 5‑Day Investigation Summary for Resident‑to‑Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to submit a required 5‑day written investigation summary to the Department following a reportable resident‑to‑resident altercation. Resident 1, admitted with diagnoses including unspecified dementia, chronic kidney disease, and cognitive function and awareness symptoms, was involved in an incident on 11/8/25 at 6 AM in which a former roommate, Resident 5, blocked the bathroom door while Resident 1 was inside, preventing Resident 1 from exiting. Resident 5 had diagnoses including orthopedic aftercare, a displaced intertrochanteric fracture of the right femur, history of falling, gait and mobility abnormalities, type 2 DM, and depression. Care plans for both residents were initiated on 11/8/25, documenting each resident as being at risk for psychosocial and mood changes related to the bathroom‑locking incident. The Social Services Director completed and submitted the initial Report of Suspected Dependent Adult/Elder Abuse to the Department on 11/8/25 but did not submit the 5‑day investigation summary. In interview, the Social Services Director stated that he completed the 5‑day investigation for the resident‑to‑resident altercation but did not send the 5‑day investigation report to the Department. In a separate interview, the DON confirmed that the 5‑day investigation summary for the altercation involving these two residents was not submitted and that there was no documentation or confirmation of submission, despite her awareness that the summary was required within five working days. The facility’s undated Abuse Investigation and Reporting policy states that the Administrator or designee will provide a written report of investigation findings to the appropriate agencies within five working days of the incident, which was not followed in this case.
Failure to Care Plan for Resident’s Prolonged Bathroom Use and Resulting Conflicts
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, individualized care plan to address one resident’s frequent and prolonged use of a shared bathroom, despite known cognitive impairment and a prior resident-to-resident altercation related to bathroom access. The resident was admitted with diagnoses including unspecified dementia, chronic kidney disease, and other cognitive symptoms, and a BIMS assessment later showed moderate cognitive impairment. A Report of Suspected Dependent Adult/Elder Abuse documented an incident in which the resident’s former roommate blocked the bathroom door while the resident was inside, preventing her from exiting. Staff interviews confirmed that this altercation was related to the resident’s bathroom use and that no care plan had been created to address the underlying issues or prevent recurrence. Multiple residents reported that the cognitively impaired resident used the shared bathroom very frequently and remained inside for extended periods, which delayed their own access and caused them to seek staff assistance or use alternative toileting locations. One resident stated she had to hold her urine and call a nurse to help the resident complete bathroom use so she could enter, while others described the situation as unfair and problematic. Staff, including a CNA and an LN, stated that the resident was forgetful, did not use the call light, removed her personal alarm, and required supervision to prevent prolonged bathroom use, yet there was no care plan addressing these behaviors or the prior altercation. The MDS coordinator and LN confirmed that the resident’s care plans did not include a problem, root cause, or individualized interventions related to bathroom use or resident-to-resident conflict, contrary to facility policy requiring comprehensive, person-centered care plans with measurable objectives and timetables based on ongoing assessments.
Failure to Implement Comprehensive Water Safety Management Program for Legionella Prevention
Penalty
Summary
The facility failed to implement a comprehensive water safety management program based on nationally accepted standards to minimize the risk of Legionella and other opportunistic waterborne pathogens. The deficiency was identified after a resident, who had been transferred to a local hospital, tested positive for Legionella pneumophila. Following this, the facility was instructed by the local Public Health Department (PHD) to test residents with respiratory symptoms and to conduct water testing for Legionella. Initial water testing was deemed inadequate by the PHD, as it was not performed by a certified company, and the facility did not have a contracted provider for certified water testing or maintenance at the time. The facility subsequently arranged for a certified company to collect water samples, but this was only after the PHD's intervention. Further review revealed that the facility's Water Safety Management Program policy and procedure (P&P) was insufficient and lacked critical components required by the CDC's Legionella Toolkit and public health guidance. The policy did not include a full facility-wide assessment of potential Legionella growth areas, a flow chart or diagram of the water system, or documentation of all water sources and their inlets and outlets. The Infection Preventionist (IP) and Director of Nursing (DON) confirmed that a comprehensive risk assessment had not been conducted, and the policy did not specify procedures for handling waterborne pathogen outbreaks or include a contract with a certified testing company. Observations and interviews with the Maintenance Director (MTD) further indicated that while some preventative measures, such as installing specialized filters, were being implemented, there was no established process for decontaminating the water system or a contracted provider for such services prior to the Legionella case. The local Public Health Officer confirmed that the facility's water management plan was essentially a copy of the CDC toolkit and lacked the required building-specific details, such as a mapped diagram of the water system and an actionable intervention plan. These deficiencies were present for a census of 54 residents.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Serve Prescribed Small Portion Diets to Two Residents
Penalty
Summary
The facility failed to ensure that dietary staff served the correct meal portions to two residents who were prescribed small portion diets. For both residents, medical records and care plans indicated the need for small portions as part of their dietary orders, with one resident on a no added salt diet and the other on a regular diet with small portions requested. During a lunch meal observation, both residents received meal trays with the same portion sizes as other residents who did not have small portion orders. The diet cards for both residents clearly indicated the need for small or half portions, but the food served did not reflect these instructions. Interviews with the residents confirmed that they consistently received full portions despite their dietary orders, and one resident expressed distress over not losing weight as a result. Staff interviews revealed that the process for calling out portion sizes during meal service was not followed correctly, leading to the error. The Food and Nutrition Services director acknowledged that the expectation was for correct portions to be served and confirmed that the observed trays did not meet the prescribed dietary requirements. Facility policy and job descriptions also required adherence to portion control guidelines, which was not followed in these instances.
Deficiencies in Food Storage and Dishwashing Practices
Penalty
Summary
The facility failed to ensure safe food storage and production for 56 residents by not labeling open food packages with a use by date and improperly stacking wet plate covers. During an observation in the kitchen, it was noted that a bag of bran cereal, a five-gallon storage bin with rice, and a bag of biscuit mix were not labeled with a use by date. The Dietary Manager (DM) acknowledged that these items should have been labeled to prevent the use of potentially expired food, which could affect the quality and nutritional value of the food served to residents. Additionally, the facility did not adhere to proper dishwashing procedures, as observed when a Dietary Aid (DA) stacked wet plate covers after removing them from the dishwasher. Both the DA and the DM confirmed that dishes should be air-dried before being stacked to prevent bacterial growth. The Director of Nursing (DON) also stated that stacking wet dishes could lead to bacterial growth, posing a risk of illness to residents. The facility's policies on dishwashing and food labeling were not followed, contributing to these deficiencies.
Facility's Unsafe Use of Smartphones Compromises Resident Privacy
Penalty
Summary
The facility failed to ensure the safe use of facility-owned smartphones for communication with medical providers regarding residents' Protected Health Information (PHI). During an inspection, a smartphone was found unattended at a nurse station, containing numerous text messages and photos with sensitive resident information. The messages included residents' names, medical conditions, and photos of laboratory test results, which were communicated to medical providers without secure messaging software, violating HIPAA regulations. Licensed Nurse 7 confirmed that the smartphone was used to communicate with medical providers, and the Director of Nursing (DON) admitted that the facility did not have a special software for secure messaging. The facility's policy required the use of a secure messaging application for text-based communication involving PHI, but this was not adhered to. Instead, the facility used iMessage, which is not HIPAA compliant, to communicate sensitive information, further compromising residents' privacy. The facility's Administrator acknowledged that the smartphones were provided to assist with communication but was unsure if anyone monitored their use or the messages sent. The facility's policy on smartphone use was not followed, as evidenced by the storage of over 3,000 items, including pictures and documents with resident information, on the device. This lack of adherence to policy and secure communication practices led to a significant breach of residents' health information privacy and confidentiality.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to ensure safe medication storage practices in several areas, including a medication cart, a medication closet, and a medication refrigerator. Specifically, Medication Cart 2 in Station 2 stored an undated inhalation medication called Ipratropium/Albuterol (DuoNeb), which was removed from its protective foil wrap and lacked proper labeling with the resident's name, date, and time of opening. Additionally, Medication Closet 1 in Station 1 contained expired test tubes, which were intended for blood collection and testing but were past their expiration date. The Director of Nurses (DON) acknowledged that these expired test tubes could lead to inaccurate test results if used. Furthermore, the medication refrigerator in Station 2 contained an opened and undated vial of Aplisol, a testing agent for Tuberculosis, which should have been discarded after 30 days of opening. The refrigerator also stored an expired container of Golytely liquid, which was never used by the resident it was intended for. The DON confirmed that the lack of proper dating and the presence of expired medications could result in ineffective treatments. The facility's policy on medication storage emphasizes the importance of proper labeling and the disposal of outdated drugs, which was not adhered to in these instances.
Significant Medication Error with Vitamin D3 Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when Vitamin D3 oral capsules were administered daily at a dosage of 50,000 units from late October to late December 2024. This error was identified during a review of the resident's physician order, which incorrectly indicated the daily administration of the high-dose Vitamin D3. The pharmacy consultant confirmed that medication regimen reviews were conducted during this period but did not catch the error. The consultant acknowledged that if the error had been identified in real-time, a recommendation would have been made to reduce the dosage and request laboratory tests for Vitamin D levels. The Medical Doctor (MD) responsible for the resident was unaware that the order was for daily administration and stated that such a dosage could lead to adverse effects like nausea, vomiting, and hypercalcemia. The Director of Nursing (DON) confirmed the daily administration of the high-dose Vitamin D3 and expressed an expectation for the pharmacy to ensure the efficacy and safety of medications. The facility's policy on medication regimen review was not effectively implemented, as the pharmacist failed to identify the clinically significant risk associated with the medication error.
Unauthorized Medication Use and Storage Deficiency
Penalty
Summary
The facility failed to ensure the safe storage and use of medications for a resident, leading to unauthorized medication use without a doctor's order. During a medication administration observation, it was found that a resident had three unlabeled medications stored at their bedside, including an inhaler and two nasal sprays. The Licensed Nurse (LN) present was unaware of these medications and confirmed that there were no doctor's orders for them in the resident's Medication Administration Record (MAR). The resident stated that these medications were prescribed by their allergy doctor and had been used for years, but the facility was not informed of their use since the resident's admission. The Director of Nursing (DON) stated that residents could use their own medications with a doctor's order and an assessment of safe storage and the resident's mental status. The facility's policies indicated that any medications brought in by residents should be given to the charge nurse and that self-administered medications should be stored securely. However, the resident's medications were not assessed or authorized for self-administration, posing a potential safety risk. The facility's failure to adhere to its policies resulted in the unauthorized use and unsafe storage of medications.
Improper Cleaning of Shared Glucometer
Penalty
Summary
The facility failed to ensure the safe cleaning and sanitization of a shared glucometer between resident uses, as observed during medication administration for two residents. Licensed Nurse 2 (LN 2) was seen using the glucometer on Resident 39 and then on Resident 10 without following the proper cleaning protocol. The nurse used a Sani-Cloth-Bleach wipe for less than 10 seconds to clean the glucometer's outer surface, which did not meet the required 4-minute wet time specified by the manufacturer and facility policy. Interviews with LN 2 and the Infection Prevention nurse (IP) revealed that the nursing staff had been educated on the correct procedure for cleaning and disinfecting shared glucometers. The IP stated that the process involved a two-step cleaning and disinfecting procedure using two wipes, as per the manufacturer's instructions. However, LN 2 did not adhere to this protocol, potentially compromising infection control measures. The facility's policy and the manufacturer's instructions both emphasized the importance of using two wipes to clean and disinfect the glucometer, with a visible wet time of four minutes to ensure effective germ elimination. Despite this, the observed practice did not align with these guidelines, posing a risk of infection spread among residents. The Director of Nursing acknowledged the importance of following the correct cleaning procedures but did not provide further details on how the process should be implemented by the nursing staff.
Failure to Sign Medication Delivery Manifests
Penalty
Summary
The facility failed to ensure that prescription medication delivery manifests, including those for narcotic controlled medications, were consistently signed by licensed staff upon delivery from the provider pharmacy. During a medication area inspection, it was observed that the delivery sheets for prescription and narcotic medications at Station 1 were not consistently signed by nursing staff upon receipt. Licensed Nurse 6 acknowledged signing the paper from the delivery driver but was unsure why most sheets were unsigned. This inconsistency in signing the delivery manifests may contribute to unsafe medication handling and the risk of drug diversion. In an interview, the Director of Nursing stated that staff signed a copy of the delivery sheet for the driver and were not required to sign the facility copy. The facility's policy on controlled substances indicated that controlled substances should be reconciled upon receipt, and both the nurse receiving the medication and the delivery agent should sign the controlled substance record of receipt. Additionally, the policy on accepting delivery of medications required that a nurse sign the delivery ticket, indicating review and acceptance of the delivery. The failure to adhere to these policies resulted in a deficiency in the facility's pharmaceutical services.
Failure to Ensure Safe Use of Psychotropic Medications
Penalty
Summary
The facility failed to ensure the safe use of psychotropic medications for a resident, identified as Resident 44, who was selected for unnecessary medication use. The resident's documented diagnosis of bipolar disorder, which was used to justify the administration of aripiprazole, was not reflected in the medical doctor's progress notes, history and physical, or previous hospitalization records. Additionally, the resident's mental health consult and medication adjustments were not communicated to the primary medical doctor, the Director of Nursing, licensed nursing staff, or the resident's representative. Resident 44 was admitted to the facility with multiple diagnoses, including Parkinson's disease, dementia, encephalopathy, psychosis, anxiety disorder, major depressive disorder, and bipolar disorder. However, the diagnosis of bipolar disorder was not supported by the medical records from the attending physician or previous hospital records. The resident's psychiatric visit progress report relied on facility records for the diagnosis, and the resident herself denied ever being diagnosed with bipolar disorder. Furthermore, the resident's primary psychiatrist confirmed that she had never been diagnosed with bipolar disorder. The facility's process for handling mental health consults and medication orders was flawed, as the social services director retained the psychiatric progress notes due to confidentiality concerns, preventing them from being included in the resident's medical record. This lack of access to critical information hindered the continuity of care and the ability of licensed nurses and attending physicians to make informed decisions about the resident's treatment. The failure to communicate and document the mental health consults and medication adjustments contributed to the unsafe use of psychotropic medications for Resident 44.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to ensure safe medication administration practices, resulting in a medication error rate of 6.67%, which is above the acceptable threshold of 5%. During a medication pass observation, a licensed nurse administered medications to a resident who refused three pills, including a laxative, Vitamin C, and a multivitamin. Despite the refusal, the nurse documented these medications as administered in the resident's electronic medical record without noting the refusal. The nurse admitted to documenting the administration before entering the resident's room and forgetting to update the record to reflect the refusal. In another instance, a licensed nurse failed to administer insulin to a resident according to the prescribed timing. The nurse measured the resident's blood sugar and administered insulin after the resident had already started eating lunch, contrary to the doctor's order to administer insulin 5-10 minutes before meals. The Director of Nursing acknowledged that the blood sugar measurement and insulin administration should have been coordinated with meal delivery to ensure accuracy and adherence to the doctor's orders. The facility's policies on medication administration and insulin administration did not adequately address medication refusal and the responsibilities of nursing staff.
Failure to Follow Enhanced Barrier Precautions During IV Antibiotic Administration
Penalty
Summary
The facility failed to ensure that nursing staff adhered to infection prevention practices and the Enhanced Barrier Precaution (EBP) guidelines during the administration of intravenous (IV) antibiotics to Resident 47. During an observation, Licensed Nurse 5 (LN 5) was seen entering Resident 47's room, which was marked with an EBP sign, without wearing a gown and with her mask worn below her nose. LN 5 proceeded to administer the IV antibiotic by accessing the mid-line without the required protective gown, which could potentially expose the resident to infection. LN 5 acknowledged awareness of the EBP requirements but admitted to forgetting to wear the gown. Interviews with the Infection Prevention nurse and the Director of Nursing confirmed that staff were educated on the importance of following EBP guidelines to prevent the spread of infection. The facility's policy and the posted EBP sign in Resident 47's room required staff to wear a gown and gloves during high-contact care activities, such as accessing an IV line, to prevent the transfer of multi-drug resistant organisms. Despite this, LN 5 did not comply with these precautions, which are crucial for residents with indwelling medical devices like central venous catheters.
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 556 citations issued within 25 miles in the last 12 months — including the 1 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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lodi
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lodi Nursing & Rehabilitation | 0.4 mi | ★★★★★ | 19 | 0 |
| Arbor Rehabilitation & Nursing Center | 0.5 mi | ★★★★★ | 22 | 0 |
| Vienna Nursing And Rehabilitation Center | 1.7 mi | ★★★★★ | 28 | 0 |
| Lodi Creek Post Acute | 1.7 mi | ★★★★★ | 24 | 0 |
| Creekside Center | 6.5 mi | ★★★★★ | 19 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 October 2026) and official state health department websites.