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 Amberwood Post Acute during CMS and state inspections, most recent first.
Surveyors found that staff repeatedly failed to follow hand hygiene and Enhanced Barrier Precautions (EBP) requirements. CNAs and an LPN provided direct care, including incontinence care, use of a mechanical lift sling, and gastric tube feeding, without performing hand hygiene before or after care and without using required gowns for residents on EBP. One CNA handled a soiled lift sling, touched his hair and face, used a touchscreen to document care, and then assisted another resident without cleaning his hands. Another CNA entered an EBP room wearing only gloves, not a gown, and did not perform hand hygiene after removing gloves. An LPN handled a feeding tube and provided care to residents on EBP without hand hygiene or gown use. A resident’s representative reported seeing staff work with a feeding tube without gloves or a gown, while staff interviews and facility policy described correct practices that were not followed in practice.
A resident with severe cognitive impairment and multiple serious diagnoses had a physician-appointed health care proxy who reported that the facility did not inform her when the resident’s condition changed or when an antibiotic was started, and that her calls were not returned for days. Another representative for the same resident stated that calls went to a general voicemail and were rarely or very slowly returned. Grievance records documented repeated concerns about delayed communication, lack of notification about new medications, and difficulty reaching staff. Other residents’ representatives similarly reported that calls to check on residents or report suspected verbal abuse went to voicemail and were returned late or not at all, while staff acknowledged that calls often went to voicemail and that several calls from representatives were missed or delayed.
The facility failed to investigate an allegation of verbal abuse and threats between two cognitively impaired roommates after a family member, who was on the phone with one resident, reported hearing the other resident yelling loudly and making threats. The resident’s representative could not reach staff by phone and contacted EMS, which responded to the facility, yet no investigation or documentation of the altercation, alleged threats, or EMS involvement was found in either resident’s record. Staff acknowledged loud yelling and arguing and initiated a room change, but the RN did not fully inform the DON, the SSD—who was not present—dismissed the event as a simple argument, and the NHA did not treat or report it as abuse, contrary to facility policies requiring identification, investigation, and reporting of possible verbal or mental abuse by other residents.
Two residents were not protected from physical abuse when another resident, following an escalating argument involving property damage and verbal altercations, threw a wheelchair armrest that struck both individuals. The incident was not witnessed by staff, who only intervened after hearing the commotion. All residents involved had behavioral and mental health diagnoses, and staff were aware of their volatile interactions, but the abuse was not prevented.
The facility failed to manage the personal funds accounts of four Medicaid-funded residents, resulting in account balances exceeding the Medicaid eligibility limit. The Business Office Manager was aware of the issue but had not notified the residents or their representatives, and the Nursing Home Administrator was not fully informed. This oversight risked the residents' Medicaid status.
The facility failed to provide appropriate restorative nursing services for three residents with limited mobility, leading to deficiencies in maintaining or improving their range of motion. One resident did not receive any restorative services despite being listed on a program, another reported infrequent services, and a third was not restarted on services after hospital discharge, risking contractures.
The facility experienced a medication error rate of 14.63%, with errors including unprimed insulin administration, failure to check blood pressure before giving Amlodipine, incorrect Senna-Docusate dosage, and misinterpretation of Metamucil instructions. Interviews highlighted the need for adherence to proper procedures and clarity in physician orders.
The facility failed to secure treatment and medication carts, leaving them unlocked and unattended. Observations revealed that two treatment carts and one medication cart were left unlocked, with residents and staff passing by. Interviews with staff, including an agency nurse and the DON, confirmed that carts should be locked when unattended to prevent access to dangerous items. The facility did not provide the medication storage policy during the survey.
The facility failed to provide necessary dental services to three residents, including one who was edentulous and seeking dentures, another with chipped teeth and tooth pain, and a third who was not notified of a dental visit. Despite care plans and requests for dental care, the residents were not referred or seen by a dentist due to scheduling and communication issues.
The facility failed to maintain an effective infection control program, with deficiencies in housekeeping procedures, resident hand hygiene before meals, and cleaning of glucometers. Housekeepers did not perform hand hygiene or use separate cleaning materials for different areas, and residents were not assisted with hand hygiene before meals. An LPN used personal hygiene wipes instead of alcohol wipes for cleaning, and staff did not properly don PPE during wound care.
A resident with schizoaffective disorder and bipolar disorder was discharged without proper documentation or notification. The facility did not provide a 30-day or immediate discharge notice, nor did they inform the resident of their right to appeal. Staff interviews confirmed the facility's inability to meet the resident's needs, but the required discharge process was not followed.
A facility failed to reassess a resident's status after a hospital transfer, directing the hospital to discharge her to a sister facility without proper documentation or communication. The resident, with schizoaffective disorder, exhibited challenging behaviors, but the facility did not develop a discharge care plan or reassess her needs post-hospitalization. Staff interviews confirmed the lack of documentation and communication regarding the discharge process.
The facility failed to implement PASRR Level II recommendations for two residents, delaying therapy initiation and lacking documentation of behavioral health services. One resident with schizophrenia experienced a three-week delay in counseling referral, while another with bipolar disorder had no evidence of receiving recommended services. The social service director cited workload challenges, and the DON was unaware of these deficiencies.
A facility failed to ensure PRN pain medications for a resident had specific parameters related to pain severity. The resident, with diagnoses including schizoaffective disorder and diabetes, had PRN orders for Oxycodone, Tramadol, and Tylenol without specified pain levels on a 1-10 scale. Staff interviews confirmed the expectation for such parameters, but the orders, initially from an emergency department physician, lacked this detail.
A facility failed to provide proper discharge notifications and develop a collaborative discharge plan for a resident with severe cognitive impairment and behavioral issues. The discharge planning process was not documented in the resident's EMR or comprehensive care plan, contrary to facility policy. Staff interviews confirmed the lack of documentation and adherence to discharge procedures.
A resident with Parkinson's disease and COPD, requiring substantial assistance with ADLs, was found with long and dirty fingernails, contrary to the facility's policy for maintaining personal hygiene. Despite the care plan's directives for regular nail care, staff interviews revealed a failure to adhere to these guidelines, resulting in inadequate grooming for the resident.
A resident with lymphedema did not receive timely treatment due to a missing physician's order for leg wraps. Despite a referral and request by an NP, the order was not entered into the EMR, delaying the treatment. The resident's care plan lacked interventions for edema, and the facility faced challenges in obtaining specialized measurements for the wraps.
A resident with hemiplegia and a need for corrective lenses did not receive timely optometry services due to the facility's failure to arrange a referral. Despite the resident's request for a vision referral shortly after admission, there was no documentation of a referral, and consent for vision services was delayed. Interviews with staff revealed challenges in scheduling ancillary services, with the SSD struggling to keep up with referrals and the DON and NHA recognizing the need for timely scheduling.
A facility failed to supervise a resident with a history of self-inflicted burns and a smoking habit. Despite being cognitively intact, the resident, diagnosed with schizophrenia and possessing a lighter, was allowed to smoke independently without a comprehensive care plan addressing the risks. Staff interviews revealed a lack of awareness and communication about the resident's smoking status and the need for supervision, posing a risk to the resident and others.
A resident with type 2 diabetes did not receive a properly administered dose of insulin due to an LPN's failure to prime the insulin pen before injection. The facility's policy requires priming to ensure accurate dosing, but this step was missed, resulting in a significant medication error.
Failure to Follow Hand Hygiene and Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to hand hygiene and adherence to Enhanced Barrier Precautions (EBP) on all four units. The facility’s own policies require hand hygiene before and after direct patient care and the use of gowns and gloves during high-contact care activities for residents on EBP. CDC guidance cited in the report emphasizes that hand hygiene protects both healthcare personnel and patients, and that EBP requires targeted gown and glove use during high-contact resident care activities, particularly for residents with wounds, indwelling devices, or MDRO colonization or infection. Surveyors observed multiple instances where staff did not follow these requirements. An unidentified CNA exited a room of a resident on EBP without wearing a gown while providing care. On another occasion, a CNA exited a resident’s room carrying a soiled mechanical lift sling without gloves, failed to perform hand hygiene, touched his hair and face, used a touchscreen to document care, and then entered another resident’s room to answer a call light and assist with a request without performing hand hygiene before or after assisting that resident. Another CNA entered the room of a resident on EBP, donned only gloves without a gown, provided incontinence care, then left the room with soiled linens and trash properly disposed of, removed gloves, but did not perform hand hygiene before caring for another resident. Additional observations showed an LPN entering the room of a resident on EBP for gastric tube feeding, setting up and handling the feeding tube without performing hand hygiene beforehand and without wearing a gown. The same LPN later entered another EBP room, provided care, and left without performing hand hygiene. A resident’s representative reported seeing staff work with the resident’s feeding tube without gloves or a gown. In interviews, CNAs and nursing staff described correct hand hygiene and EBP practices, including washing hands for about 20 seconds and using gowns and gloves for residents on EBP, and the DON stated she expected staff to perform hand hygiene when entering and exiting rooms and to follow EBP procedures requiring gown and glove use. These stated practices conflicted with the observed failures in hand hygiene and EBP adherence documented by surveyors.
Failure to Notify Health Care Proxy and Return Calls Regarding Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to inform a resident’s physician-appointed health care proxy of changes in the resident’s condition and new treatments, and to return the proxy’s calls in a timely manner. Facility policy on Notification of Changes required informing the resident, consulting with the physician, and notifying the family member or legal representative when there was a change requiring such notification, and specified that when residents were incapable of making their own decisions, the representative would make necessary decisions. Resident #1 was under 65, admitted with diagnoses including paralysis and weakness following a stroke, respiratory failure, cognitive communication deficit, and encephalopathy, and was documented as severely cognitively impaired with a BIMS score of 0/15, indicating reliance on the health care proxy for decision-making. The health care proxy reported that the facility made it very difficult to contact the resident, stating that staff did not return calls for days and that she was not informed when the resident developed an infection and was started on an antibiotic until after the medication had already been initiated. She stated she had several questions about the medication and was not consulted on the medical decision prior to its start. Another representative reported that calls to the facility went to a general voicemail and that her messages were either not returned or took several days for a response. Grievance records showed repeated concerns from the resident’s representatives about delays in speaking with the resident, delays in return calls, and lack of notification about new medications and changes in condition. Additional interviews with other residents’ representatives supported a broader pattern of delayed or absent communication. One representative of another resident reported that his call to check on a newly admitted resident went to voicemail and was not returned for two days. Another resident’s representative and a secondary witness reported that when they attempted to report suspected verbal abuse, their calls to the facility and to the SSD went to voicemail and were never returned. Staff interviews confirmed that calls first went to the front desk and then to the nurses’ stations, that calls often went to voicemail when nurses were unable to answer, and that voicemail messages were expected to be returned within 24 hours. The NHA acknowledged that several calls from the resident’s representatives went to voicemail and that calls were often made during shift change when it was harder to reach the nurse on duty, but there was no documentation to support the claimed regular communication with the health care proxy.
Failure to Investigate Alleged Verbal Abuse Between Cognitively Impaired Roommates
Penalty
Summary
The deficiency involves the facility’s failure to investigate an allegation of verbal abuse and threats between two cognitively impaired residents after a family member reported overhearing the incident. Facility policy on abuse, neglect, exploitation, and misappropriation requires that all possible incidents of abuse, including verbal and mental abuse by other residents, be identified, investigated, and reported within required timeframes, with residents protected from further harm during investigations. The policy on identifying types of abuse specifies that yelling or hovering over a resident with intent to intimidate is an example of mental and verbal abuse. Despite these policies, the facility did not initiate or document an investigation into a reported verbal altercation that included alleged threats. One resident, under age 65, with dysphagia, left-sided hemiplegia, attention and concentration deficit, delusional disorder, and major depressive disorder, had moderate cognitive impairment and was dependent on staff for most ADLs. He reported that he and his roommate yelled back and forth at each other after the roommate told him to “shut the [expletive],” but he did not recall the specific words used and denied any physical contact. His guardian stated that he later reported being fearful of his roommate after the incident. Another representative, who was on the phone with him during the event, reported hearing the roommate yelling loudly and making threats toward him, then hearing a nurse enter to calm the situation. This representative attempted to call the facility to report the yelling and threatening behavior, was sent to voicemail without a return call, and subsequently contacted emergency services. The roommate, an older resident with dementia, cognitive communication deficit, depression, and insomnia, also had moderate cognitive impairment and required staff assistance for most ADLs. He did not recall the incident, and his representative only learned of it the following day and was told it involved yelling about loud phone use. A review of both residents’ medical records revealed no documentation of the verbal altercation, the alleged threats, or related concerns, and no investigation documents were produced when requested. Staff interviews confirmed there had been loud yelling and arguing, that EMS responded to the facility, and that a room change was initiated due to the incident, but the RN who responded did not report the EMS involvement to the DON. The SSD, who was not present during the incident, characterized it as just an argument and stated there were no threats, and the NHA stated the event was not reported as abuse because they believed no threats were made. No contemporaneous interviews with the residents were documented, and no inquiry was made by facility staff into why EMS had been called in relation to the altercation, resulting in a failure to investigate the allegation of verbal abuse as required by facility policy.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by another resident. The incident began when one resident entered the shared room of two others, leading to an argument in which food was thrown. The situation escalated when the first resident, after discovering his property had been damaged, returned and threw a wheelchair armrest at one of the residents, which then struck both individuals. This altercation was not witnessed by staff, but staff responded after hearing the commotion and separated the residents. No injuries were reported, but the event involved physical aggression and property damage. The residents involved had documented histories of behavioral and mental health issues, including anxiety, depression, and, in one case, schizoaffective disorder. Assessments indicated that at least one resident had a history of verbal behavioral symptoms directed toward others, and care plans noted the potential for physical aggression related to anger and poor impulse control. Despite these known risks, the altercation occurred without staff intervention until after the physical abuse had taken place. Staff interviews confirmed that the residents had a history of volatile interactions, described as similar to a sibling rivalry, and that staff were aware of the need to monitor their interactions. However, the incident was not prevented, and staff only intervened after the situation had escalated to physical abuse. The facility's policy required the protection of residents from abuse by anyone, including other residents, but this policy was not effectively implemented in this instance, resulting in a failure to prevent physical abuse.
Failure to Manage Resident Personal Funds Accounts
Penalty
Summary
The facility failed to manage the personal funds accounts of four Medicaid-funded residents accurately, leading to account balances exceeding the Medicaid eligibility limit. Specifically, the facility did not notify the residents or their legal representatives when their personal funds accounts reached $200 less than the eligibility resource limit for one person. Record reviews revealed that the account balances for these residents were significantly over the $2000 Medicaid eligibility limit, with amounts ranging from $585.18 to $1,575.87 over the limit. Interviews with the Business Office Manager (BOM) and the Nursing Home Administrator (NHA) highlighted a lack of communication and oversight regarding the management of these accounts. The BOM, who started working at the facility in August 2024, acknowledged awareness of the over-limit accounts but had not yet notified the residents or their responsible parties. The NHA was only aware of one resident's account being over the limit and was not informed about the other three accounts. This oversight put the residents at risk of losing their Medicaid status due to exceeding the allowable personal funds limit.
Deficiency in Restorative Nursing Services for Residents with Limited Mobility
Penalty
Summary
The facility failed to provide appropriate care for three residents with limited mobility, leading to deficiencies in maintaining or improving their range of motion (ROM). Resident #43, who was cognitively intact and dependent on staff for various activities of daily living (ADLs), did not receive restorative nursing services despite being listed on a restorative program. There was no documentation of restorative services being provided, and the resident's care plan did not include a focus on restorative services. Resident #51, also cognitively intact and dependent on staff for dressing and personal hygiene, reported that her restorative program was not conducted as frequently as required. The facility had reduced the frequency of restorative services, and documentation showed only two sessions over a 30-day period. Like Resident #43, there were no physician's orders or care plan focus for restorative services for Resident #51. Resident #66, who had severe cognitive impairment and required total assistance for ADLs, was identified as needing occupational therapy to assess for a restorative nursing program. However, there was no documentation of restorative services being provided. The MDS coordinator acknowledged that Resident #66 should have been restarted on restorative services after returning from the hospital, but this was not done, leading to a risk of contractures.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, with an observed error rate of 14.63%, equating to six errors out of 41 opportunities. During medication administration observations, several errors were noted. An LPN administered insulin to a resident without priming the insulin pen, which is necessary to ensure the correct dosage is delivered. Another LPN failed to check a resident's blood pressure before administering Amlodipine Besylate, as required by the physician's order, and administered an incorrect dosage of Senna-Docusate Sodium. Additionally, a different LPN misinterpreted the packaging instructions for Metamucil, leading to an incorrect dosage being given, and administered aspirin in a chewable form instead of the prescribed oral capsule. Interviews with staff revealed a lack of adherence to proper medication administration procedures. The DON confirmed the importance of priming insulin pens and following physician orders precisely to prevent potential harm. The RCC acknowledged the need for clarity in physician orders, especially for bulk medications like Metamucil, to prevent dosage errors. These findings indicate a significant lapse in medication administration practices, contributing to the high error rate observed during the survey.
Failure to Secure Treatment and Medication Carts
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were properly stored in accordance with accepted professional standards. Specifically, two of three treatment carts and one of three medication carts were found unlocked and unattended during the survey. On multiple occasions, treatment carts on both the south and north halls were observed to be unlocked and unattended, with residents and staff walking past them. The treatment cart on the south hall was left unlocked for an extended period until a nurse was notified and locked it. Similarly, the medication cart on the south hall was found unlocked and unattended, with staff, including the DON, passing by without noticing its status. Interviews with staff revealed a lack of adherence to the facility's policy regarding the locking of treatment and medication carts. An agency nurse acknowledged that the treatment cart should be locked when unattended to prevent residents from accessing its contents. The DON confirmed that both treatment and medication carts should be locked when unattended, as they contained items such as scissors and medications that could be dangerous to residents, particularly those with mental health issues and wandering behaviors. Despite these acknowledgments, the facility's failure to provide the medication storage policy by the end of the survey further highlights the deficiency in ensuring proper storage of drugs and biologicals.
Failure to Provide Dental Services to Residents
Penalty
Summary
The facility failed to assist residents in obtaining routine or emergency dental services as needed for three residents. Resident #18, who was edentulous and had expressed a desire to see a dentist for dentures, had not been referred to a dentist since his admission. Despite a signed consent for dental services, there was no documentation of a referral being made. The resident's care plan indicated a potential risk for altered nutritional intake due to being edentulous, yet no action was taken to address his request for dental services. Resident #32, who had chipped teeth and reported tooth pain, had been seeking dental care since his admission. Although there were notes indicating the need for a dental appointment due to tooth pain, the resident was not seen by the dentist. The resident was placed on a reserve list for dental treatment but was not seen due to time constraints during the dentist's visit. The resident's care plan included interventions for dental issues, but these were not effectively implemented. Resident #51 requested to see the dentist but was not notified or taken to the dentist when they visited the facility. Despite being placed on a reserve list for the next dental visit, there was no documentation of her being scheduled. The facility's staff interviews revealed issues with scheduling and communication regarding dental services, contributing to the residents not receiving the necessary dental care.
Infection Control Deficiencies in Housekeeping, Resident Hygiene, and Equipment Cleaning
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by multiple deficiencies observed during a survey. Housekeeping staff did not adhere to proper infection control procedures when cleaning resident rooms. Specifically, housekeepers were observed not performing hand hygiene before starting cleaning tasks or between glove changes. They also failed to use separate cleaning materials for different areas of the room and did not allow disinfectants to remain on surfaces for the required contact time. Additionally, high-touch surfaces were not adequately cleaned, and the cleaning process did not follow the recommended sequence from cleaner to dirtier areas. The facility also failed to ensure residents were assisted with hand hygiene prior to meals. During meal service observations, residents were not offered hand hygiene after touching potentially contaminated surfaces or before eating. Some residents were observed engaging in activities that could spread germs, such as folding utensils into napkins without changing gloves or performing hand hygiene after touching personal items or coughing into their gloves. Despite the availability of moist towelettes, residents were not encouraged or assisted in using them for hand hygiene before meals. Furthermore, the facility did not ensure proper cleaning of glucometers and adherence to infection control procedures during wound care. An LPN was observed using personal hygiene wipes instead of alcohol wipes to clean a resident's finger and glucometer, contrary to facility policy. Additionally, during wound care for a resident on enhanced barrier precautions, staff did not perform hand hygiene before donning PPE, and their wrists were exposed due to improper gowning. The wound care nurse also reached under his gown to retrieve a marker, compromising the protective barrier of the PPE.
Failure to Provide Appropriate Discharge Process
Penalty
Summary
The facility failed to ensure that a resident was permitted to remain in the facility and was not transferred or discharged without an appropriate process. The resident, a 65-year-old with schizoaffective disorder and bipolar disorder, exhibited behaviors such as hallucinations, delusions, and aggression. Despite these challenges, the facility did not provide the necessary documentation or notification for the resident's discharge to a sister facility. The facility's policy requires that residents be allowed to remain unless specific criteria are met, and that proper documentation and notification are provided. However, in this case, there was no documentation indicating the reason for the discharge or the anticipated date. Additionally, the resident or their representative was not notified of the immediate discharge to the hospital, nor were they informed of their right to appeal the discharge. Interviews with staff revealed that the facility's interdisciplinary team had determined they could not meet the resident's needs due to her behaviors. Despite this, the facility did not issue a 30-day or immediate discharge notice, nor did they educate the resident about the appeal process. The lack of proper discharge documentation and notification was acknowledged by the facility's administration.
Facility Fails to Reassess Resident Post-Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after a hospital transfer, violating the resident's right to remain in the facility. The facility did not reassess the resident's status upon her request to return, instead directing the hospital to discharge her to a sister facility. This decision was made without proper documentation or communication with the resident, who was her own responsible party. The resident, a 65-year-old with schizoaffective disorder and bipolar disorder, exhibited behaviors such as hallucinations, delusions, and aggression. Despite these challenges, the facility did not develop a discharge care plan or document a reassessment of her needs post-hospitalization. The facility's policy requires that residents be allowed to return unless specific criteria are met, which were not documented in this case. Interviews with staff revealed that the facility's interdisciplinary team and primary care physician decided the resident's needs could not be met at the facility. However, there was no evidence of a discharge plan being discussed with the resident or documented in her care plan. The social services director admitted to not discussing discharge planning with the resident, and the director of nursing confirmed the lack of documentation for the discharge process.
Failure to Implement PASRR Level II Recommendations
Penalty
Summary
The facility failed to incorporate the recommendations from the PASRR Level II determination and evaluation report into the assessment, care planning, and transition of care for two residents. Specifically, the facility did not initiate therapy as recommended by the PASRR Level II in a timely manner for these residents. The Behavioral Health Services policy and procedure, revised in February 2019, mandates that the facility provide behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being of residents. However, the facility did not adhere to this policy for the residents in question. Resident #65, who was admitted with diagnoses including schizophrenia and a history of suicidal behavior, had a PASRR Level II recommendation for psychiatric case consultation, case management, individual therapy, and a crisis intervention plan. Despite receiving the PASRR Level II notice of determination on 9/19/24, the facility delayed processing the referral for counseling until 10/10/24, three weeks later. This delay in initiating the recommended therapy was a significant oversight in the resident's care plan. Resident #43, diagnosed with bipolar disorder and other medical conditions, had a PASRR Level II recommendation for behavioral health services to address self-isolation and enhance her quality of life. Although a referral for behavioral health services was documented on 3/22/24, there was no evidence in the resident's electronic medical record that these services were provided. The social service director acknowledged the lapse in initiating a new referral after the previous behavioral health services provider vacated their position, citing an inability to keep up with responsibilities due to a lack of assistance. The director of nursing was unaware of the deficiency in providing behavioral health services to these residents.
Lack of Pain Management Parameters for PRN Medications
Penalty
Summary
The facility failed to ensure that the administration of as-needed (PRN) pain medications for a resident met professional standards of quality. Specifically, the orders for PRN pain medications, including Oxycodone, Tramadol, and Tylenol, lacked specific parameters related to the severity of the resident's pain level on a scale of 1-10. This deficiency was identified for a resident who was cognitively intact and had diagnoses including schizoaffective disorder, bipolar disorder, and diabetes mellitus. The resident's care plan indicated a risk for pain or discomfort, with a goal to relieve pain to a tolerable level, but the lack of specific pain level parameters in the medication orders did not align with this goal. Interviews with staff, including LPNs and the Director of Nursing, revealed that there was an expectation for PRN pain medications to have clear pain scale parameters. However, the orders for the resident's PRN pain medications, which were initially ordered by an emergency department physician, did not specify the pain levels for which each medication should be administered. This oversight was acknowledged by the staff, who indicated that the facility had reviewed and audited the PRN pain medication orders during the survey.
Failure to Provide Proper Discharge Notifications and Planning
Penalty
Summary
The facility failed to provide proper discharge notifications and develop a collaborative discharge plan for a resident with severe cognitive impairment and multiple diagnoses, including dementia and type 2 diabetes mellitus. The resident, who exhibited behavioral symptoms such as hallucinations and aggression, was not involved in the discharge planning process, nor was there documentation of such planning in the resident's electronic medical record (EMR) or comprehensive care plan. Despite the facility's policy requiring a post-discharge plan to be reviewed with the resident or their representative at least 24 hours before discharge, this was not adhered to. The facility's social services director (SSD) and regional clinical consultant (RCC) confirmed that the discharge planning process was not documented as required. The SSD acknowledged the lack of documentation in the resident's EMR, and the RCC emphasized that the discharge process should be part of the comprehensive care plan. The nursing home administrator (NHA) indicated that the SSD was responsible for documenting and developing the discharge plan, but this was not done, leading to a deficiency in the facility's discharge procedures.
Failure to Maintain Resident's Personal Hygiene
Penalty
Summary
The facility failed to ensure that a resident who was unable to carry out activities of daily living (ADL) independently received the necessary services to maintain good grooming and personal hygiene. Specifically, the facility did not ensure that the resident's fingernails were trimmed and clean. The resident, who was cognitively intact and required substantial assistance with various ADLs, was observed with long and dirty fingernails, which he expressed a desire to have cut. The facility's policy required that residents unable to perform ADLs independently receive appropriate care to maintain hygiene, including nail care. The resident's care plan included interventions for bathing, showering, and nail care, but these were not adequately implemented. Interviews with staff, including an LPN and the DON, revealed that nail care should be performed as needed and checked during bathing. However, the resident's fingernails were not maintained according to these guidelines, indicating a lapse in the facility's adherence to its own policies and procedures for resident care.
Delayed Treatment for Lymphedema Due to Missing Physician's Order
Penalty
Summary
The facility failed to provide timely treatment for a resident with lymphedema, a condition characterized by swelling due to lymph fluid buildup. The resident, who was over 65 years old and cognitively intact, was dependent on staff for dressing and personal hygiene. Despite a nurse practitioner's referral to a lymphedema clinic and a request for lymphedema wraps on 9/17/24, the necessary physician's order for the wraps was not entered into the resident's electronic medical record. Consequently, the resident did not receive the recommended treatment. The care plan for the resident included interventions for skin breakdown but did not address edema or the use of wraps. The director of nursing acknowledged difficulties in finding a service provider to measure the resident's legs for the wraps, as it required specialized services. The regional clinical consultant later indicated that the director of nursing had entered the physician's order and documented a progress note, but the deficiency occurred due to the initial delay in obtaining the necessary measurements and orders.
Failure to Provide Timely Vision Services
Penalty
Summary
The facility failed to ensure timely access to optometry services for a resident, leading to a deficiency in maintaining the resident's vision abilities. The resident, a 67-year-old individual with hemiplegia, was admitted with a need for corrective lenses and expressed a desire for a vision referral shortly after admission. Despite this, there was no documentation in the resident's electronic medical record indicating a referral to an eye doctor, and a consent for vision services was not obtained until several weeks after the resident's request. Interviews with facility staff revealed systemic issues in scheduling ancillary services, with the Social Services Director (SSD) acknowledging difficulties in keeping up with referrals. The SSD noted that while ancillary services were offered quarterly and upon admission, there had been challenges in ensuring timely referrals. The Director of Nursing (DON) and the Nursing Home Administrator (NHA) both recognized the need for timely scheduling of ancillary services, with the NHA acknowledging that the SSD required additional support to fulfill her duties effectively.
Inadequate Supervision of Resident with Smoking Habit and History of Self-Inflicted Burns
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures for a resident with a history of self-inflicted injury from fire and a smoking habit. The resident, who was cognitively intact and had a history of schizophrenia, suicidal behavior, and severe burns, was assessed as being able to smoke independently without supervision. However, the facility did not have a comprehensive care plan addressing the resident's smoking habit, nor did it document a plan to monitor the resident, who possessed a lighter and smoked over ten times per day. Interviews with staff revealed a lack of awareness and communication regarding the resident's smoking status and the associated risks. The social service director and assistant director of nursing acknowledged the need for a safety plan and supervision due to the resident's history of self-inflicted burns. Despite this, the resident was allowed to smoke independently, with the nursing home administrator emphasizing the resident's autonomy. This oversight in care planning and supervision posed a risk to the resident and others in the facility.
Failure to Prime Insulin Pen Leads to Medication Error
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of insulin. The incident involved a resident over the age of 65, who was diagnosed with type 2 diabetes mellitus and was cognitively intact. During a medication administration, an LPN did not prime the insulin pen before administering a 50-unit dose of Tresiba insulin to the resident. This action was contrary to the professional guidelines provided by the Tresiba product information, which requires the pen to be primed by dialing to two units and expelling the insulin before administering the prescribed dose. The facility's policy on administering medications emphasizes the importance of following prescriber orders and ensuring safe medication practices. However, the LPN failed to adhere to these guidelines, as confirmed by the director of nursing and the regional clinical consultant. They acknowledged that priming the insulin pen is crucial to ensure the resident receives the full dose of insulin. This oversight was documented during an observation and interview process, highlighting a significant medication error in the facility's administration practices.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 512 citations issued within 25 miles in the last 12 months — including the 8 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Denver
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brookshire Post Acute | 0 mi | ★★★★★ | 3 | 1 |
| Rowan Community, Inc | 0 mi | ★★★★★ | 3 | 0 |
| South Valley Post Acute Rehabilitation | 0.6 mi | ★★★★★ | 17 | 0 |
| Holly Heights Care And Rehabilitation | 0.6 mi | ★★★★★ | 39 | 0 |
| Highline Post Acute | 0.6 mi | ★★★★★ | 1 | 1 |
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 July 2026) and official state health department websites.