Below average — CMS composite of the measures below.
The next survey window likely opens around May 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 Medallion Post Acute Rehabilitation during CMS and state inspections, most recent first.
Pest Control Program Failed to Control Mice and Insects The facility did not maintain an effective pest control program to keep the LTC building free of mice, spiders, and other insects. Surveyors observed an open kitchen alleyway door, a gap under an exterior exit door, spiders in hallways, and traps in resident rooms containing spiders, bugs, and mouse droppings. Residents reported spiders on beds and walls, mice in rooms and hallways, and mouse droppings in rooms, while resident council minutes showed the mouse problem had continued for months. Pest control invoices repeatedly noted open doors and door gaps, but those issues remained unresolved in the observations reviewed.
A facility failed to maintain resident dignity by allowing repeated delays in answering call lights and by not treating residents respectfully during meal service. Residents reported waiting 15 minutes to several hours for help, being left soiled, and hearing staff laughing while call lights went unanswered; during lunch, a CNA loudly referred to two residents as “feeders” within earshot of others.
Medication Storage and Labeling Deficiencies: The facility failed to properly store and label medications in a medication cart and medication room. Surveyors found an expired bottle of latanoprost in the med room, several opened meds in the cart without open dates, one fluticasone bottle without a resident name or open date, and 33 unidentified loose pills in the cart drawers. RN and DON interviews confirmed that staff were expected to date opened meds, check for expirations, and clean the carts.
Inaccurate code status documentation was found for two residents. One resident’s MOST form and CPO conflicted, with one record showing CPR/full treatment and another showing DNR, while a second resident’s MOST form showed no CPR but the CPO showed CPR/full code until it was changed during the survey. Staff said they relied on the EMR in emergencies, even though paper MOST forms were kept at the nurses’ station, and interviews showed inconsistent handling of admission paperwork and code status entries.
A resident receiving HD had incomplete pre- and post-dialysis documentation and inconsistent communication between the facility and the dialysis center. The resident, who had ESRD, DM2, chronic respiratory failure, and seizures, reported staff often failed to complete the dialysis binder unless reminded. Records showed dialysis forms were sometimes incomplete, blank, or replaced with sticky notes or loose paper, and the EMR did not consistently show post-dialysis VS or dialysis center information.
Failure to Arrange Follow-Up Dental Care: A resident with cognitive intactness, ADL dependence, and documented cavities/dental decay reported a tender tooth and had repeated dental findings of severe inflammation, plaque, calculus, and possible decay. A dentist recommended extraction of a non-restorable tooth and later periodontal maintenance, but the EMR did not show timely follow-up dental appts were scheduled, and oral/dental status was not evaluated on readmission. Staff said dental follow-up was handled through charge nurses, SS, and the scheduler, but the DON was unaware of the resident’s dental issues.
A facility failed to keep the daily nurse staffing posting current and prominently posted. The staffing sheet remained dated and listed an outdated census, did not show the actual nursing staff working hours, and had not been updated since the scheduler went on leave; the DON said the charge nurse was supposed to complete the posting but it was not being done.
A resident with a history of falls and fractures experienced a fall, reported severe pain, and requested hospital transfer. An LPN and CNA assisted the resident into a wheelchair without a hands-on RN assessment, and there was a delay in notifying EMS and obtaining physician orders. The resident was eventually sent to the hospital over an hour later, where she was diagnosed with a dislocated and fractured shoulder and a fractured hip, both requiring surgery. The facility failed to follow professional standards for assessment, documentation, and timely response to the resident's acute condition.
A resident with dementia and other conditions eloped from an LTC facility due to inadequate supervision and monitoring. The resident, who was at risk for elopement, left unnoticed and was later found by police and admitted to a hospital. Staff failed to perform required checks and inaccurately documented the resident's presence and meal intake, delaying the realization of the elopement.
A resident with multiple health conditions sustained a leg injury in a LTC facility, which was not consistently monitored or documented as per facility policy. Despite initial treatment, the injury worsened, leading to hospitalization for cellulitis and surgery. Staff interviews revealed lapses in monitoring and documentation, contributing to the deficiency.
The facility failed to honor resident choices for bathing and address noise concerns, affecting four residents. A resident with Parkinson's disease did not receive promised showers, while another resident experienced inconsistencies in their shower schedule. A third resident was not offered a bed bath after declining a shower due to surgery. Additionally, a resident faced unresolved noise issues with a roommate's loud television, with staff failing to provide solutions or document interventions.
The facility failed to promptly address resident grievances, particularly regarding staffing shortages and delayed call light responses. Residents reported long wait times for assistance, leading to incontinence episodes. Staff interviews revealed a lack of awareness of the grievance process, and the facility's efforts to address concerns through ambassador rounds were insufficient.
The facility failed to maintain a clean and homelike environment, with issues such as chipped sinks, missing drawer fronts, stained ceiling tiles, and improperly secured fixtures. The maintenance director noted delays in repair approvals, contributing to ongoing deficiencies.
The facility failed to provide necessary ADL assistance for residents, resulting in untrimmed fingernails for two residents and another resident attending meals in a hospital gown due to lack of dressing assistance. Staff interviews revealed a lack of awareness and action regarding these needs.
The facility failed to properly store and label medications, with controlled drugs not double-locked and expired medications found in storage areas. Staff interviews revealed lapses in the process of checking and removing expired medications, and the DON acknowledged the need for reviewing medications brought from home.
The facility failed to treat residents with dignity and provide timely care. A resident experienced privacy violations when staff entered her room without knocking, while another resident did not receive timely incontinence care, remaining in a wet brief for nearly two hours. Staff interviews confirmed these actions were against facility policy.
A resident with severe cognitive impairment was unable to access her call light due to it being consistently found on the floor, despite facility policy requiring it to be within reach. Observations showed staff repeatedly failed to place the call light within reach, and interviews confirmed this oversight. The resident, who often kicked the call light off the bed, was left unable to call for assistance, highlighting a failure in adhering to the facility's policy.
A resident with multiple medical conditions reported a grievance about a CNA's unfamiliarity with her care and disrespectful behavior. The facility's grievance process failed to address her specific concerns, as the grievance form lacked details and the follow-up did not resolve the issue. The DON acknowledged that grievances should be resolved satisfactorily, but this was not achieved in this case.
A resident was found with medications left at her bedside, contrary to facility policy. The resident, who was cognitively intact, had requested water to take her morning medications but did not receive it, leaving her unable to take the pills. The night nurse had also left medications from the previous night without verifying ingestion. The facility's policy requires observation to ensure complete ingestion, but there was no physician's order or care plan documentation for self-administration.
A facility failed to develop an effective discharge plan for a resident with Parkinson's disease who wished to return to the community. The resident's goals were not documented or pursued, and the social services assessment inaccurately indicated long-term care placement. The comprehensive care plan lacked discharge goals and interventions, and there was no evidence of active discharge planning.
A resident with severe cognitive impairments and multiple health conditions did not receive necessary meal set-up assistance, leading to inadequate food intake. Despite being observed struggling to eat, staff did not intervene, and the resident experienced significant weight loss over four months without new nutritional interventions being implemented.
A resident with Parkinson's disease experienced increased hand tremors due to inconsistent administration of carbidopa-levodopa medication. The facility failed to administer the medication at regular intervals, as recommended, leading to worsened symptoms. The medication was often given in less than four-hour intervals, and administration times varied significantly, contributing to the resident's increased tremors.
The facility failed to provide timely dental services to two residents. One resident had broken teeth and had not been offered dental care since admission, while another resident, who was edentulous, was promised dentures a year ago but had not received them. Staff interviews revealed a lack of awareness and follow-up on the residents' dental needs, contrary to the facility's policy requiring prompt assistance in obtaining dental care.
The facility failed to maintain an effective infection prevention and control program, as housekeeping staff did not disinfect high-touch surfaces or adhere to disinfectant dwell times. Observations revealed a housekeeper entering rooms without gloves, failing to perform hand hygiene, and not cleaning high-touch surfaces. Staff interviews highlighted discrepancies between facility policies and actual practices.
A facility's transition to a smoking-friendly environment revealed significant gaps in smoking safety protocols, leading to a resident with cognitive impairment and oxygen use sustaining first-degree burns while smoking. The facility did not update its smoking policy, resident evaluations, or implement smoking agreements. Additionally, staff were not adequately trained on smoking safety protocols, resulting in insufficient supervision of residents who smoked. These deficiencies contributed to an unsafe environment and a serious incident involving a resident smoking with oxygen.
Pest Control Program Failed to Keep Facility Free of Mice, Spiders, and Insects
Penalty
Summary
The facility failed to provide an effective pest control program to keep the building free from mice, spiders, and other insects. The facility policy required a written agreement with a qualified outside pest service and use of appropriate indoor and outdoor pest control methods, but survey observations and interviews showed ongoing pest activity throughout the facility. During the survey, a kitchen alleyway door was observed propped open when not in use, a gap was seen under an emergency exit door with daylight visible through it, and spiders were observed in hallways and near exit doors. Sticky traps and mousetrap boxes were also observed in resident areas, with some traps containing spiders, bugs, and mouse droppings. Resident interviews documented repeated reports of pests in rooms and common areas. One resident reported seeing spiders every day and said there had previously been an ant issue. Another resident reported seeing a mouse in the room two days earlier, and mouse droppings were observed by the window sill and under the sink during the interview. Other residents reported spiders on beds, large spiders under beds and on walls, mouse droppings in rooms, and insects crawling across floors. In a group interview, residents reported spiders in rooms, recent spider bites, and mice running through rooms and hallways. Resident council minutes from December 2025 through May 2026 documented an ongoing mouse problem, with continued use of traps and daily checks, but did not show that the problem had been resolved. Pest control invoices showed that the pest control company repeatedly identified open doors and door gaps as issues and recommended repairs, sealing gaps, and keeping doors closed when not in use. The invoices also documented that these concerns remained open across multiple visits. Despite these recommendations, survey observations still found the kitchen alleyway door propped open and a gap under an exterior emergency exit door. Staff interviews confirmed that spiders and mice had been seen in the facility, that residents had complained about pests, and that the maintenance director had focused on traps and routine pest service while missing the pest control company’s notes about door openings and gaps.
Dignity and Call Light Response Failures
Penalty
Summary
The facility failed to maintain residents’ dignity and ensure call lights were answered in a timely manner. Multiple residents reported long waits after activating call lights, including waits of 15 to 20 minutes, 30 minutes or more, 45 minutes, an hour, and in some cases several hours. One resident said she had lain in bed for an hour and a half waiting for help after being incontinent, and another said she had been left in her own feces for too long. Residents also reported hearing staff talking and laughing in the hallway while their call lights remained unanswered, and some said staff would turn off the call light before the request was completed, requiring the resident to activate it again. Observations during the survey showed four call lights activated and visible at the nurses’ station while CNAs were nearby, including one using a phone and others talking in the common area. Staff had to be prompted by the ADON to answer the call lights. Record review showed multiple grievances from residents and visitors about prolonged call light wait times from January through May, with reports of waits from 20 minutes to several hours, including overnight. Call light audits documented several response times over 15 minutes, and no night shift audits were documented from early February through the end of May. Resident council minutes also reflected repeated concerns about delayed responses, staff turning off call lights before completing requests, and night shift coverage issues. The facility also failed to ensure residents were treated with dignity during meal service. During lunch observation, a CNA stood in the dining room and loudly asked a dietary aide if he had the two “feeder’s meals” coming up while pointing at two seated residents. The comment was made loudly enough to be heard from the other end of the dining room and within earshot of other residents. Staff interviews confirmed that referring to residents as feeders was considered disrespectful and not appropriate, and that staff should speak directly to residents rather than talking around them.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards in one medication cart and one medication storage room. During observation with the DON, one bottle of latanoprost 0.005% eye drops was found in the medication room with an expiration date of 1/25/26. The report also identified that the facility did not ensure expired medications were removed from inventory and disposed of according to policy. During observation of medication cart one with RN #5, multiple medications were found without the date opened, including latanoprost ophthalmic solution 0.005%, two bottles of fluticasone propionate nasal suspension 50 mcg/act, ipratropium-albuterol inhalation solution, and azelastine HCl ophthalmic solution 0.05%. One bottle of fluticasone propionate nasal suspension was also not labeled with a resident's name or the date it was opened. In addition, there were 33 unidentified pills loose on the bottom of the first and second drawers of the medication cart. RN #5 stated that the nurse who opens a medication should mark the open date and expiration date, that nurses on each shift should clean the medication carts, and that night nurses should check for expiration dates and open dates. The DON stated that night shift nurses were responsible for checking the medication room and carts for open dates and expiration dates and for discarding expired medications, and that the pharmacy consultant completed monthly audits.
Inaccurate Code Status Documentation
Penalty
Summary
The facility failed to document resuscitation choices accurately in the medical record for two residents. Surveyors found that the code status information in the computerized physician orders (CPO) did not match the residents’ MOST forms, and staff interviews showed that nursing staff relied on the electronic record in emergencies even though the physical MOST forms were kept in a binder at the nurses’ station. For one resident, the MOST form in the chart and advance directive binder indicated CPR with full treatment, including IV antibiotics, fluids, and intubation, but the CPO contained a physician order for DNR. A second MOST form for the same resident, uploaded during the survey, indicated no CPR and comfort-focused treatment, creating conflicting documentation in the record. The resident had diagnoses including COPD, CKD, dementia, and Alzheimer’s disease, and the MDS showed moderate cognitive impairment with a BIMS score of 10 out of 15. The resident’s representative said she was not sure what documentation had been completed at admission and stated she would want CPR at that moment, depending on the resident’s condition. For the other resident, the MOST form in the binder and EMR indicated no CPR with comfort-focused treatment, but the CPO showed CPR/full code orders that were later discontinued and replaced with DNR/comfort measures during the survey process. The resident was cognitively intact with a BIMS score of 13 out of 15 and said he had originally chosen no CPR on admission but had changed his decision a few days earlier to receive CPR without extreme measures. Staff interviews showed that the charge nurse, medical records official, DON, and ADON had different roles in entering or uploading admission paperwork, and the DON stated the code status in the EMR should match the MOST form. The record review and interviews showed that the residents’ resuscitation choices were not documented consistently across the MOST forms and physician orders.
Dialysis Assessments and Communication Not Consistently Documented
Penalty
Summary
The facility failed to communicate effectively with the dialysis center for one resident receiving hemodialysis and did not ensure pre- and post-dialysis assessments were completed and documented per professional standards. The resident had end stage renal disease, type 2 diabetes mellitus, chronic respiratory failure, and seizures, and the MDS indicated moderate cognitive impairment with a BIMS score of 12 out of 15. The resident reported that nursing staff were supposed to complete information in a dialysis binder before each dialysis appointment, but that this was not consistently done, and she said she usually had to remind staff to complete it. Facility records showed the dialysis communication form was intended to be completed by facility nursing staff before dialysis and by dialysis center staff during treatment. However, the pre-dialysis section was not fully completed on one form, the dialysis center section was blank or nearly blank on several forms, and on multiple occasions no dialysis communication form was provided and the dialysis center wrote resident assessment information on a sticky note or blank piece of paper instead. The electronic medical record did not show that dialysis center information from several dialysis dates had been obtained or recorded by the facility. The record also did not show that the resident was assessed or had vital signs obtained consistently after dialysis from March through early June 2026. The medication administration record showed vital signs were documented before and after dialysis on only some dates, while no other pre- or post-dialysis vital signs were recorded for the resident during the reviewed period. Staff interviews confirmed that nursing staff were expected to obtain and document vital signs before and after dialysis and to record them in the dialysis binder and EMR.
Failure to Arrange Follow-Up Dental Care
Penalty
Summary
The facility failed to provide routine dental services and to ensure follow-up dental care was obtained for a resident who had documented dental decay and cavities. The resident was cognitively intact, required assistance with oral hygiene and other ADLs, and had diagnoses including epilepsy and adult failure to thrive. The resident’s MDS documented obvious or likely cavities or broken natural teeth, and the resident later reported a tender tooth and said she believed she should see a dentist. Record review showed repeated evidence of oral disease and recommended dental treatment. A dental hygiene visit documented severe inflammation, high decay rate, heavy bleeding, plaque, calculus, poor oral hygiene, and possible decay in multiple teeth, with recommendations for extractions and scaling/root planing. A later dentist exam documented moderate plaque accumulation, moderate to severe bone loss, and tooth #15 as not restorable, with fluoride applied and extraction of tooth #15 recommended at the next visit. The record did not show that follow-up dental appointments were scheduled after that recommendation. Subsequent dental hygiene documentation again noted severe inflammation, high decay rate, heavy bleeding, plaque, calculus, poor oral hygiene, and possible decay for tooth #15, with a recommendation for periodontal maintenance. The EMR still did not show follow-up dental appointments were scheduled. After the resident was readmitted, the oral/dental status was not evaluated on admission, and later documentation again noted obvious or likely cavities or broken natural teeth. Staff interviews indicated the facility relied on charge nurses, social services, and the scheduler to arrange dental appointments, but the DON stated she was not aware of any dental issues for the resident. The resident was not scheduled to be seen by the dentist until during the survey process, long after the resident’s decay had been identified and after the dentist had recommended extraction of tooth #15.
Failure to Update Daily Nurse Staffing Posting
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted in a prominent place and updated daily. During observations on 6/11/26 and again on 6/15/26, the staffing posting was present but still showed the date 5/18/26 and a census of 59 residents, even though the facility census during the survey was 57 residents. The posting also did not reflect the actual working hours for nursing staff, and the information had not been updated since 5/18/26. In interview, the DON stated the scheduler was responsible for updating the daily nurse staff posting, but the scheduler was on leave, so the charge nurse was supposed to complete it; the DON said she did not ensure the charge nurse was doing so.
Failure to Provide Timely Assessment and Hospital Transfer After Resident Fall
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards for a resident with a history of falls and previous fractures. The resident, who was cognitively intact and ambulated independently with a walker, experienced a fall while walking to the bathroom. After the fall, the resident was found on the floor, complaining of significant pain (8 out of 10) in her left shoulder and left hip, and requested to be sent to the hospital. The LPN on-site notified the DON, who was the RN on-call, but no RN was present in the facility to conduct a hands-on assessment at the time of the incident. The resident was assisted into a wheelchair by the LPN and a CNA despite her complaints of severe pain and refusal to allow removal of her clothing for a skin evaluation. Documentation revealed that the DON's assessment was based on the LPN's report rather than a direct evaluation, and the nursing note was not entered into the electronic medical record until several hours later. There was no evidence that the physician was notified of the resident's acute pain and refusal of a skin evaluation prior to moving her, nor was there documentation of physician orders for X-rays before the resident's representative insisted on hospital transfer. The resident was ultimately transported to the hospital over an hour after her initial request, where she was diagnosed with a dislocated and fractured left shoulder and a fractured left hip, both requiring surgical intervention. Interviews with staff and the resident's representative confirmed inconsistencies in the facility's response, including delays in contacting EMS and obtaining physician orders, as well as discrepancies in staff accounts regarding the resident's pain and requests for hospital transfer. The facility's policies required a physical assessment by a licensed nurse after a fall and immediate attention for significant changes in condition, but these procedures were not followed. The lack of timely and appropriate assessment, documentation, and response to the resident's acute pain and request for hospital evaluation constituted a failure to provide care in accordance with professional standards.
Resident Elopement Due to Inadequate Supervision and Monitoring
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident diagnosed with metabolic encephalopathy, unspecified psychosis, dementia, and anxiety. The resident, who was at risk for elopement, left the facility unnoticed and was found by local police approximately 0.3 miles away. The resident was subsequently admitted to a local hospital for evaluation and treatment of a urinary tract infection. The deficiency occurred because the facility staff did not perform the required two-hour checks on the resident throughout the evening. The resident's care plan indicated a history of wandering and elopement, yet the staff failed to monitor the resident as per the facility's protocol. Additionally, the resident had refused to wear a wanderguard, which contributed to the lack of immediate detection of the elopement. Documentation errors were also noted, as staff inaccurately recorded the resident's meal intake and presence in the facility. The LPN and CNA on duty documented that the resident had no exit-seeking attempts and was present in the facility, despite the resident having been admitted to the hospital earlier that evening. This misdocumentation further delayed the realization that the resident was missing, highlighting a significant lapse in the facility's monitoring and documentation processes.
Failure to Monitor and Document Resident's Leg Injury
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for a resident who sustained an injury to her right lower leg. The resident, who had multiple diagnoses including type 2 diabetes, chronic kidney disease, and heart failure, struck her leg on a metal bed frame while maneuvering her electric wheelchair. Despite the initial assessment and application of ice, the facility did not consistently document observations or monitor the injury as required by their policy. The resident reported increased pain and swelling, but the facility's documentation was inconsistent, with gaps in monitoring and incorrect entries regarding the location of the injury. The wound doctor did not assess the resident's leg during a visit, and the facility failed to document the status of the injury for several days. This lack of monitoring and documentation led to the resident being sent to the emergency department, where she was diagnosed with cellulitis and required surgery and IV antibiotics. Interviews with staff revealed that the nurses should have continued to monitor and document the injury until it was resolved. The nurse practitioner and director of nursing acknowledged the lack of documentation and monitoring. The medical director confirmed that the wound doctor had seen the lesion but did not document it, contributing to the oversight that resulted in the resident's hospitalization for an infected hematoma.
Failure to Honor Resident Choices and Address Noise Concerns
Penalty
Summary
The facility failed to honor resident choices for bathing and assistance with hearing the television, affecting four residents. Resident #59, who has Parkinson's disease and mild cognitive impairment, reported receiving only one shower since admission, despite being promised two showers per week. Documentation confirmed that Resident #59 did not receive the expected number of showers, with records showing only one shower in August 2024. Resident #7, who is cognitively intact and dependent on staff for bathing, expressed frustration over not receiving showers according to the established schedule. The facility's documentation showed inconsistencies with the resident's reported schedule, and records indicated missed showers in June, July, and August 2024. Resident #4, also cognitively intact, declined a shower due to recent surgery but was not offered a bed bath as an alternative. Documentation revealed that Resident #4 received only half of the scheduled showers from April to August 2024, with several refusals and blank entries in the records. Resident #23, who is cognitively intact and dependent on staff for various activities, reported issues with his roommate's loud television, which affected his ability to hear his own television and sleep. Despite raising the issue with staff, no solutions were offered, and the resident was incorrectly informed that filing a grievance would require him to move rooms. The facility's records did not document any interventions to address the noise concerns, and staff interviews revealed a lack of communication and protocol in handling the situation.
Facility Fails to Address Resident Grievances Promptly
Penalty
Summary
The facility failed to ensure prompt action was taken upon the filing of grievances by residents, particularly concerning staffing shortages and delayed responses to call lights. The facility's grievance policy, revised in August 2024, mandates that grievances be addressed promptly to prevent discrimination or reprisal. However, interviews with residents revealed dissatisfaction with the facility's handling of grievances, particularly regarding the lack of timely responses and inadequate staffing, especially during specific hours and weekends. Residents reported significant delays in call light responses, with some waiting 20 to 30 minutes or longer for assistance. This delay led to incidents where residents experienced incontinence episodes due to the lack of timely care. Residents expressed that staff often ignored call lights or turned them off without providing the necessary assistance. The grievances also highlighted issues with the facility's refusal to use agency staff to address staffing shortages, further exacerbating the problem. Interviews with staff, including CNAs and the social services director, indicated a lack of awareness and understanding of the grievance process. The social services director acknowledged an increase in grievances related to call light response times but was unaware of any follow-up actions taken. The director of nursing and the nursing home administrator admitted to oversight in addressing grievances and recognized the need for cultural change within the facility. Despite implementing ambassador rounds to address resident concerns, the facility failed to ensure grievances were formally followed up and resolved.
Facility Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for its residents, as evidenced by multiple maintenance issues observed during a survey. These issues included chipped sinks and dresser drawers, missing drawer fronts, disconnected window curtains, missing baseboards and trim, stained ceiling tiles, and patched walls that required painting. Additionally, a fan was improperly secured to the wall, posing a potential safety risk to a resident, and a light fixture was missing its cover. These deficiencies were noted in various rooms and common areas, indicating a widespread problem with facility maintenance. Interviews with the maintenance director (MTD) revealed that the facility used an electronic work system to track repairs, but most staff did not have access to it. The MTD conducted daily walk-throughs and building inspections, noting issues and informing the nursing home administrator (NHA) of any problems. However, the approval process for repairs, especially those costing over $2500, could be lengthy, requiring approval from the NHA and corporate office. This delay in addressing maintenance issues contributed to the ongoing deficiencies observed in the facility.
Deficiencies in ADL Assistance and Personal Hygiene
Penalty
Summary
The facility failed to provide necessary services for residents who were unable to perform activities of daily living (ADLs), specifically in maintaining good grooming and personal hygiene. Resident #18, who was cognitively intact, reported that his fingernails were long and untrimmed, with brown matter underneath them. Despite having fingernail clippers, they were ineffective for him. The care plan for Resident #18 did not include nail care, and there was no documentation of nail care being provided from July 12 to August 15, 2024. Resident #45, who had severe cognitive impairments, also had long fingernails with brown matter underneath. He stated that his nails had not been trimmed since admission, and staff had not offered to trim them. The care plan for Resident #45 similarly lacked information on nail care, and there was no documentation of nail care being provided during the same period. Interviews with staff, including CNAs and LPNs, revealed a lack of awareness and action regarding the residents' nail care needs. Resident #5, who was cognitively intact and dependent on staff for dressing, was observed wearing a hospital gown instead of her preferred clothing. She reported that staff did not have time to assist her in getting dressed, resulting in her attending meals in a hospital gown. The care plan did not reflect her preference for personal clothing, and there was no documentation of her refusing to get dressed. The DON acknowledged that residents should be given a choice of clothing and assisted accordingly, but was unaware of why Resident #5 was not dressed in her preferred attire.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that medications and biologicals were properly stored and labeled according to professional standards. During observations, it was found that controlled medications were not securely stored under double lock, as evidenced by a bottle of lorazepam, a controlled anti-anxiety medication, being left unsecured in the medication storage room. Additionally, expired medications were not removed from the medication carts and storage room, including various ointments, creams, and oral medications with expiration dates ranging from 2014 to 2024. Furthermore, some medications, such as magic mouthwash, lacked expiration dates on their pharmacy labels. Interviews with staff revealed that the night shift nurse was responsible for checking medication carts for expired medications and ensuring their removal. However, this process was not effectively implemented, as expired medications were still present. The Director of Nursing (DON) acknowledged that medications brought from home by residents should be reviewed for expiration and appropriateness, but this was not consistently done. The facility's policy required controlled medications to be stored separately and securely, which was not adhered to, contributing to the deficiencies observed.
Failure to Ensure Resident Dignity and Timely Care
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by the actions of staff members towards two residents. Resident #4, an 82-year-old with multiple health conditions including diabetes and heart failure, was observed to have her privacy violated when staff members entered her room without knocking or announcing themselves. This occurred on multiple occasions, with staff delivering items or removing trays without acknowledging the resident or her roommate, despite the facility's policy requiring staff to knock and announce themselves before entering a resident's room. Resident #5, a 68-year-old with conditions such as diabetes and chronic respiratory failure, experienced a lack of timely incontinence care. Despite requesting assistance to change her brief before attending a music program, the resident was left waiting for 28 minutes without receiving the necessary care. Her husband had to assist her to the program without the brief being changed, resulting in the resident remaining in a wet brief for nearly two hours. This delay in care was contrary to the facility's policy of checking on incontinent residents every two hours and prioritizing their care over other tasks. Interviews with staff, including CNAs and the DON, confirmed that the facility's policies were not followed in these instances. Staff acknowledged the importance of knocking before entering rooms and providing timely incontinence care, yet these standards were not met, leading to the deficiencies observed by the surveyors.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to provide reasonable accommodations for a resident's mobility and accessibility needs, specifically regarding the accessibility of the call light. The resident, an 83-year-old with severe cognitive impairment due to Alzheimer's disease and dementia, was dependent on staff assistance for various activities of daily living. Despite the facility's policy requiring call lights to be within reach of residents, observations revealed that the resident's call light was consistently found on the floor at the foot of her bed, out of her reach. Multiple observations over several days showed that unidentified staff members entered and exited the resident's room without ensuring the call light was accessible. The resident herself was unaware of the call light's location, and staff interviews confirmed that the call light should never be on the floor. The facility's policy emphasized the importance of call light accessibility, yet staff failed to adhere to this policy, leaving the resident unable to call for assistance. Interviews with staff, including a CNA, LPN, and the DON, highlighted a lack of consistent practice in ensuring the call light was within reach. The DON acknowledged that the resident could use the call light but often chose to yell for help instead, and staff were aware that the resident frequently kicked the call light off the bed. Despite this knowledge, there was no consistent documentation or intervention to address the resident's behavior, leading to repeated instances of the call light being inaccessible.
Failure to Resolve Resident Grievance Promptly
Penalty
Summary
The facility failed to ensure prompt resolution of grievances for a resident, who had repeatedly communicated concerns about her care. The resident, who was cognitively intact and had multiple medical conditions including type 2 diabetes, chronic kidney disease, and heart failure, reported an incident where a CNA was unfamiliar with her care needs and left her waiting for 30 minutes. Upon returning, the CNA argued with the resident and spoke disrespectfully. The resident filed a grievance about this incident, but the facility did not address her specific concerns about the CNA's behavior. The facility's grievance policy requires that grievances be acknowledged within three working days and resolved promptly. However, the grievance form provided by the facility did not include the resident's name or specific concerns, and the follow-up action did not address the issue of the CNA's disrespectful behavior. Interviews with the DON revealed that grievances were supposed to be resolved satisfactorily for the resident, but in this case, the resident's concerns were not adequately addressed, indicating a failure in the grievance process.
Failure to Ensure Proper Medication Administration
Penalty
Summary
The facility failed to adhere to professional standards of practice during medication administration for a resident. The resident, who was cognitively intact and independent with eating and drinking, was found with two cups of pills at her bedside. One cup contained seven pills intended for the morning, and the other contained two pills from the previous night. The resident reported that she had requested fresh ice water to take her morning medications but had not received it, preventing her from taking the pills. Additionally, the night nurse had left the previous night's medications at the bedside without verifying ingestion. The facility's policy requires that medications be administered as prescribed and that residents be observed to ensure complete ingestion. However, the resident's electronic medical record did not contain a physician's order for self-administration, nor was there documentation in the care plan regarding her ability to self-administer medications. An LPN confirmed that medications were left at the bedside and that she checked back with the resident two hours later. The DON stated that medications could be left at the bedside if the resident was assessed to self-administer safely, but the nurse should verify ingestion before the end of their shift.
Failure in Discharge Planning for Resident
Penalty
Summary
The facility failed to develop and implement an effective discharge plan for a resident who was admitted for short-term rehabilitation with the goal of returning to the community. The resident, who had mild cognitive impairment and Parkinson's disease, expressed a desire to be as independent as possible and did not wish to remain in the facility for long-term care. However, the facility did not engage the resident in discharge planning discussions beyond the initial admission assessment, and the social services assessment inaccurately documented the resident's discharge plan as long-term care placement without considering the resident's expressed goals or exploring alternative living arrangements. The social services director admitted to not being aware of the resident's desire to return to a previous living arrangement or explore assisted living options. The comprehensive care plan lacked documentation of the resident's discharge goals and interventions to achieve those goals. Additionally, there was no evidence of active discharge planning in the resident's electronic medical record. The failure to involve the resident in discharge planning and to document and pursue the resident's goals led to the deficiency identified in the report.
Failure to Provide Nutritional Assistance to Resident
Penalty
Summary
The facility failed to provide necessary nutritional care and services to a resident, identified as Resident #39, who was part of a sample of 33 residents. The resident, an 83-year-old with severe cognitive impairments and multiple health conditions including dementia and malnutrition, required meal set-up assistance to maintain adequate nutrition. Despite these needs, the facility did not provide the required assistance during meal times, leading to the resident's inability to consume his meals fully. Observations revealed that during a meal, Resident #39 was not given proper set-up assistance, such as having his plate and utensils positioned correctly. The resident struggled to reach his food and inadvertently mixed food with his drink, which went unnoticed by the staff, including a registered dietitian and a registered nurse present in the dining room. The resident was left to eat without assistance for 41 minutes and did not consume 100% of his meal, missing out on dessert as well. The resident's care plan indicated a need for set-up assistance due to cognitive and mobility impairments, but it lacked specific details on the extent of assistance required. Despite a documented weight loss of 9.8 pounds over four months, no new nutritional interventions were implemented. Interviews with staff confirmed that the resident required set-up assistance, yet this was not consistently provided, contributing to the resident's nutritional decline.
Medication Administration Errors in Parkinson's Disease Management
Penalty
Summary
The facility failed to ensure that a resident with Parkinson's disease was free from significant medication errors. The resident, who had been living with Parkinson's disease for a long time, experienced increased hand tremors due to the improper administration of his medication, carbidopa-levodopa. The medication was not administered at regular intervals as recommended by the manufacturer, which led to the resident experiencing worsened symptoms, including significant hand tremors that affected his ability to participate in physical therapy. The facility's medication administration policy outlined specific time frames for administering medications, but the resident's carbidopa-levodopa was not scheduled at specific times, leading to inconsistent administration intervals. The medication was often given in less than four-hour intervals, and the administration times varied significantly from day to day. This inconsistency in medication administration was confirmed through a review of the medication administration record (MAR) and interviews with the nursing staff and pharmacist. Interviews with the nursing staff, pharmacist, and physical therapy assistant revealed that the facility's failure to administer the medication at regular intervals contributed to the resident's increased hand tremors. The pharmacist confirmed that the medication should be administered at the same time every day and within four-hour intervals to maintain consistent blood levels and alleviate the symptoms of Parkinson's disease. The director of nursing acknowledged that the medication was not being administered according to the guidelines, which resulted in a significant medication error.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to assist residents in obtaining necessary dental services, as evidenced by the cases of two residents. Resident #23, who was cognitively intact and dependent on staff for various activities, had broken teeth but had not been offered dental services since admission. Despite expressing a desire to see a dentist, there was no documentation of any dental care being provided or arranged for him. The facility's policy required that dental needs be identified and addressed in the resident's care plan, but this was not adhered to in Resident #23's case. Resident #18, who was also cognitively intact, had been without natural teeth and was promised dentures a year prior. Although he had seen the dentist, he had not received the dentures as promised. The facility's records failed to document any follow-up or offer of dental services in multiple quarterly assessments. The care plan for Resident #18 indicated a need for dental care coordination, but there was no evidence of timely action to provide the dentures. Interviews with staff revealed a lack of awareness and follow-up regarding the residents' dental needs. The social service director, responsible for arranging dental services, was unaware of the residents' needs and had not received dental records from the dentist. The facility's policy required prompt assistance in obtaining dental care, but this was not effectively implemented, leading to the deficiencies noted in the report.
Inadequate Infection Control Practices in Housekeeping
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program on one of its units, as evidenced by observations and interviews. Housekeeping staff did not disinfect high-touch surfaces such as call lights, door handles, and light switches in resident rooms. Additionally, the staff did not adhere to the required surface disinfectant dwell times, which are necessary for the disinfectant to effectively kill germs. The cleaning process was not conducted from clean areas to dirty areas, as recommended by both the CDC and the facility's own policies. During observations, a housekeeper was seen entering a resident's room without wearing gloves and failing to perform hand hygiene at various stages of the cleaning process. The housekeeper did not allow the disinfectant to remain wet on surfaces for the manufacturer-recommended dwell time and did not clean high-touch surfaces. The housekeeper also used the same cleaning materials across different areas without changing gloves or performing hand hygiene, which could lead to cross-contamination. Interviews with staff, including the infection preventionist and housekeeping manager, revealed discrepancies between the facility's cleaning policies and the actual practices observed. The infection preventionist stated that bathrooms should be cleaned last, and high-touch surfaces should be cleaned daily, while the housekeeping manager emphasized the importance of allowing disinfectant to sit for the required time. However, these practices were not followed by the housekeeping staff, leading to the identified deficiencies.
Smoking Safety Deficiencies and Resident Injury
Penalty
Summary
The facility failed to ensure a safe environment for residents who smoked, particularly those requiring supervision, leading to a serious incident on 3/27/24 involving Resident #1. Despite transitioning to a smoking facility in March 2024, the facility did not adequately revise its smoking policy, smoking evaluations, or implement resident smoking agreements. This lack of updated documentation and oversight contributed to Resident #1, a supervised smoker with cognitive impairment and oxygen use, sustaining first-degree burns to the neck, head, and face while smoking with his oxygen on. The facility's failure to address the risks associated with smoking and oxygen use for residents like Resident #1 created a situation with the potential for serious harm. Furthermore, staff at the facility were not adequately trained on smoking safety protocols following the transition to a smoking facility. The lack of education and oversight led to instances where residents were not properly supervised while smoking, as seen in the incident involving Resident #1 on 3/27/24. The facility's failure to provide comprehensive training to staff on the new smoking program and safety interventions further exacerbated the risk of accidents and harm to residents who smoked, especially those requiring supervision. The deficiencies in the facility's smoking policy, lack of updated resident smoking evaluations, absence of smoking agreements, and inadequate staff training all contributed to the unsafe environment for residents who smoked. These failures in oversight and implementation of safety measures directly resulted in the incident on 3/27/24 where Resident #1 suffered burns while smoking with his oxygen on.
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 108 citations issued within 25 miles in the last 12 months — including the 2 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 Colorado Springs
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Advanced Health Care Of Colorado Springs | 1.1 mi | ★★★★★ | 12 | 0 |
| Life Care Center Of Colorado Springs | 1.2 mi | ★★★★★ | 5 | 1 |
| Sunny Vista Living Center | 1.2 mi | ★★★★★ | 0 | 0 |
| Fountain View Rehabilitation And Nursing Llc | 1.7 mi | ★★★★★ | 2 | 0 |
| Kiowa Hills Rehabilitation And Nursing, Llc | 2.2 mi | ★★★★★ | 3 | 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.